Decision Report 201608588

Summary

Mr C complained about the clinical and nursing care and treatment given to his late mother (Mrs A) while she was a patient at Royal Alexandra Hospital. Mr C also complained that there was a failure to notify him of Mrs A's deteriorating condition.

We took independent advice from a nurse and a consultant physician. We found that falls assessments were not undertaken as they should have been and that Mrs A had not been provided with the walking frame that she required. We also found that Mr C was alerted neither to Mrs A's deteriorating condition nor to her fall and the injuries she suffered as a result. Similarly, Mr C appeared not to have been told of Mrs A's low sodium which was likely to have contributed to her fall and agitation. Therefore, we upheld these aspects of Mr C's complaint.

In relation to clinical treatment, we found the care to be reasonable. We did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to alert him to Mrs A's deteriorating condition and to her fall and injuries, as well as the failure to advise of her poor prognosis. 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:

• Where a fall occurs, relatives should be alerted in a timely way. Similarly, they should be informed where a poor prognosis is anticipated.
• Medical staff require to communicate effectively with ward staff about the seriousness and risk of common metabolic problems.

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.