Decision Report 201804898

Summary

Mr C complained to us about the care and treatment that his late mother (Mrs A) received at Glasgow Royal Infirmary. Mrs A had vascular dementia (a common type of dementia caused by reduced blood flow to the brain, which can cause problems with mental abilities and the physical activities of daily life). Mrs A was admitted to hospital with a fractured collarbone, following a fall at home. During her hospital admission, Mrs A had difficulties swallowing and eating. Her condition worsened and she was diagnosed with aspiration pneumonia (an infection caused by food, saliva or stomach acid being inhaled into the lungs). After Mrs A was discharged home, she was readmitted to the hospital around a week later. Her condition failed to improve and she died in hospital.

Mr C complained that the board had failed to provide Mrs A with reasonable medical care and treatment. In particular, Mr C felt that Mrs A's swallowing difficulties were wrongly attributed to her having advanced dementia. Mr C felt that Mrs A was not given appropriate treatment for her pneumonia because of this. We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that it was reasonable that Mrs A's swallowing difficulties were attributed to her having advanced dementia. We also found that overall, Mrs A's pneumonia was treated appropriately; and there was no evidence that it was left untreated because of her having advanced dementia. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to provide Mrs A with reasonable nursing care; in particular, that she was not given appropriate nutritional care in light of her difficulties swallowing and eating. We took independent advice from a nurse. We found that the nursing staff took reasonable action to try to address Mrs A's nutritional needs. However, we found that on one occasion, Mrs A was given the wrong meal for her diet. We also found that when Mrs A's condition worsened during her first admission, nursing staff failed to escalate this to medical staff. These failings had been identified and acknowledged by the board.

In light of these failings, we upheld this aspect of Mr C's complaint.

Recommendations

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

• Patients on a restricted diet should receive the appropriate meal.

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.