Decision Report 201810022

Summary

C complained about various aspects of the care and treatment that their parent (A) received from the board.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly) and from a nurse. We found that A was unreasonably discharged from Victoria Hospital when they had an infection, which may only have been partially treated, and that there may have been uncertainty about the effectiveness of the antibiotics A was receiving. We also found that A did not receive medical reviews when their delirium was active; that there should have been an earlier assessment of the possibility that A had a chest infection; that A was discharged from Queen Margaret Hospital to a care home without a prescription for stronger pain medication; and that no nursing transfer letter or discharge summary was provided to the care home when A was transferred from Queen Margaret Hospital.

We upheld C's complaint that the care and treatment provided to A was unreasonable.

C also complained about the board's communication. We found that there was a failure to discuss A's transfer arrangements, ongoing care (including palliative care) and medication with C prior to A's transfer to the care home. Therefore, we upheld this aspect of C's complain.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for: discharging A from Victoria Hospital, not carrying out a medical review of A, not carrying out an earlier assessment of the possibility that A had a chest infection, discharging A from Queen Margaret Hospital to the care home without a prescription for stronger pain medication, not providing a transfer letter or discharge summary to the care home when A was transferred, and for failing to discuss A's transfer arrangements, ongoing care (including palliative care) and medication prior to A's transfer to the care home. 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:

• Consideration should be given to the pain medication prescribed to patients who are approaching the end of their life and are being discharged from a hospital to a care home.
• Patients who are known to have delirium should receive regular medical reviews.
• Staff should discuss transfer arrangements, ongoing care (including palliative care) and medication with a patient's family when a patient is being transferred from hospital to a care home.
• Where a patient has been identified as potentially having a chest infection this should be assessed at the earliest opportunity.
• Where appropriate, the effectiveness of antibiotic treatment should be assessed prior to discharging a patient with an infection.

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.