Decision Report 201305212

Summary

Mrs C complained that the board failed to take reasonable steps to mobilise her father (Mr A) during his stay in the Western General Hospital.

During our investigation, we took independent advice from three of our medical advisers, a consultant physician, a physiotherapist and a nursing adviser, after which we upheld Mrs C's complaint. The consultant physician said that the medical care Mrs C's father received was generally of a high standard and that the decision to discharge him had been reasonable. However, we were concerned that there was no reference in Mr A's medical records to the decision to prescribe him a second antidepressant. In addition, the physiotherapist said that Mr A did not appear to have received much in the way of mobility input during his first month in hospital and that physiotherapy care fell below what would be considered an acceptable standard. Physiotherapy treatment received later was, however, appropriate and acceptable.

There also appeared to be a lack of communication between physiotherapy, the medical team and the nursing team and a lack of coherent mobility planning involving the whole multi-disciplinary team. Our nursing adviser said that, while some aspects of Mr A's nursing care were reasonable, there were some failings in relation to record-keeping which made it difficult to establish some key aspects of the care provided, particularly in terms of his mobilisation and his confusion.

Recommendations

We recommended that the board:

• ensure that relevant staff members are made aware of our adviser's comments in relation to the use of a formal depression score to aid decision-making around antidepressant treatment, and given the opportunity to reflect on these for their future practice;
• 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 us;
• consider including a section on mobility on the standard care plan;
• ensure that our adviser's comments about the lack of communication between physiotherapy and the medical and nursing team and a lack of coherent mobility plan involving the whole multi-disciplinary team are brought to the attention of the relevant staff;
• provide evidence of the systems in place to monitor the standard of record-keeping in relation to nursing and physiotherapy care, to ensure that assessment, care planning and evaluation of care delivery does reflect individual care needs; and
• apologise for the failings identified.