Decision Report 201700457

Summary

Miss C's mother (Miss A) had lung cancer which had spread to her brain. The steroid medication she was taking to alleviate the symptoms caused psychotic symptoms, requiring an admission to Dumfries and Galloway Royal Infirmary. One day when her family went to visit they were unable to find her. They subsequently found her in a stairwell, disorientated and upset. Miss C complained about the board's failure to ensure that Miss A did not leave the ward. She also complained that the board's complaints handling was unreasonable.

We took independent advice from a nursing adviser. The adviser highlighted the importance of the balance to be struck between weighing the risks of staff monitoring patients and promoting some independence and dignity. In their response to the complaint the board said that the ward was extremely busy and that, although staff did their best to ensure that vulnerable patients were monitored, they were extremely sorry and disappointed that on this occasion they were unable to prevent Miss A from leaving. We considered the board's response to the complaint to have been reasonable and did not consider that Miss A should have been under closer supervision. We did not uphold this aspect of Miss C's complaint.

We found the board's complaints handling to have been poor. The family's complaint was initially not taken forward because it was believed that Miss A's consent was required, and she lacked capacity to give consent. We found that the board failed to communicate their reasons for not taking the complaint forward, and did not investigate until the Patient Advice and Support Service became involved. We upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in their complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints handling staff should be confident about when consent is required before a complaint can be investigated. In this instance, matters could have been investigated without the need for Miss A's consent.

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.