Decision Report 202102779

Summary

C complained about the care and treatment provided to their elderly parent (A) during their admission to St Andrew’s Community Hospital for post-surgery rehabilitation. C complained about several aspects of A's care during their admission including in relation to their eating and drinking, management of their medicines, the discharge arrangements, and the general care provided to them as a person living with dementia.

We took independent advice from a senior nurse. We found that aspects of A's care in relation to their eating and drinking had been reasonable. However, the board had failed to undertake regular weight checks or re-assess A's risk of developing malnutrition. As such, we upheld this aspect of C's complaint and made recommendations for learning.

In relation to the management of A's medicines, their discharge planning, and the care provided to them as a person living with dementia, we found the care provided by the board to A to be reasonable. Therefore, we did not uphold these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to accurately assess or review A's MUST score or record their fluid output. 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:

• Assessments should be accurate and updated in keeping with care planning or when a change in the patient’s condition prompts a further review.
• Where poor food and fluid intake has been identified, there should be documentation of the necessary observations to enable full assessment and management of this (MUST scores, oral intake such as on a food record chart and urinary volumes measured and recorded on fluid balance charts).

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.