Decision Report 202205403

Summary

C complained on behalf of their parent (A) who suffered from dementia and was admitted to hospital with multiple medical issues including a chest infection, delirium, kidney failure and poor mobility including recent falls.

C raised a number of complaints, including that there were failures in the medical care provided to A with respect to falls and post falls care and seizures. C also complained of failings in nursing care relating to diet and nutrition, hygiene and cleanliness, and the general monitoring and awareness of A’s condition. Lastly, C complained regarding restrictions on visitation and poor communication.

We took independent advice from a consultant specialising in the care of the elderly and a second experienced nursing adviser. We found that the medical care provided appeared to have been reasonable. We therefore did not uphold this complaint, however, we were critical of the standard of medical record keeping and we provided feedback to the board about this.

We found that there were failures to complete the necessary risk assessments and care documentation including the risk assessment tool for malnutrition, monitoring fluid balance and applying appropriate wound care and a failure to identify and respond to a deterioration in A’s condition. We therefore upheld this complaint.

We found that general communication with the family appeared reasonable, and that pandemic restrictions were an unfortunate reality for many patients and families. However, it appeared that there had been a failure to notify the family that A had significantly deteriorated. This resulted in the family not being present when A passed away and on this basis we upheld the complaint regarding communication.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. 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:

• Patients should be appropriately assessed by nursing staff in particular in relation to malnutrition, fluid balance, wound care and nursing care provided in line with the assessments carried out. Any significant deterioration should be appropriately recognised and acted on as required. Records about a patient’s care and treatment and decisions made should be clearly and accurately documented and accord with the relevant professional standards and guidelines. Patient’s records should include clear details explaining why a decision about care and treatment has been made.

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.