"All we were wanting was an update on my father"

About: Royal Alexandra Hospital / Accident & Emergency Royal Alexandra Hospital / General Medicine

(as a relative),

My father arrived by ambulance at the RAH in Paisley one Thursday in August just before midnight he was seen right away and the staff were very professional and ran tests instantly as on admission. He was very confused. He has a history of chronic heart failure and previous triple by pass. He was then transferred to AMU just before 05.00hrs staff in AMU were very good. The next day I spoke with the nurse in AMU who was looking after my father and she gave my family an update on my father's wellbeing. I asked about his blood results he had sepsis, pneumonia, urine infection and delirium. Care in AMU was excellent. Keep up the good work A&E and AMU. 

The day after we were informed that my father was now in ward 14 and that is when the problems began. My mother and brother went up to ward 14 in afternoon  and my father was wearing another patients clothes they  asked the nurse for an update and was his blood results improving to be told she doesn't know. My brother called me to update me of this and when i arrived my father's bed was all wet I asked the auxiliaries for clean linen so I  could change the bed however they did it right away.  I then asked the nurse at the nursing station could I speak with the nurse looking after my father. Myself and my family waited for an update and nearly an hour had passed and no one had came near us. 

I approached the office where a Dr was on the  computer and I knocked the door there was a  nurse sitting at nursing station and they said can I help you I said yes I want to speak to a Dr with regards to my father I would like an update. The nurse said the Drs are busy the now. So I said that's absolutely fine but I am not leaving this ward until I find out what is going on with my father. A nurse then came to my fathers bedside  and I said we are looking for  an update on my father and I asked after his blood results, the nurse said very abruptly they didn't know this information only Drs can retrieve blood results I said well can I speak with a Dr then. I was told they were dealing with an emergency, maybe they could have said at the moment i am not sure but i could find this out and get back to yous . They were very abrupt and very rude.

I then asked the auxiliaries about half an hour later is the Drs still dealing with an emergency to be told there is no emergency on the ward. All we were wanting was an update on my father not a lot to ask for. We  fully understand and appreciate how busy the wards can be and how staff work very hard but to treat and speak to a patients family the way we were treated was a disgrace. 

My father finally got discharged on the Tuesday still very confused and when he got home he laid all his medication on his bed and said how am I meant to take all this medication so I started going through the medication and i realised that some of the medication was not my father's medication. I then discovered in my father's discharge letter a piece of paper with another patients name on it and how  this other patient  to take his medication that was when i realised the nurse that discharged my father had discharged my father with his own medication as well as another patients medication bearing in mind my father was still  confused.

What happened to patient confidentiality and if my dad took this other patients medication what would the outcome have been for my father. I think this a major clinical error and I want this fully investigated.

I called the ward instantly to make them aware of what had happened and I spoke to a nurse, they apologised and asked me to dispose of the other patients medication. Does ward 14 know anything about patient confidentiality, treating people with dignity and respect and what about upholding the name of the profession as i didnt see any of that from the staff I came into contact with. 

Responses

Response from Paul Hendry, Lead Nurse, Medicine, NHSGGC We have made a change

Thank you for contacting us to tell your story. I am re-assured to hear of the positive interactions both you and your father experienced with the Emergency Department and the Acute Medical unit teams at the beginning of his episode of care – your comments have been passed to them for sharing.

On behalf of the ward 14 team, I am very sorry to hear of the negative experience you describe when your father’s care transitioned from AMU to ward 14. Our aim is to deliver excellence in care during all stages of the patient journey through consistent caring and compassionate behaviours and clearly this would not appear to have been the case for you and your father. I have shared your comments with the Senior Charge Nurse and ward 14 team and asked how we would avoid this situation in the future.

We have now taken the opportunity to reflect on our processes for both meaningful communication with relatives and discharge planning. Some immediate actions from our review will include the Nurse in Charge having a more visible presence and offering opportunity to discuss care updates for relatives at structured times within the ward routine. The near miss with your father’s medication is considered as avoidable and thankfully with your diligence, there appears to have been no unintentional consequence. Please be re-assured the Hospital internal incident reporting procedure will ensure a thorough review of this incident will be completed to help us learn and consider any necessary actions for implementation to improve upon patient safety. As an interim measure, additional staff education and training is being delivered to ensure correct procedures are followed during the handling of patient discharge medications to ensure a safe and seemless transition of care from Hospital to Home.

I would be happy to meet with you in person if you feel that would be helpful. My contact details are paul.hendry@ggc.scot.nhs.uk.

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