Decision Report 201803694

Summary

Mrs C complained about the nursing care and treatment given to her late husband (Mr A) at Dumfries and Galloway Royal Infirmary. She also complained that communication by the board was poor.

Mr A had a complicated medical history. As he began to experience an increase in symptoms, he was admitted to hospital. Mrs C said that when she visited she found him in an undignified state. Later, she found that he had six stitches to a head wound, about which she had not been informed.

We took independent advice from a registered nurse. We found that the assessment taken on Mr A's admission noted that he could not properly answer questions to elicit information about his mental state, and that despite this, no further enquiries were made into whether or not he could be experiencing delirium, as was required. Similarly, despite his low score about his mental state, which should also have triggered a falls prevention plan and care plan, this did not happen. Mr A went on to fall twice, the second fall required him to have stitches. Furthermore although Mr A also appeared to be suffering delirium, the prescribed care for this was not evidenced in the nursing records and there were gaps in his care. We also found little record of conversations with Mrs C and she had not been told about his head wound until she visited him.

Given these failures, we upheld both aspects of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the identified failures in Mr A's care and treatment.
• Apologise to Mrs C for failing to communicate in a reasonable and appropriate way. 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 admitted to hospital should have falls risk assessments carried out in line with the Board's Falls Management Policy and assessments identified following review, carried out promptly. Nursing care provided to patients should be in line with the Nursing and Midwifery Code, particularly in relation to the importance of good record-keeping. Patients should receive medication as prescribed and this should be documented appropriately.
• Family members and carers, as appropriate, should be kept up-to-date about a patient's treatment and condition. Where specific and reasonable requests for meetings/discussions have been made, these should take place and be recorded.