Decision Report 201800954

Summary

Mrs C complained about the care and treatment provided to her late father (Mr A) during an admission to Glasgow Royal Infirmary. At the time, Mr A had a long standing cardiac and respiratory (heart and lung) illness and was admitted with a chest infection, shortness of breath, confusion and hallucinations.

We took independent advice from a consultant in respiratory medicine. We found that many aspects of the care provided were reasonable. However, we found no evidence that an inhaler review had been appropriately performed or planned. On balance, we upheld this aspect of Mrs C's complaint.

Mrs C also had concerns about the nursing care provided to Mr A, and the way in which his discharge was handled. We took independent advice on these matters from a registered nurse. We found that the dietary monitoring performed was reasonable and we found no failings in the way nurses interacted with Mr A. We concluded that the nursing care provided was reasonable. Similarly, we were not critical about the way Mr A's discharge was handled. We found no evidence of unreasonable failings and concluded that the handling of the discharge was reasonable. We did not uphold these complaints.

Finally, Mrs C complained about the way her complaint was investigated by the board. We did not find failings in the way the board investigated or responded to the complaints raised. However, we found that the board did not update Mrs C about the delay in responding to her, in accordance with the NHS Scotland Complaints Handling Procedure. On balance, we upheld this aspect of the complaint but noted that the board had already apologised for this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that an inhaler review was not performed during the admission or planned. 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 patient suffers repeat significant disabling breathlessness attributable to chronic obstructive pulmonary disease, inhaler assessment and medication review should be undertaken or planned.

In relation to complaints handling, we recommended:

• Where a complaint response cannot be provided within 20 working days, the person making the complaint should be updated on the reason for the delay and be given a revised timescale for completion. Delays in investigation should be minimised.

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.