Decision Report 202203333

Summary

C complained on behalf of a relative (A) who had a learning disability and had been prescribed a special adjusted diet according to the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines. A had choked on their food and required emergency care. C complained that A’s food, a takeaway meal, had not been suitable for them and had not been prepared in line with their adjusted diet. They considered that this and other failings caused the near fatal choking incident.

We took independent advice from a speech and language therapist. We found that it was reasonable for staff to have obtained a takeaway meal for A and did not uphold this part of C’s complaint. However, we found that staff had failed to follow guidance and ensure that an assessment had been carried out as to whether this meal was safe for A, and that they failed to prepare the meal for A in line with their adjusted diet. Therefore, we upheld these complaints. In addition, we upheld complaints that the partnership had failed to provide A with the correct cutlery and that they failed to appropriately investigate the incident.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified in this decision. 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:

• Relevant staff should ensure that for any patient on the International Dysphagia Diet Standardisation Initiative (1) recommendations made by the multidisciplinary professionals are adhered to, (2) that recommendations/guidance issued by the multidisciplinary professionals are clearly understood and followed in relation to a patient’s diet and (3) recommendations/guidance issued by the multidisciplinary professionals are clearly understood and followed in relation to any adaptations that may be needed for the patient when eating.

In relation to complaints handling, we recommended:

• The partnership’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement.

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.