Decision Report 201405868

Summary

Mrs C raised a number of issues about the care and treatment her late mother (Mrs A) received during a number of admissions to Glasgow Royal Infirmary during 2013 and 2014.

During our investigation, we took independent advice from a nursing adviser and a physician and orthogeriatrician (who specialises in the care of elderly patients with conditions involving the musculoskeletal system) who has experience in the assessment and management of a range of medical problems. While some aspects of the care and treatment Mrs A received during the various admissions was reasonable, we identified a number of concerns. In particular, in relation to her first admission to the hospital, the physician and orthogeriatrician adviser found no evidence that an appropriate multi-disciplinary assessment had been carried out to ensure a safe discharge home. The physician and orthogeriatrician adviser and the nursing adviser also had concerns about the adequacy of record-keeping by both medical and nursing staff in relation to a number of the admissions. In relation to Mrs A's second admission, we noted that the board accepted there had been a delay in diagnosing a fracture to Mrs A's wrist. We were critical of this delay.

We were also concerned that Mrs A experienced delays when she had to again attend the hospital. In addition, the advice we received and accepted from the physician and orthogeriatrician adviser was that an earlier ultrasound would have been more appropriate management, and the use of diuretics during Mrs A's fourth admission to the hospital would not generally be regarded as appropriate.

We upheld several aspects of the complaint and made a number of recommendations to address the failings.

Recommendations

We recommended that the board:

• apologise for the failings we identified;
• remind staff of the need to carry out an appropriate multi-disciplinary assessment to ensure safe discharge;
• consider the nursing adviser's comments about the standard of record-keeping and provide details as to how improvements to nursing documentation will be implemented;
• consider the suggestions made by the physician and orthogeriatrician adviser in relation to the need for attention to be given to the process of review of x-rays and report back to us on any further action taken;
• consider this case to see if any further lessons can be learned and report back to us on any action taken;
• take steps to ensure that medical staff are complying with Records Management: NHS Code of Practice (Scotland); and
• bring the physician and orthogeriatrician adviser's comments about the timing of ultrasounds and the use of diuretics to the attention of relevant staff and report back to us on any action taken.