Decision Report 202106371

Summary

C complained that the board failed to provide reasonable care and treatment to their late parent (A), who died following an admission to hospital. This included issues relating to A contracting COVID-19, that the board unreasonably failed to carry out an SAER/independent review, and that the board failed to reasonably respond to the complaint.

We took independent advice from a specialist in geriatrics (medical care for the elderly). We found that the board had carried out a review of A’s care and had accepted some failings, including that there had been an unnecessary transfer and a delay in cleaning. They apologised for this and had taken improvement action and organised training, which we welcomed and considered were appropriate.

Whilst there were a number of aspects of care provided to A which were appropriate and reasonable, given the unnecessary transfer, the apparent delay in cleaning, and failings with regard to communication, on balance, we upheld this aspect of the complaint.

We also identified complaint handling failings. Whist the complaint response was detailed and lengthy, and attempted to address all of C’s concerns, we upheld this aspect of the complaint, given the lack of detail in the complaint response regarding learning and improvement actions.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in communication, and the lack of information in the complaint response. 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:

• The board are implementing an electronic handover which will reduce the risk of human error and highlight any issues timeously.
• Patients who have disabilities such as hearing impairments which may result in them and their families requiring additional support should have their communication needs fully supported and met.
• The board held Deaf Awareness sessions.

In relation to complaints handling, we recommended:

• Complaint responses should contain full information to explain decisions and should include information about learning and improvement actions.

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.