Decision Report 201704861

Summary

Mr C complained on behalf of his mother-in-law (Mrs B) about the care and treatment provided to her husband (Mr A) at Raigmore Hospital. Mr C complained that the board failed to manage Mr A's falls risk appropriately and failed to provide a reasonable standard of oral and nutritional care to Mr A.

We took independent advice from a nursing adviser. We found that Mr A sustained seven falls during his admission, with the last fall resulting in him suffering a serious injury. The board had apologised for this and the lack of communication by their nursing team on some occasions, and we acknowledged the action that the board said they had taken to address this. However, we found that there were additional failings and an unreasonable level of care provided to Mr A not identified by the board. We noted that there appeared to have been a lack of action and a failure in record-keeping in relation to the management of Mr  A's falls risk. We considered that the supervision provided was unreasonable and highlighted that there was no person-centred care plan provided to record the management of Mr A's falls risk and interventions in place to reduce the risk of falls, or the level of observation he required. In addition, communication with Mr A's family was unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

In relation to Mr A's oral and nutritional care, the board accepted that this was not of an acceptable standard and apologised. We found that there were shortcomings in the assessment and management of Mr A's nutritional needs and in record-keeping. Although staff made urgent referrals to the dietician, Mr A did not appear to have been treated as a priority. We also found no evidence that Mr A's oral care needs were met. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B and her family for the unreasonable level of care provided to Mr A in relation to falls sustained by Mr A, his nutritional and oral care, record-keeping and communication with Mrs B and her family. 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:

• Patients at high risk of falls should have their falls risk appropriately managed.
• Nursing records should be maintained in accordance with the nursing and midwifery code of practice.
• Patients should have their nutritional and oral care appropriately assessed and managed.
• There should be adequate communication with a patient's family and this should be appropriately documented.