Decision Report 202103292

Summary

C complained about the standard of care and treatment provided to their parent (A) whilst A was in hospital. C's concerns covered A’s medical care, nursing care and physiotherapy care.

C said that A’s myeloma (blood cancer) treatment was delayed by a failure to provide the specialists treating A with blood samples for analysis. Additionally, A was not given an infusion correctly, as nursing staff failed to give A intravenous fluids first to ensure A was hydrated. C felt A’s pain relief was inappropriately managed, with A’s medication being unnecessarily reduced, resulting in A suffering significant and avoidable pain. C also believed that A was injured during a physiotherapy session and that this contributed to A’s decline.

We took independent advice from a registered nurse, a consultant haematologist (specialist in the the diagnosis and treatment of patients who have disorders of the blood and bone marrow) and a chartered physiotherapist. We found that nursing staff had not followed written instructions for the administration of A’s treatment, and A’s records showed that they had consumed only around 15% of the food and water that they should have in the period leading up to the infusion treatment. Nursing staff could not therefore have ascertained that A was properly hydrated. Nursing staff did not appear to have taken all the requested blood samples from A, and they had not taken steps to address A’s pain management. Therefore, we upheld this part of C's complaint.

In relation to A's medical care and treatment, we noted that their condition was progressing rapidly and that they had already had a number of treatments. The decision that A was not suitable for further treatment was not impacted by the missing blood sample and overall, we found that the medical care A received was reasonable. Therefore, we did not uphold this part of C's complaint.

In relation to A's physiotherapy care, we found that there was no evidence within the physiotherapy records that A had sustained an injury. Although there were some unexplained gaps in A’s physiotherapy records, it was clear that the decision to cease physiotherapy treatment was driven by the decision to designate A for palliative care only, rather than active treatment. Therefore, we did not uphold this part of C's complaint.

C also complained about the way that their complaint was handled. We found that the board’s complaint investigation had fallen below a reasonable standard. The evidence showing the failings in A’s nursing care should have been identified by the board’s own investigation. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of nursing care and for failing to provide C with a reasonable response to their complaint. 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 fluid and nutrition needs should be appropriately monitored. Where there is evidence that fluid and hydration needs are not being met, appropriate action should be taken.
• Patients’ level of pain should be reviewed and where the patient is unable to comply with the administration of pain relief orally, action should be taken to explore alternative means of medication delivery.
• Staff should ensure that written instructions by medical staff and, where appropriate, manufacturer’s guidance is followed when administering infusions and that, where appropriate, the patient is adequately hydrated.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that responses are accurate and reflect the information available in the clinical record.

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.