Decision Report 201810642

Summary

C complained about the care and treatment provided to their parent (A) at Queen Elizabeth University Hospital. A was admitted to hospital for an operation, which required a long period of rehabilitation. A's condition began to deteriorate after the operation and they died a few weeks later. C complained that clinical failings relating to hydration, record-keeping and communication were contributing factors to A's deterioration and death. C was also concerned about the way clinicians communicated with them.

We took independent advice from two advisers: a nurse specialist in critical care and respiratory and a consultant in acute medicine. We found that there were unreasonable failings in nursing care including record-keeping, which had an adverse effect on the management of A's hydration, and that the lack of fluid management had a distressing impact on A and their family at the end of their life. However, these failings did not substantially impact on A's chance of survival or death. We also found that opportunities were missed to inform A's family of their condition which meant that they were unprepared for A's deterioration and death. We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Ensure a reasonable standard of communication which meets the needs of patients and their families.
• Ensure a reasonable standard of fluid management.
• Ensure patients' hydration is managed reasonably.

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.