Decision Report 202301629

Summary

C complained about the nursing care provided to their late parent (A) in hospital. A had been transferred from another health board for rehabilitation having suffered a stroke. C said that there was infrequent care rounding and that the provision of and monitoring of A’s diet, nutrition and fluid intake was poor. C also complained about communication, catheter care and pain management.

We took independent advice from a nurse. We found that record keeping was not to the standard required in areas such as care rounding, fluid balance and food charts, and pain assessment documentation. The lack of accurate records of A’s nutritional assessment and needs suggested that A’s nutritional intake was not delivered to a reasonable standard and that they were at risk of malnutrition. Additionally, the absence of pain assessments on A’s observation and care rounding charts indicated a failure to properly evaluate A’s pain levels, making it difficult to determine if the pain medication provided was effectively relieving their pain. We determined that there had been a lack of assessment, evaluation, and implementation of A’s care needs and lengthy gaps between care interventions. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• 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:

• Nursing staff should be aware of and achieve the required standards of the Nursing and Midwifery Council: The Code in relation to record keeping. A patient’s pain should be appropriately assessed and documented in their patient records.

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.