Decision Report 201401890

Summary

Ms C raised a number of concerns about the care and treatment her father (Mr A) received at Biggart Hospital. Mr A had been transferred from another hospital for rehabilitation after he suffered a fracture to his right upper arm after a fall.

We took independent advice on the case from a medical adviser and a nursing adviser.

The medical adviser considered that while communication between ward staff and the fracture clinic fell below a reasonable level, the board had acknowledged this and apologised. The medical adviser said the length of Mr A's stay at the hospital was reasonable, based on the injury he had suffered and his particular circumstances. The medical adviser considered the initial assessment of Mr A's chest fell below a reasonable standard because, although in their complaints response the board stated that this was to treat a chest infection, Mr A's medical records did not record why he was prescribed antibiotics and how this treatment would be reviewed.

The medical adviser and the nursing adviser both considered that further investigation and assessment should have been made when swelling to Mr A's leg was identified by nursing staff.

The advisers also said that Mr A had not been provided with a reasonable amount of physiotherapy treatment and there was a lack of provision of physiotherapy for Mr A on weekends and bank holidays. They also considered the amount of occupational therapy provided to Mr A was below a reasonable level. Although the board had apologised to Ms C that the level of support fell short of her expectations, the medical adviser was critical of the board's failure to acknowledge that a lack of staff time and workload commitments had impacted on the service Mr A received.

Recommendations

We recommended that the board:

• feed back the findings about Mr A's swollen leg to the staff involved, for reflection and learning, including reminding nurse practitioners to highlight abnormal clinical findings to medical staff;
• feed back the failures in relation to record-keeping to the staff involved, for reflection and learning;
• provide evidence of the review of physiotherapy staffing levels and provision of their services;
• consider and report on steps taken to address the failings in provision of occupational therapy identified by this investigation; and
• issue a general written apology to Ms C, acknowledging the failings identified in this investigation.