Decision Report 201811034

Summary

Miss C complained about the care and treatment which her late father (Mr A) received at Forth Valley Royal Hospital. Mr A, who had a number of pre-existing health conditions, had been admitted after a fall as his general health had deteriorated. He was in pain and died not long after the admission. The family felt that there had been a lack of investigations by staff into a diagnosis and that they failed to appropriately manage Mr A's pain control or provide him with a reasonable standard of nursing care.

We took independent advice from a consultant physician and from a senior nurse. We found that while Mr A received a reasonable level of overall care, the management of his pain could have been better in that the rationale behind the decisions to change/amend medication for pain relief were not clear. The level of communication between the staff and Mr A's family could also have been improved. We upheld this aspect of the complaint.

In regards to the nursing care, we found that, although there was evidence of good care at times, there was also a failure by nursing staff to fully record Mr A's pain score and other charts which would have evidenced whether appropriate care had been given. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings in managing Mr A’s pain control and in communication with the family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Apologise to Miss C for the failure to record whether action was taken to address Mr A’s pain; nutrition and fluid balance needs. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• Staff should be aware of the importance of appropriately managing a patient’s pain control and ensuring that appropriate communication is given to family members.
• Staff should ensure that when action is taken to address patient needs that the appropriate records are completed in line with record-keeping guidelines.