Decision Report 202306836

Summary

C complained that the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate.

C complained about the care that they received from the board during two hospital admissions. In particular, that staff were unprofessional and unempathetic and became impatient and abrupt when C was unable to do as staff asked.

We took independent advice from a senior nurse. We found that there was a lack of communication and understanding of C’s cognitive impairment which resulted in staff not fully understanding the issues C was dealing with on a daily basis and the challenges their diagnosis presents. There was also a lack of appropriate care planning and a failure to complete all documentation and risk assessments. This led to a failure to provide reasonable emotional and psychological care to C whilst an inpatient, a poor patient experience for C and anxiety over future hospital care. Therefore, we upheld C's complaint.

In addition, we also found that the board’s response to C’s complaint was poor and did not demonstrate the learning or improvement required.

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:

• Documentation and communications regarding care needs should be highlighted at admission, with all relevant risk assessments completed reflecting accurate assessment and planning of care needs. Care plans should be person-centred to incorporate patients who have a cognitive impairment.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures (www.spso.org.uk/the-model-complaints-handling-procedures). The board should fully investigate and address the issues raised and appropriately identify and action learning.

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.