Decision Report 202306916

Summary

C complained about the nursing care provided to their late spouse (A) during their admission to hospital. C raised specific concerns about the personal care and stoma care provided.

We took independent advice from a nurse. We found that the personal care provided to A was reasonable. However, we identified significant failings in how A’s ileostomy care needs were provided and significant gaps in documentation. Therefore we upheld this part of C's complaint.

C also complained about the communication with both A and C about A's health and prognosis. We found that prior to A’s decline C was communicated with in a reasonable manner. In relation to the communication with A in the days before their passing, we found that A was experiencing increasing confusion and cognitive impairment throughout their stay in hospital and at times lacked capacity. In light of this, it was unreasonable to inform A of their poor health without C present. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. 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 communicated with in a reasonable manner, and, in line with their capacity, with next of kin present for support if necessary.
• Patients should have a person-centred care plan and staff should follow this.
• The care delivered should be captured in appropriate documentation.
• Stoma care is appropriately recorded in the correct area to support correct stoma care being provided in a reasonable manner.

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.