Decision Report 202205990

Summary

C complained on behalf of their parent (A) about the care and treatment A received from the board while they were in hospital.

C complained that the hospital failed to consider the relevant medical and practical considerations, particularly with respect to A’s medication and whether it may have contributed to delirium and the falls A suffered while in hospital. C also complained that the board had failed to adequately consult with family members when the decision was made to discharge A. C further complained that the board’s handling of their complaint was unreasonable.

We took independent advice from a consultant specialising in the care of the elderly. We found that C had raised legitimate concerns that the medication could contribute to delirium and the risk of falls. It appeared that the dose prescribed had changed on a number of occasions without a clear rationale recorded in the records and that the care provided with respect to prescribing and monitoring A’s medication fell below a reasonable standard. We therefore upheld this aspect of the complaint.

We also identified a lack of detail in the pre-discharge assessment of A, and a lack of discussion with the family. We upheld this aspect of the complaint.

Lastly, there were elements of C’s complaint that were not adequately or accurately addressed in the board's complaint response and on this basis we upheld this aspect of C’s complaint.

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:

• A patient’s suitability for discharge should be appropriately assessed. The rationale for discharge should be properly documented and any relevant documentation completed. Where appropriate, the patient’s family should be included in discussions about planning for the patient’s discharge.
• Decisions about medication prescribed for a patient and any changes to that medication should be accurately recorded in the patient’s medical records and contain details of all pertinent information.
• Staff are aware of the importance of prescribing and monitoring a patient’s medication appropriately.

In relation to complaints handling, we recommended:

• Complaint responses should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaint responses should address the key issues raised, should be factually accurate and should acknowledge the concerns of the complainant.

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.