That was the stark message from the Northern Ireland Public Service Ombudsman following an investigation into the death of an elderly lady in the hospital (in Ward 1 South at Craigavon Area Hospital). The report has just been made public - with a far reaching recommendation calling for progress towards the goal of maintaining a single patient record for all patients in Northern Ireland. The Ombudsman stated the patient had died in a ‘malnourished state’, having been “without adequate nutrition for...just over a month”, an attempt was made to insert a Nasal Gastric tube without permission and that no record had been made of the attempt (contrary to nursing standards) and the Trust had not taken account of the patient’s rights. In her report the Ombudsman, Marie Anderson, said: “I received a complaint regarding the actions of the Southern Health and Social Care Trust in relation to the care and treatment the complainant’s mother received while a patient in Craigavon Area Hospital. The complainant had complained to the Trust on 30 April 2015 but remained dissatisfied with its response. “I investigated the complaint and found failures in a number of areas. In particular, I found that there were delays in arranging a Speech and Language Therapist (SALT) and dietician referral and inadequacies in nutritional and nursing care and treatment. “I also made a finding of maladministration in regard to record keeping. “As a result of these failings, I am satisfied that the complainant suffered the injustice of loss of opportunity, upset, distress and discomfort. I am also satisfied that the complainant and her family suffered the injustice of upset, distress, uncertainty and frustration.” The Ombudsman noted: “I consider the failure to record that an attempt was made to NG tube feed... without sedation to be inappropriate and unreasonable and not in line with good nursing practice. I also consider the failure in record keeping to be contrary to NMC standards and to constitute maladministration. “I have considered the detail of the complaint. In particular that a nurse undertook the NGT without sedation. On the balance of probability, I find that the nurse undertook this intervention. I consider the patient to have suffered the injustice of pain and discomfort during the attempt to insert an NG tube without sedation. “I also consider the complainant to have suffered the injustice of uncertainty and frustration as a result of the incomplete record and subsequent confusion and misinformation about what care and treatment her mother was afforded on [that morning]. Therefore, I uphold this element of the complaint. The report stated: “The complainant complained to my office about the nutritional care and treatment and nursing care and treatment her mother had received in Craigavon Area Hospital. “I consider the Trust’s delay in providing adequate nutrition to the patient, without recording the rationale for not doing so, failed to meet NICE guidance and GMC guidelines.” “In reaching my conclusion I have carefully considered all of the issues in the complaint. I have also considered the Trust’s responses, the patient’s medical notes and records and the advice of a number of IPAs. In considering the injustice experienced by the complainant and her mother, I have taken into account her letter of complaint where she has described the upset and distress her mother and her family experienced in the last weeks of her mother’s life.” The report went on: “I consider that in attempting to insert a NG tube without sedation against the patient’s stated wishes and in failing to address her nutritional needs in a more timely manner, the Trust did not have sufficient regard for her rights.” The report pointed to the ‘malnourished state’ in which the lady died: “Based on the clinical advice, I conclude that, given... significant co-morbities and frail health, earlier intervention may not have prevented the sad outcome of the patient’s death. However. I consider that appropriate and timely intervention may have alleviated her discomfort and distress in the last weeks of her life. “I am mindful also of the distress of her family who witnessed their mother dying in a malnourished state. “I note that the complainant seeks an improvement in patient care. I sincerely hope that, on reading my findings and recommendations, the complainant and her family will be reassured that their main issues of concern have been carefully and fully investigated, and further that the Trust will have learned important lessons from this complaint to the benefit of patient experience in the future. “From my investigation of the complaint I have found failures in care and treatment with regard to the triaging of the SALT referral, failure to provide adequate nutritional care and treatment to the patient, and failings with regard to some aspects of nursing care and treatment. I have also identified instances of inadequate record keeping which constitutes maladministration. I consider that the Trust had a number of opportunities to provide adequate and timely nutritional care and treatment to the patient. “In this respect her medical team failed to supplement her nutrition at an earlier stage. I am satisfied that, as a result of these failings, she suffered the injustice of loss of opportunity, upset, distress and discomfort. I am also satisfied that the complainant and her family suffered the injustice of upset, distress, uncertainty and frustration in dealing with these issues. I uphold these issues of complaint.” In her most far reaching conclusion she noted: “I have observed that the main dietetic notes are held separately from the clinical and nursing notes and that this may have been a factor which contributed to the failings I have identified in this case. I therefore ask the Trust to report to me on progress towards the goal of maintaining a single patient record for all patients in Northern Ireland.” A spokesman for the Southern Health and Social Care Trust said: “The Trust has taken all appropriate action in relation to the recommendations made by the Ombudsman in the recent NIPSO investigation report. A letter of apology (and payment) was sent to the family and failings identified in the report will be shared with relevant staff for learning and improvement.” The ‘solatium payment’ made was £750.