Decision Report 202201665

Summary

C complained that the partnership did not provide reasonable care and treatment to their parent (A). A was admitted to hospital on three occasions during one month following falls. After their third admission, A was discharged to C’s home due to the COVID-19 pandemic. A week later, A was admitted to another hospital and was diagnosed with a lumbar (spinal) fracture and incomplete spinal cord damage. C raised a number of complaints with the partnership about the care and treatment A received and about their discharge.

The partnership did not indicate any concerns about A’s care and treatment or discharge but noted that discharge planning had been disrupted due to the COVID-19 pandemic. The partnership also undertook a Significant Adverse Event Review (SAER).

We took independent advice from an appropriately qualified adviser. We found that the partnership did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of changes in A’s condition. Therefore, we upheld this part of C’s complaint.

In relation to A’s discharge, we found no clear evidence that the concerns expressed by the physiotherapist about deterioration were assessed before the decision to discharge A was made. Therefore, we considered A was unreasonably discharged and upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family that partnership staff did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of increased leg weakness in A, that concerns expressed by physiotherapy staff about deterioration in A were not assessed before the decision to discharge A was taken and that the findings of the SAER were not shared with A and their family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. Enquire whether A’s family wish to meet with the hospital manager and lead nurse and, if so, arrange and hold that meeting.

What we said should change to put things right in future:

• Communications related to changes in patient care or decisions are reasonably documented.
• Decisions to discharge always take into account the circumstances of the patient at the time, and that if any change in a patient’s condition could affect the decision to discharge them, this must be considered at the time.

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.