Decision Report 201906846

Summary

C complained about the nursing care that they received whilst an in-patient at Forth Valley Royal Hospital. C complained that during their stay in the hospital there were errors in the administration of their medication and that they were manhandled by a member of staff when trying to get out of bed. They also said that there was a delay in providing pain relief after this incident.

We took independent advice from a nursing adviser. We found that, overall, the care given to C with regards to moving and the handling of pain control was reasonable. However, while we found no evidence that their medication dosages were incorrect and we were satisfied that C's medication was given as appropriate, there was an occasion when a prescribed dose of morphine was not recorded as being given. While we had no reason to doubt C's recollection of events which had led to them complaining they had been manhandled, there was no record of the incident in the clinical records and the staff member's recollection was different to C's account of what happened. However, C's pain score had not been checked at this time and had it been checked, this may have shed a light on the matter. We found that the failure to record C's pain score was unreasonable.

On balance, because of the failure to administer all C's morphine doses as prescribed and because of the failure to record C's pain score, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to administer slow acting morphine as prescribed or record the reason why it was not given and for failing to record pain scores on the morning specified. 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:

• Pain scores should be recorded appropriately and in a timely manner.
• All medication prescribed should be recorded as being given or where medications are not administered, reasons for this should be documented.

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.