Decision Report 201508646

Summary

Mrs C's mother (Mrs A) was admitted to Raigmore Hospital with a broken arm. Mrs A was transferred to Nairn Town and County Hospital six days later for rehabilitation and discharged home. During this period, Mrs C became concerned that Mrs A had broken her arm again and complained about a number of aspects of the discharge arrangements including the inadequacy of the discharge package. Shortly after her discharge home, staff decided to place Mrs A in a care home because it became apparent that the discharge package was insufficient to help her remain at home safely. Mrs A returned home six weeks later but was later readmitted to Raigmore Hospital, where she died. Mrs C was also concerned that district nursing staff had failed to successfully treat Mrs A's pressure ulcer. Finally, Mrs C complained that the board failed to provide her with a full copy of their internal review of the discharge.

We took independent advice from an orthopaedic adviser and a nursing adviser. We found that the medical care and treatment was reasonable, including the decision to treat the fracture conservatively (giving no medical treatment involving radical therapy or an operation), and that while the fracture did not heal as expected, this did not indicate a further fracture or an unreasonable standard of care. We also found that the pressure ulcer care was reasonable, as was the decision to send a summary of the key findings of the internal review to Mrs C. We therefore did not uphold these aspects of Mrs C's complaints. However, in relation to the discharge we found significant failings around discharge planning and the subsequent package, which meant that Mrs A had to be transferred to a care home for a short period. We therefore upheld this complaint. However, in light of the actions already taken by the board to address these failings, and their acknowledgement and apology to Mrs C, we made no recommendations.