Decision Report 201911248

Summary

C complained about the medical and nursing care that their late parent (A) received at Forth Valley Royal Hospital. Regarding A's medical care and treatment, we took independent advice from a general and colorectal (bowel) surgeon. We found that reasonable action was taken to assess A's cardiac murmur (unusual sounds made by turbulent blood in or near the heart). However, following the exclusion of malignancy or an acute surgical issue, it would have been reasonable to involve a more specialised team involved in the care of the aged. It was reasonable that the board made a referral to the Aging and Health department in the circumstances. However, we found that it was unreasonable that this specialist review did not take place (which may have provided a different perspective on A's symptoms). We noted that the board had already acknowledged and apologised for this failure and had described that the board took reasonable action to address this. We upheld this aspect of C's complaint and requested evidence of the action the board had taken.

Regarding A's nursing care, we took independent advice from a nursing adviser. We found that the assessment and control of A's pain was reasonable and that there was evidence that A's pain level was regularly assessed and that a review of their nursing notes did not indicate that A was in pain for most of their in-patient stay. However, we also found that it was unreasonable that A's fluid intake and output were not monitored using a food balance monitoring chart given their overall condition, cognitive issues, feeling of nausea, low blood pressure, swollen legs and that they had been receiving IV fluids. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not monitoring A's fluid intake and output appropriately using a fluid balance monitoring chart. 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:

• Fluid balance monitoring charts should be used to monitor fluid intake and output, particularly where the patient has cognitive issues, feelings of nausea, low blood pressure, swollen legs or have been receiving IV fluids.

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.