Decision Report 202201151

Summary

C complained about the care and treatment that their parent (A) received. A had sight and hearing difficulties. Following a fall at home A was admitted to hospital where they stayed as an inpatient for several weeks before being discharged to a care home. A died a few weeks later.

C complained that the care and support that A received at home to encourage movement and general wellbeing was not continued while A was in hospital. As such, A’s mobility and mental health deteriorated and they developed pressure sores due to the length of time that they were immobile in bed. C did not consider that A’s blindness and hearing difficulties were taken into account by the hospital staff and complained that A’s calls for assistance were ignored.

We took independent advice from a nursing adviser. We found that the lack of a person-centred care plan led to the failure to support A to enjoy activities that would have provided some stimulation. This along with the restricted face-to-face visits due to the COVID-19 pandemic, meant that A was unreasonably isolated and this impacted on their anxiety and mobility.

We found that there were a number of issues with documentation and the management of A’s pre-existing pressure ulcer. The lack of clear documentation was concerning and the HSCP failed to have in place documentation and equipment to record, assess, review and treat a pressure ulcer that evidently deteriorated throughout A’s admission.

Overall, we found that A was unreasonably isolated throughout their admission due, in part, to a failure to adapt A’s care in recognition of their sensory impairments and that there were clear failures to maintain important documentation. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not provide a reasonable standard of care to A. 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 hospital adopt person-centred care planning.
• The hospital are compliant with current Health Improvement Scotland (HIS) Prevention and Management of Pressure Ulcer standards 2020.

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.