Decision Report 201800972

Summary

Ms C complained about the nursing care provided to her father (Mr A) at Dumfries and Galloway Royal Infirmary. Ms C raised a number of concerns including:

• Mr A having suffered a fall that resulted in a wound to his arm;

• the suitability of his diet;

• his developing of a pressure ulcer;

• him not seeing a dietician and;

• poor record-keeping, specifically the failure to record her father's fall.

We took independent advice from a nurse. We found that risk assessments about the risk of developing a pressure ulcer and being nutritionally compromised had not been completed correctly. This resulted in Mr A not receiving adequate pressure ulcer prevention interventions and being assessed at a lower risk of being nutritionally compromised than he should have been. We also found that important records relating to fluid intake and weight were not kept up to date and that the board failed to follow their policy when they became aware of Mr A's fall. We considered the care and treatment Mr A received was unreasonable and upheld this complaint.

Ms C also complained about the board's responses to her complaints. Ms C was concerned about the tone of the board's response, whether the response reasonably addressed the complaints she raised, the time taken to respond and the efforts to communicate the response when it was clear Mr A was in the final days of his life. We found that the tone of the response had been reasonable but not all of the issues raised had been responded to and that some of those that were, were unreasonable. We found that the response had been provided within a reasonable timescale but the board had not acknowledged Ms C's complaints as they should have. We found that it was unreasonable for the board to have refused to read their decision letter, which was awaiting a final signature, to Ms  C over the telephone so she could communicate it to Mr A before he died. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide reasonable care to Mr A during his admission to hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for not responding reasonably to her complaints about Mr A's time in hospital. The apology should meet the standards 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:

• The board should ensure they are following the Healthcare Improvement Scotland Standards for Prevention and Management of Pressure Ulcers (2016). The standards clearly lay out what is expected in terms of leadership and governance; education, training and information; assessment of risk for pressure ulcer development; reassessment of risk; care planning for prevention and treatment and; assessment, grading and care planning for identified pressure ulcers.
• The board should ensure that they are following the Healthcare Improvement Scotland Standards for Food, Fluid and Nutritional Care.
• The board should ensure that all staff follow their Falls Risk Assessment policy.

In relation to complaints handling, we recommended:

• The board should appropriately respond to the points of concern within complaints. The board should ensure that each aspect of the correspondence is addressed.
• Complaints should be dealt with in accordance with the model Complaints Handling Procedure (CHP).

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.