Decision Report 202201239

Summary

C complained about the care and treatment that their late parent (A) received from the board. A was admitted to hospital after a fall at home. A’s condition declined whilst in hospital. C complained that during A’s admission there were clinical errors, inappropriate treatment and insufficient diagnosis work. In C’s view, this contributed to and hastened A’s death. C stated that clinicians had fixated on alcohol as the primary cause of A’s condition. A post-mortem later confirmed this not to be the case and that A had Lewy Body dementia (a brain disorder that can lead to problems with thinking, movement, behaviour, and mood) or similar when they died. C also asserted that A’s two brain bleeds sustained in the fall were not adequately monitored or treated. C highlighted concerns that there was no intervention and no repeat computed tomography (CT) scan carried out to check the condition/size of the two brain bleeds. This was despite a decline in A’s neurological condition.

In addition to this, C complained that the board’s communication with A’s family fell below a reasonable standard. C stated that, in their view, A’s two brain bleeds were more significant than clinicians had led the family to believe at the time of admission. They also highlighted an unwitnessed fall on the ward that was not reported to the family.

We took independent advice from a neurologist adviser. We found that the treatment provided by the board was reasonable. Given A’s circumstances and presentation, we did not consider the focus on alcohol-related cognitive failure to be unreasonable or that it materially affected the treatment provided. We also found that the decision not to carry out an additional CT scan to be reasonable. However, we highlighted concerns about some of the board’s justification for not carrying out an additional CT scan. We also received a limited amount of advice from an independent nursing adviser about some additional concerns raised by C. We found that in the context of the difficult circumstances of A’s condition, the nursing care provided was reasonable. Overall, we concluded that the board provided a reasonable standard of treatment during A’s admission. Therefore, we did not uphold this aspect of the complaint.