Decision Report 202101009

Summary

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted and discharged from hospital on two separate occasions. A died shortly after their third admission to hospital.

We took independent advice from a consultant in geriatric medicine and general medicine (a specialist in care of the elderly).

We found that while some aspects of A’s care were reasonable, particularly in relation to cardiac (heart) care, given the complexity and combination of A’s conditions, age and frailty, A should not have been discharged the day after their first admission. A should have remained in hospital given that a deterioration in their condition was very likely to occur, and as they also required further detailed assessment of their mobility. It was determined that A’s combination of problems would have required inpatient care even for a previously healthy patient and the acute exacerbation of A’s conditions would have been profound and life threatening.

We also found that there was a lack of detailed assessment of A’s mobility difficulties prior to being discharged. We found that the board failed to take account of the evidence in A’s records that they had struggled with their mobility and had needed supervision and support. We noted that an assessment of A’s mobility had been part of the medical plan at the time of their first admission. Given the severity of A’s illness, age, and the difficulty with walking, there should have been a specific and detailed assessment of A’s mobility prior to their discharge. We also found that the board failed to provide a full response to C’s complaint.

Taking account of the evidence and the advice we received, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in discharging A from the hospital the day after their admission, for failing to carry out a full and detailed assessment of A’s mobility prior to their discharge and for the failure to provide C with a full and informed response in relation to their complaint. 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:

• In similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and in line with recognised guidelines.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate.

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.