Decision Report 202004854

Summary

C made a complaint about the nursing care and treatment that their late parent (A) received at University Hospital Wishaw. C was concerned that A was not nursed in an elevated position and was kept lying flat. C also said that A's nutrition was not taken seriously and that the food record charts were not completed properly to monitor A's intake.

We took independent advice from a nursing adviser. We found that it is not usual to document a patient's position in bed (whether they are upright or lying flat). Therefore, we were not critical of the board's record-keeping in this regard. We found that the monitoring of A's nutrition and fluid intake was unreasonable because the Malnutrition Universal Screening Tool (MUST) assessment was not completed within 24 hours of A's admission to hospital, the food record chart and the fluid balance chart were not completed appropriately during A's admission and A's personal centred care plan was not updated to reflect their condition. We upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not completing the MUST within 24 hours of A's admission, not appropriately completing the food record chart and fluid balance charts during A's admission and not updating A's person centred care plan to reflect their condition. 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:

• Patient intake of fluid should be accurately and timeously recorded.
• Person-centred care plans should be reviewed and, where necessary, updated to reflect the needs of the patient.

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.