Decision Report 201907212

Summary

C, an advice worker, complained on behalf of their client (B) about the treatment B's spouse (A) received from the board. A had a rare form of dementia and their condition deteriorated to the point where they become a potential risk to themselves. A was admitted to hospital so their medication could be monitored and altered more effectively but they died a few days after being admitted.

B was concerned about the pain relief medication A was given in the final days of their life. In B's view, the pain medication was not administered consistently and A did not receive sufficient medication to alleviate their pain. B felt that a syringe driver should have been used to administer morphine, as they did not feel nursing staff provided pain relief medication as required.

We took independent advice on this complaint from a nursing specialist. We found evidence of good nursing care being provided and confirmed that it was reasonable for a syringe driver not to be used in this instance. However, we also noted a significant gap in the nursing records where there was no evidence of A's level of comfort being monitored. While acknowledging that there was evidence of good care being provide to A, the significant gap in some of the records and the inconsistency in the record-keeping meant we could not conclusively say what happened during this period and what condition A was in. This led us to conclude that the board failed to adequately evidence that A was monitored appropriately and provided with appropriate pain relief during this period. In light of this, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the fact that they were unable to evidence that A was monitored appropriately and provided with appropriate pain relief. 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:

• Appropriate tools should be in place to allow staff to effectively record pain experienced by patients with cognitive impairment.
• Nursing staff should comply with required aspects of record-keeping at all times.

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.