Decision Report 201705362

Summary

Mrs C complained to us about the nursing care and treatment her mother (Mrs A) had received at the Western General Hospital after she had fallen and injured her head. Mrs C, who had power of attorney for Mrs A, was concerned about the nursing care she received. Mrs C had particular concerns about her falls care and monitoring; pain relief; personal care and hygiene; and the communication with Mrs A. Mrs C also had concerns about a lack of response to Mrs A's weight loss and to her swollen leg.

We took independent advice from a nurse. We found that there was a failure to prepare timely and comprehensive care plans in relation to Mrs C's care needs, and to review the ongoing effectiveness of those care plans. We found that this should have been carried out with the appropriate involvement of Mrs C and her powers of attorney but there was no evidence that this had been done. We also found that there were failings in the board's records-keeping, as there were gaps in completing care round checklists which were sometimes not completed fully. We upheld Mrs C's complaint.

We noted that the board did not identify the failings we found in the nursing care provided to Mrs C. In addition, the board did not provide us with all relevant documentation at the appropriate point in our investigation. Therefore, we made recommendations in relation to their complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in the nursing care Mrs A received.

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

• Patients should have comprehensive nursing assessments and clear care plans in place, which are regularly reviewed, to facilitate consistent and person-centred care, with the appropriate involvement of patients and their powers of attorney.
• Care round checklists should be completed consistently and fully.

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.
• The board should ensure that clinical evidence demonstrating the treatment and care provided is provided at the appropriate point in an SPSO investigation.

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.