Decision Report 201403176

Summary

Ms C complained about the care and treatment her late father (Mr A) received at the Royal Northern Infirmary. She said the board failed to provide adequate nursing care for her father and unreasonably failed to diagnose his broken collarbone and stroke.

We obtained independent advice on the case from a nurse adviser and a GP adviser. Our nursing adviser said Mr A's fluid balance and food intake, repeat fall assessments and care planning fell short of what should have been in place. However, she said that even if these areas of Mr A's care had been up to standard, the outcome may not have changed. Our adviser said the board's response to Ms C's complaint was poor and she would have expected the board to have recognised their shortcomings, and to have apologised and ensured lessons had been learned.

Our GP adviser said there was documented evidence in Mr A's medical records of a review of his condition after each of his falls by a clinical member of staff. She noted that the documentation of the examination and assessment was thorough and of a reasonable standard. She said the doctor who attended to Mr A noted his on-going confusion, poor mobility and number of recent falls. The doctor identified that Mr A's condition had deteriorated and arranged transfer to Raigmore Hospital for further investigation. The doctor also identified that Mr A may have had a stroke and correctly referred him to Raigmore Hospital for a scan. Our adviser said this was reasonable management and was in accordance with relevant guidelines.

Recommendations

We recommended that the board:

• feed back our decision on this case to the nursing staff involved;
• remind their nursing staff about the importance of falls assessment and care planning; and
• provide Ms C with a written apology for the failings identified.