This report outlines the investigation conducted by the Health Ombudsman into a complaint from a complainant about the standard of care that her father (the patient) received at Rockhampton Hospital between July 2013 and his death in August 2013.

The patient suffered from multiple health problems, including severe chronic obstructive pulmonary disease and right-sided heart failure (right ventricular failure). He died after developing haemorrhagic shock following a bleed from an undiagnosed duodenal ulcer.

The scope of the investigation was to determine whether (outcomes of the investigation are listed below each identified issue):

1. The clinical treatment provided to the patient at Rockhampton Hospital was appropriate
   Finding: Failings in the medical care afforded the patient were substantiated.
2. There should have been an available staff member to place an orogastric tube in the patient’s stomach in order to drain the bleeding
   Finding: Failings in the medical care afforded the patient were substantiated.
3. The patient’s pain management was appropriate
   Finding: Failings in the patient’s pain management were substantiated.
4. The quality of communication between the patient, his family and the nursing staff at the hospital was reasonable and appropriate
   Finding: The hospital acknowledged that the quality of communication between staff, patient and the family requires improvement.
5. The record keeping practices of associated practitioners were of a standard reasonably expected
   Finding: The standard of record keeping was below the standard reasonably expected.
6. The discharge and transfer arrangements were reasonable and appropriate
   Finding: The transfer from the ICU to the ward was below a standard reasonably expected.
7. The standard of care by the practitioners involved in the patient’s care was of a standard reasonably expected
   Finding: The issues identified were systemic and not the failing of individual health practitioners.
8. There are any areas for improvement within Rockhampton Hospital’s policies and procedures
   Finding: The hospital has recognised deficiencies in its systems.
9. This matter was identified as a reportable death by Rockhampton Hospital, and if it wasn’t, to determine whether it should have been
   Finding: Hospital staff contacted the Coroner as required.
10. Rockhampton Hospital has undertaken corrective actions in response to any systemic issues identified as a result of this complaint
    Finding: The hospital has recognised deficiencies in its systems and is taking action to respond to the issues.

As a result of the investigation, the Health Ombudsman made the following recommendations:

1. Rockhampton Hospital amend its Anticoagulants—safe use of policy, effective from 24 December 2014, to include the requirement to document within the nursing plan, prior to administration of the drug, the consideration of contraindications to administration of prophylactic anticoagulants.
2. Rockhampton Hospital develop, implement and evaluate a communication strategy to inform staff of the amendments to the Anticoagulants—safe use of policy.
3. Rockhampton Hospital undertake a baseline and follow-up audit to assess staff compliance with the amended Anticoagulants—safe use of policy.
4. Rockhampton Hospital report on the implementation status of all recommendations identified in the RCA report and provide evidence of implementation. Where not fully implemented, continue to implement or provide information on what alternative risk mitigation strategies have been put in place.

The Health Ombudsman is monitoring Rockhampton Hospital’s compliance with the recommendations.