Decision Report 201910848

  • Case ref:
    201910848
  • Date:
    May 2021
  • Body:
    Forth Valley NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained to us on behalf of their late parent (A). A was admitted to Forth Valley Royal Hospital after falling at home. A few days into their admission, A was diagnosed with pneumonia (a chest infection) and then later developed sepsis (a severe complication of infection). A's condition deteriorated and they died.

C complained about A's medical treatment; in particular, that there was a delay in recognising and treating A's sepsis. We took independent advice from a geriatric (medicine of the elderly) adviser. We found that A's medical care and treatment was reasonable. We did not uphold this complaint.

C also complained about A's nursing care. C said that A was not given enough help with personal care and that their conversations with nursing staff had not been recorded adequately. We took independent advice from an acute nursing adviser. We found that the standard and frequency of the communication recorded appeared reasonable. However, we found that there was a lack of evidence of regular and appropriate care rounding to meet A's personal care needs. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified in A's nursing care. 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:

  • Patients should be given timely and appropriate nursing care.

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.

Updated: May 19, 2021