Decision Report 201700481

Summary

Miss C complained about care and treatment provided to her late mother (Mrs A) at Queen Elizabeth University Hospital. Miss C complained that both the nursing and medical care and treatment provided to Mrs A were unreasonable.

We took independent nursing advice. We found that, whilst a number of aspects of nursing care and treatment were reasonable, there was a failure by staff to discuss continence issues with Mrs A. We also found that nursing staff failed to complete fluid balance documentation fully and accurately, and failed to appropriately complete pressure ulcer risk assessments. We also found that there were issues with infection prevention and control. We upheld Miss C's complaint about the nursing care and treatment provided to Mrs A.

We also took independent advice from a consultant physician. We found that some aspects of medical care and treatment provided to Mrs A had been reasonable, however we determined that the frequency of dosing of morphine (a pain relief medication) was unreasonable and failed to take into account Mrs A's kidney function. We also found that there was a failure to document Mrs A's adverse reaction to tramadol (a pain relief medication) appropriately. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to provide a reasonable standard of nursing and medical care and treatment to Mrs A. The apology should meet the standards set out in the SPSO guidance on apology, available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• When a patient has continence issues, these should be discussed with them and their continence should be assessed. They should be assisted to manage any issues in a way that protects and promotes dignity, in line with the Nursing and Midwifery Code.
• Fluid balance charts should be fully completed when required.
• Pressure ulcer risk assessments should be completed when required.
• Infection prevention and control guidance, such as the Healthcare Improvement Scotland standards for Healthcare Associated Infections, and the National Institute for Health and Care Excellence quality statement on Vascular Access Devices, should be followed.
• Kidney function should be considered when prescribing morphine.
• If a patient suffers a reaction to medication, this should be documented.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.