Decision Report 201704209

Summary

Mr C, a solicitor, complained on behalf of his client (Mr B) about the care and treatment Mr B's mother (Mrs A) received at Stratheden Hospital after she broke her hip. Mr C complained that Mrs A did not get appropriate treatment for her physical health issues; in particular, that her condition was not appropriately monitored, which led to her becoming dehydrated. Mr C also complained about the nursing care, particularly that Mrs A did not receive appropriate nutritional care and that there was a lack of action in response to her weight loss. Additionally, Mr C raised concerns about the board's complaints handling.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that Mrs A's treatment plan was reasonable and that she received appropriate treatment for her physical health issues, which led to an improvement in her condition. However, we found that her fluid balance was not recorded appropriately during that time, as the board had acknowledged. We found that after Mrs A's condition improved, the board decided to take a more limited approach to her treatment. We considered that the reasons for that decision were not properly recorded, and Mrs A's condition was not monitored appropriately afterwards. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the nursing care provided to Mrs A, we found that insufficient action was taken in relation to her nutrition and weight loss. The board identified these failings and apologised to Mr B. We upheld this aspect of Mr C's complaint.

Finally, we found that the board did not clearly respond to all aspects of Mr B's complaint. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for the failures to appropriately monitor Mrs A's condition, to record relevant information about her care and treatment, and for not providing a clear response to aspects of his complaint. 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:

• In similar cases, fluid balance sheets should be completed appropriately and in accordance with the board's procedure.
• If a decision is made to change the treatment plan for a complex patient, the clinical reasons should be clearly recorded, along with the parameters of what that means for managing their condition.
• Nutritional screening should be carried out promptly and patients should receive effective nutritional care, which is in line with the relevant national nutritional guidance.

In relation to complaints handling, we recommended:

• Complaint responses should be clear to avoid any misunderstandings and the issues should be thoroughly investigated.

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.