Decision Report 201301582

Summary

Miss B and Miss C complained that the nursing and physiotherapy care and treatment given to their mother (Mrs A) in hospital was inadequate. They said that although their mother had advanced dementia she had been living an active life. Although not independent, she had been fully mobile unaided, eating by herself, interested in her surroundings and reading and talking. However, after she was discharged from hospital she had a urine infection and pressure ulcers on her heels. She was immobile, and no longer able to swallow tablets or eat solid food. She also took little notice of her surroundings and did not talk. Her daughters believed that this was a result of what happened in hospital.

Our investigation considered all the relevant documentation, including the complaints correspondence and Mrs A's medical records. We also obtained independent advice from two of our advisers (a nursing adviser and a physiotherapist). We upheld the complaint, as our investigation found that there were aspects of Mrs A's care and treatment that were unsatisfactory. A care plan should have been put in place when Mrs A's heels became discoloured. Although we found no evidence that Mrs A developed a urine infection while in hospital, we found that her medical records lacked detail. The content of the physiotherapy treatment provided was appropriate, but the frequency of treatment was not. It was not in accordance with Scottish Intercollegiate Guidelines Network (SIGN) guidelines and was inadequate, although our adviser noted that the outcome was unlikely to have been different even with more sessions. We also found that Mrs A's overall management and treatment lacked documented evidence of planning and what was done. There was also no documented evidence of discharge planning or contact with community physiotherapy about follow-up treatment.

Recommendations

We recommended that the board:

• provide the Ombudsman with a copy of the board's own implementation plan relating to the national standards for dementia care implemented in 2011;
• undertake an audit of current practice of skin care in the hospital and report back to the Ombudsman;
• provide the Ombudsman with a copy of an action plan to illustrate learning from this complaint in relation to the prevention and management of pressure ulcers;
• provide the Ombudsman with a copy of an action plan to address the failings identified in relation to medical records;
• apologise to Miss B and Miss C for the failings identified;
• review their processes to ensure that they meet relevant standards;
• remind physiotherapy staff of the need to maintain full and accurate records in line with the Chartered Society of Physiotherapy guidance; and
• bring the issues raised in this complaint to the attention of the physiotherapy staff involved to see if lessons can be learned, and report back to the Ombudsman.