Decision Report 201802724

Summary

Mrs C, an advocate, complained on behalf of her client (Mrs B) about the medical and nursing care that Mrs B's late husband (Mr A) received at Wishaw General Hospital.

Mrs B was concerned that a urine sample was not taken around the time Mr A was admitted to hospital; that sepsis may not have been treated properly; that staff did not recognise the severity of a fall Mr A sustained; and an opiate painkiller was not given at a particular time. Mrs B was also concerned that; no falls assessment was carried out and wheelchair transportation was inappropriate after Mr A's second fall; record-keeping regarding a fall was contradictory and did not capture the severity; intravenous paracetamol should have been given instead of oral paracetamol; and Mr A's blood pressure and heart rate were not properly monitored.

We took independent advice from a GP consultant and from a registered nurse. We found that there was a failure to take a urine sample which the board had accepted and apologised for. However, overall we did not identify any significant failings in Mr A's medical care and did not uphold this aspect of the complaint.

However, we found that it was unreasonable that Mr A was not transported by trolley to have his scan carried out and that there was a failure to escalate his worsening blood pressure reading to medical staff. Therefore, we upheld the complaint that Mr A's nursing care was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to escalate Mr A's blood pressure reading to medical staff; and for not transporting Mr A by trolley for his scan. 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 comply with the board's policy on deteriorating patients and NEWS escalation.
• Nursing staff should ensure that appropriate consideration is given to a patient's transportation following falls.

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.