Decision Report 201702378

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) while she was a patient at two different hospitals. Mrs A was admitted to University Hospital Crosshouse with a hip fracture following a fall at home. Mrs A was then transferred to Ayrshire Central Hospital for rehabilitation and physiotherapy. While she was there, Mrs A had a fall and hit her head. Mrs A was then transferred back to University Hospital Crosshouse. Mrs C was concerned about the medical treatment Mrs A received at University Hospital Crosshouse and the nursing care she received at Ayrshire Central Hospital.

Regarding Mrs A’s medical treatment, Mrs C complained about the length of time it took the board to carry out a test to see if Mrs A had deep vein thrombosis (DVT, a blood clot in a vein). We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the board did not consider the cause of Mrs A’s initial fall and that Mrs A was not seen by a geriatrician during her first admission. We found that there was an unreasonable delay in ordering and performing a scan of Mrs A’s leg. When it was suspected that Mrs A had a clot in her leg, Mrs A’s dose of dalteparin (medication that helps to reduce the risk of blood clotting in the legs) was increased from a preventative dose to a treatment dose. Mrs A received clopidogrel (medication to prevent clots that cause strokes and heart attacks) at the same time as the treatment dose of dalteparin. We found that it was unreasonable that Mrs A’s clopidogrel medication was not stopped at the same time that the dose of dalteparin was increased. We upheld this aspect of Mrs C's complaint.

Mrs C had a number of concerns about the nursing care provided to Mrs A, in particular about the communication from nursing staff, that Mrs A’s care needs and preferences were not taken into consideration, that adequate pain relief was not provided to Mrs A, that steps were not taken to prevent her from having another fall and that the action taken by nursing staff following her second fall was not appropriate. We took independent advice from a nursing adviser. We did not find evidence that the communication from nursing staff was unreasonable. We found that the nursing care regarding pain relief, falls prevention, and the action following Mrs A’s second fall was reasonable. However, we found that the board failed to document Mrs A’s care needs and preferences in her assessment and care plan documentation as well as follow the instructions in Mrs A’s “Getting to Know You” document. Therefore, we upheld Mrs C’s complaint. We noted that the board had already acknowledged and apologised that there was a failure to follow the instructions in Mrs A’s “Getting to Know Me” document.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to consider the cause of Mrs A's fall, that Mrs A was not seen by a geriatrician, the delay in ordering and performing the scan, the delay in stopping the clopidogrel medication, the failure to follow the instructions in Mrs A's “Getting to Know Me” document and the failure to record Mrs A's care needs and preferences. 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:

• Where a treatment dose of dalteparin is prescribed, appropriate adjustments should be made to any other medication prescribed to the patient. Patients should receive appropriate scans in a timely manner when DVT is suspected. Where patients have fallen and are unable to give an account of the reason for their fall, medical staff should carry out appropriate checks to try and determine the cause of the fall. All patients over the age of 65 presenting with a fragility fracture should have routine access to acute orthogeriatric medical support (orthopaedic care for elderly patients) in line with national guidance.
• Nursing assessments and care plan documentation should clearly document the care needs and preferences of patients.

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.