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Case ref:201005181
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Date:June 2012
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Body:Greater Glasgow and Clyde NHS Board
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Sector:Health
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Outcome:Some upheld, action taken by body to remedy, no recommendations
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Subject:clinical treatment; diagnosis
Summary
Mrs C complained about the care and treatment provided to her mother (Mrs A) in hospital. Mrs A had dementia and was admitted to hospital after a neighbour found her wandering the streets in her nightclothes. Mrs C said that her mother did not have capacity to make decisions about her own healthcare. However, we found that there was no clear statement about this in Mrs A's case records. We also found that the board's use of Adults with Incapacity documentation (which is about treating patients who are unable to give consent) was also below a standard that could be reasonably expected.
We upheld this complaint, although we acknowledged that the board had taken action in response to it. They had compiled a learning plan for the ward as there was a clear requirement to increase staff knowledge of the Adults with Incapacity framework. The board also apologised to Mrs C for these failings.
Mrs C also complained about the medication administered to her mother. Mrs A's family had felt that she was being over-sedated and took her home against medical advice. Mrs C complained that the board failed to put a discharge plan in place to ensure that Mrs A received appropriate medical treatment and support in the community. We found that it would be unreasonable to criticise the board for this, given the irregular nature of the discharge. However, we felt that the board could improve the irregular discharge form, by amending it to indicate the status of the person signing on behalf of the patient.
Our investigation found that the drugs chosen and used were standard and reasonable. However, we found that the board failed to involve the family in the decision to prescribe and administer some of the medication, as they should have done in line with the Adults with Incapacity legislation. In addition, the reason for this medication being used was documented inconsistently and in insufficient detail. We upheld the complaint. However, as the board had apologised for the problems we identified and had taken action to try to prevent them from occurring again, we had no recommendations to make.