-
Case ref:201802138
-
Date:October 2019
-
Body:Lothian NHS Board - Acute Division
-
Sector:Health
-
Outcome:Some upheld, recommendations
-
Subject:clinical treatment / diagnosis
Summary
Ms C complained about the care and treatment her late mother (Mrs A) received at the Royal Infirmary of Edinburgh. When Mrs A was admitted, it was recorded that she had known lung cancer and she was initially treated for pneumonia (inflammation of the lungs). It was subsequently planned that Mrs A would be discharged, but a CT scan showed that she had an accumulation of blood in her abdominal muscle. Mrs A later had a fall. She was monitored overnight, but died the following day.
We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the medical treatment provided to Mrs A had been reasonable. We did not uphold this aspect of the complaint.
Ms C also complained about the nursing care provided to Mrs A. We took independent advice from a nursing adviser. We found that there was no evidence of any failings that had led to Mrs A's fall in the hospital or that a specific injury sustained in the fall led directly to her death. A robust post falls assessment was also undertaken after the event, which did not indicate any specific injury.
Overall, the nursing care provided to Mrs A had been reasonable. However, there were gaps in the nursing notes provided. There was also a lack of evidence of communication with Mrs A's family. In addition, the board's response to Ms C's complaint did not address many of the points she had raised. Given these failings, we upheld this aspect of the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Ms C for the failure to provide evidence that nursing staff communicated with her appropriately. 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:
- Nursing staff should maintain records in line with the Nursing and Midwifery Council's guidance on record-keeping.
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.