The following relates to a complaint made in 2014 to the Health Quality and Complaints Commission (HQCC). The complaint was made by the daughter of a patient regarding the health service her late mother (the patient) received from the Gold Coast and Robina hospitals between 28 March 2013 and 25 June 2013. The patient died on 25 June 2013 while in the care of the Gold Coast Hospital.

The original complaint to the HQCC failed to identify any one practitioner responsible for the treatment and care provided to the patient and the original HQCC investigation scope only covered the health service provided by the Gold Coast and Robina hospitals. Therefore, the investigation related only to the Gold Coast and Robina hospitals and not to individual providers.

The complainant raised the following concerns:

• there was a two to three month delay in diagnosing the patient’s duodenal ulcer
• following diagnosis of the patient’s duodenal ulcer, no immediate treatment was taken to treat the ulcer
• the duration of the patient’s illness on her death certificate is incorrect and should be amended.

As part of the investigations into the matter, the following evidence was considered:

• the patient’s medical records from the Gold Coast and Robina hospitals
• the Gold Coast Hospital and Health Service (GCHHS) submission
• the Human Error and Patient Safety report from the GCHHS
• the GCHHS follow up submission
• the patient’s medical records from her general practitioner
• clinical advice from an independent clinical expert with a specialty in gastroenterology and hepatology.

The following issues were identified during the investigation:

Issue one—During the patient’s admission to the Robina Hospital on 28 March 2013:

• an alleged failure to appropriately diagnose the patient correctly and ascertain if the patient was improperly discharged in this instance.

Issue two—During the patient’s admission to the Robina Hospital on 8 May 2013 to 14 May 2013:

• an alleged failure to diagnose and treat the patient appropriately
• an alleged lack of appropriate follow up of the patient’s CT scan results conducted on 8 May 2013.

Issue three—During the patient’s admission to the Robina and Gold Coast hospitals on 17 June 2013 to 25 June 2013:

• an alleged delay in the treatment and care provided to the patient from the time of admission on 19 June 2013 to the time of death on 25 June 2013
• an appropriate follow up after the patient’s endoscopy performed on 19 June 2013
• a death in this instance was a ‘reportable death’ as defined in part 2 of the Coroners Act 2003.

Issue four—The adequacy of the verbal communication between the patient, her family and the treating practitioners and the adequacy of the notes recorded in the patient’s clinical records:

• the alleged lack of verbal communication between treating staff and family members
• the alleged deficiencies in written patient notes and record keeping.

Issue five—The overall treatment and management of the patient during her three separate admissions to the Robina and Gold Coast hospitals:

• the appropriateness of the overall treatment provided to the patient at each admission to the Robina and Gold Coast hospitals
• the appropriateness of the way the patient’s treatment was managed by the Robina and Gold Coast hospitals.

After reviewing and analysing the evidence, the Health Ombudsman determined that the overall clinical coordination, treatment and care provided to the patient by the Robina and Gold Coast hospitals was adequate. The Health Ombudsman noted that given the clinical complexity of the patient’s multiple presentations, and the fact that no individual health practitioner was identified as exhibiting unsatisfactory professional performance in this matter, that no further action should be taken in regard to the matter.