Decision Report 201704127

Summary

Mrs C complained about the care and treatment provided to her late mother (Ms  A) at Woodland View. Ms A was transferred there for rehabilitation after several weeks in hospital, where she was treated for recurrent urinary tract infections (UTIs), and delirium. Ms A suffered further UTIs and did not make progress with her medication. She was transferred to a mental health ward for treatment of her delirium, low mood and physical symptoms. Ms A also had a background history of bipolar disorder (a mental health condition marked by alternating periods of elation and depression). Ms A's condition deteriorated further and she was transferred back to hospital with aspiration pneumonia (a  type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). She was given palliative care and died in hospital.

Mrs C complained that there was inadequate care planning to manage Ms A's delirium and UTIs. She felt staff focussed on Ms A's age and bipolar disorder as an explanation for her condition and did not fully appreciate the impact of the UTIs and delirium. Mrs C was also concerned about the way the hospital and ward transitions were managed, and about Ms A's overall care and treatment. Mrs C said she was not involved in care planning and decisions, despite being Ms A's carer and welfare power of attorney, and she felt some nursing staff were hostile or resistant when she made suggestions for Ms A's care. The board met with Mrs C when she first complained (during Ms A's admission) and a number of actions were agreed, but Mrs C said these were never completed. The board also gave a written response to Mrs C's later complaint (following Ms A's transfer back to hospital). Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse. We found there was a lack of proactive care planning for Ms A's UTIs and delirium at times, and Ms A had also had an untreated UTI for about ten days. While we did not find evidence that staff were hostile or lacked compassion, we found that Mrs C was not always included in care planning for her mother, and there were not always clear and comprehensive records of communication. We also found that the board did not have evidence to show they had fully followed through on some of the actions agreed at the complaint meeting. We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in care planning, communication and complaint handling. 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:

• Where a patient suffers from recurrent urinary tract infections and/or delirium, there should be dedicated care planning to address this (and this should be carried over where a patient changes wards).
• The patient's carer or welfare power of attorney should be fully and proactively involved in care planning.

In relation to complaints handling, we recommended:

• Any actions agreed following a complaint should be completed.
• Where a complaint investigation finds that errors or failings have occurred (although not in relation to the specific complaints raised), the board should still acknowledge and apologise for this.