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Case ref:201904112
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Date:September 2020
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Body:Forth Valley NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
C's parent (A), who has a diagnosis of Alzheimer's disease (the most common type of dementia), was a patient in Falkirk Community Hospital. On discharge, A was moved to a nursing home, as they required greater care. C questioned the board's care of A while they were a patient in the hospital; in particular about the prolonged use of Risperidone (an antipsychotic drug). C was also unhappy about the delay in issuing a discharge letter and the fact that it was sent to the nursing home. C complained that the letter contained incorrect information.
The board's view was that A had been prescribed Risperidone before they were admitted to hospital and that as they remained agitated and confused at times, in the absence of any clinical indication that they were experiencing side effects, there was no reason to alter the dose that had already been prescribed. Furthermore, they said that the medication was regularly monitored. The board agreed that there had been a delay in issuing a discharge letter and apologised that the letter contained incorrect information.
We took independent advice from an appropriately qualified adviser. We found that Risperidone had been prescribed reasonably and appropriately to A and that its use had been regularly monitored. We did not uphold this aspect of the complaint. However, we found that with regard to the discharge letter, the level of care given to A (with regard to delay and release of sensitive information) fell below the standard they could have expected. Therefore, we upheld this aspect of the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for the delay and failing to discuss/obtain consent for the sensitive content of a discharge letter prior to releasing it to the care home.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets
What we said should change to put things right in future:
- Discharge letters should be issued in a timely way. Sensitive information included in a discharge letter should be discussed with and consent obtained from the patient/guardian prior to its inclusion.
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.