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Case ref:202204521
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Date:December 2023
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Body:Highland NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained on behalf of their spouse (A) who was admitted to hospital with pain, spams and weakness in their right leg which was later diagnosed as being caused by an infection in the iliopsoas muscles (a group of muscles running from the lower spine to the thigh). A is a dialysis patient and had also previously suffered a stroke, leaving them with weakness on the right side and wheelchair bound. C therefore usually supports A with dialysis and medication.
The complaint centres around an incident in the first week of A’s admission when both C and a nurse separately administered A’s evening medication. C stated that they had previously been given the medication by ward staff to support A. C had administered the evening medication and gone out for a few hours. On return, they had found A to be unresponsive. A nurse said that they had also administered evening medication. C complained that this overdose of medication had occurred and that record keeping and incident management had been unreasonable.
We took independent advice from a nursing adviser. We considered that this incident should not have happened, and that it indicated a lack of clarity, process, recording and communication within the ward.
We found that record keeping before and after the incident had been lacking, as there had been no clear record in a person centred care plan to state that the medication was being held and administered by C, that there had been a 24 hour gap in nursing records over the period of the incident and that no extra observations or conversations with a doctor had been recorded following the incident. We found that categorisation and management of the incident had been unreasonable. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C and A for poor record keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
- Apologise to C and A that an extra dose of medication was administered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
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.