Decision Report 202302985

Summary

C’s elderly parent (A) spent two months in hospital due to extensive bruising on their arms and legs with no obvious cause. A suffered acute hip pain while in hospital and became dependent on oxygen. C complained about concerns that they had regarding many aspects of A’s experiences, including A’s discharge after a few weeks and readmission just over a week later. On the day of readmission, A had been visited by district nurses who had administered morphine to A. A died on readmission.

We took independent advice from an adviser specialising in medicine for the elderly. C complained that A was unreasonably discharged. We found that steps had not been taken to ensure that A and C had been provided with reasonable information about the medication that A had been prescribed. Therefore we upheld this aspect of the complaint. Additionally, C complained that district nurses unreasonably failed to administer an appropriate amount of morphine to A. We found that the district nurses’ should have administered an additional dose after the initial dose of morphine did not take effect. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failures in this case. 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 reflective reviews undertaken to reduce the risk of similar issues emerging in future should have included specific discussion of information about medication being provided to patients and, where appropriate, their carers/families or other support.

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.