A BEREAVED Dunfermline man has welcomed an ombudsman ruling which found several failings into his late wife's care.

Hiram Dunn, who lost his wife Linda in May 2022, had contacted the Scottish Public Services Ombudsman after making complaints to NHS Fife.

As reported previously by the Press, the family spent months fighting for answers over the care of Linda after a visit to the Victoria Hospital on May 18, nine days before her death.

Linda, who was suffering from terminal lung cancer, had recorded a complaint on May 20, after the appointment in which she was due to undergo a procedure to insert a stent to help with oedema.

After waiting for more than two hours for a bed, she had been left in "great discomfort" and her arms were leaking water because of the oedema.

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She required help from Hiram to get into the bed and was given tea and biscuits, though no other food over the course of her 13-hour visit.

There was also an issue where a nurse attempted to insert a cannula but could not locate a vein, resulting in multiple puncture wounds.

After the stent procedure, Linda said she was "completely ignored" in the ward, did not receive any water, and was unable to take her steroid medication on time.

She discharged herself from the hospital, having relayed her disappointment in her experience to both a doctor and senior charge nurse, and returned home with Hiram and their daughter.

On May 21, a GP attended the couple's home and assessed that Linda had suffered stroke during the night. She died six days later.

After taking independent advice, the SPSO upheld Hiram's complaint.

Describing Hiram as C and Linda as A, the report stated: "We found that A lacked person centred information to prepare them for admission which caused distress, that there was a failure to provide a clear pathway for a patient diagnosed with end stage lung cancer the Peripheral Vascular Cannula (PVC) process was not followed.

"We found that a pressure ulcer risk assessment was not undertaken and a plan of care not developed or implemented to prevent pressure damage."

The Ombudsman found there was a failure to provide Linda with her prescribed steroids despite requesting them.

It added: "We noted record keeping failures during A’s admission and found failings in the board’s handling of the complaint, with the complaint not addressing all the issues raised by C and failings to fully investigate and respond to C about the PVC process."

The SPSO ordered NHS Fife to apologise for the failings identified and ordered improvements.

"Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant nursing and midwifery standards," it said.

"Patients should be appropriately assessed to prevent pressure ulcer damage, in accordance with the current pressure ulcer prevention and management standards."

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NHS Fife has been told that patients should receive appropriate information to prepare them for a procedure, and to manage expectations about the admission.

Relevant staff should be made aware of the requirements of the complaints handling procedures, particularly with respect to investigating and addressing all the elements of a complaint.

Pleased that the SPSO has listened to his concerns, Hiram has also raised his concerns with the GMC and Nursing and Midwifery Council.

Along with a group of families pressing for answers over the treatment of their loved ones at Victoria Hospital, he plans to continue his quest for improvement.

"We are wanting a patient commissioner not just for Fife but for the whole of Scotland but in Fife to begin with," he said. "It is now nearly 20 months since my wife died – it took 99 days to get some sort of a reply.

"The SPSO are superb. I didn't have much faith to start off with but they were meticulous. I gave them the facts and they investigated it and got the right answer.

"I want the nurses in that ward to get sorted out. There is something seriously wrong."

Responding to the ombudsman report, NHS Fife's Director of Nursing, Janette Keenan, said: “We recognise that the care we provided in this instance well fell below the standards that our patients should expect and we accept the findings of the Ombudsman.

“We are in the process of implementing the Ombudsman’s findings in full and have apologised to the family involved for the failings in their loved one’s care.”