Decision Report 201704145

Summary

Ms C complained about the medical care and treatment and the nursing care provided to her late mother (Mrs A) at Royal Alexandra Hospital. Mrs A was admitted to the hospital with a urinary infection. Mrs A was discharged from the hospital and readmitted within a few hours. Mrs A had a seizure while in hospital and sustained a broken leg.

We took independent advice from a consultant in acute medicine. While the board provided reasonable medical care in a number of areas, we found that the board failed to:

• take steps to increase Mrs A's sodium levels and monitor the effect of this on her delirium prior to discharging her

• ensure that Mrs A received a prompt review from medical staff following her seizure

• administer anti-seizure medication to Mrs A because stocks were not available on the ward

• ensure that Mrs A's records made it clear that she had a fractured leg

We also took independent advice from a nursing adviser. In relation to Ms C's complaint that the board did not provide reasonable nursing care to Mrs A, we found that there were a number of failings. In summary the board failed to:

• ensure the recording regarding Mrs A fluid and nutritional needs followed the appropriate policy and guidance

• record the use of a red silicone mat at mealtimes

• record the date Mrs A's special diet was ordered

• record Mrs A's oral care needs and what oral care was provided

• record Mrs A's episodes of pain

• record Mrs A's specific personal care needs and the frequency that personal care was required in her care plan

• complete a multidisciplinary moving and handling care plan

• involve Mrs A and her family in the assessment and care planning process

• record the physical assessment carried out by nursing staff following Mrs A's seizure

• update Mrs A's care plan to detail what her post-fracture needs were.

In view of these failings we upheld Ms C's complaints that the board did not provide reasonable medical care and treatment and nursing care to Mrs A. We also found that the board did not identify these failings during their own investigation of Ms C's complaints and made recommendations in light of this finding.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients with low sodium levels should not be discharged without attempts to increase them.
• Patients who have a seizure should be reviewed promptly by medical staff.
• Where prescribed medication is not available on the ward, this should be obtained from another ward or the pharmacy and administered accordingly.
• Fractures should be recorded clearly in patient medical records.
• Patients should receive adequate nutritional, hydration and oral care assessment and care planning in accordance with the relevant standards.
• Patient food and fluid recording charts should be completed in line with policy and guidance.
• Nursing assessments and care plans should clearly document the care needs of patients and what care has been provided.
• Where appropriate, assessments, care plans and reviews of care should be completed in collaboration with patients and their family members.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified and enable learning from complaints to inform service development and improvement.

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.