Decision Report 201706201

Summary

Ms C complained about the care and treatment her late brother (Mr A) received at Glasgow Royal Infirmary. Mr A had previously suffered a brain injury and required to be managed under the Adults with Incapacity Act 2000. Mr A had difficulty swallowing and was considered unsafe for all food by mouth. Although Mr A required to undergo a number of investigative procedures, these could not be carried out due to his reluctance. Mr A also fell twice and after Ms C raised concerns with staff, he was later found to have broken his hip for which he required surgery. Before this could be carried out, Mr A suffered a heart attack and died a few days afterwards. Ms C complained that the gastroenterology (digestive system), nursing, orthopaedic (musculoskeletal system) and cardiology (heart and circulatory system) care and treatment Mr A received was unreasonable.

We took independent advice from consultants in acute care, orthopaedics and cardiology and from a registered nurse. We found that the team looking after Mr A struggled to balance the need to perform interventions with a desire not to treat him forcibly or against his will. We considered that the gastroenterology care Mr A received was reasonable. Mr A's cardiology treatment was also found to be reasonable. Therefore, we did not uphold these aspects of Ms C's complaint.

In relation to Mr A's nursing care, we found that he was not properly supervised and a number of nursing procedures were not correctly followed or recorded. In particular, despite being unsteady on his feet, he was sent for x-ray unsupervised and he fell. This incident was not recorded or followed-up as it should have been. After this fall, we found that the orthopaedic care was poor and there was a delay in planning the surgery required which was contrary to national guidelines. We considered the nursing care and orthopaedic care to be unreasonable and, therefore, we upheld these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to properly follow procedures, to keep full records and notes and for the delay in proposed surgery. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• All nursing records should be completed as appropriate in accordance with the requirements of the Nursing and Midwifery Council.
• Patients should undergo surgical intervention within 48 hours in line with national guidelines.