Decision Report 202207681

Summary

C complained about the care and treatment provided to their late parent (A) by the board. A was living independently but fell and injured their knee. A was admitted to hospital and underwent surgery. C believed that A did not receive adequate food or drink and that A was not provided with antibiotics timeously. A died in hospital and C complained about the way that A’s end of life care was managed, as well as a delay in providing C with a death certificate.

We took independent advice from a consultant physician and a registered senior nurse. We found that A’s medical and nursing care fell below a reasonable standard. During the end-of-life period, we also found that A’s nursing care fell below a reasonable standard, although their medical care was reasonable. We also found that there was an unreasonable delay in providing C with A’s death certificate. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings identified. 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:

• Care for patients receiving end of life care should be planned and their care plan updated to reflect their specific needs. Appropriate end of life care should be provided in particular in relation to repositioning and comfort care and this should be documented.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring, as well as appropriate and regular monitoring of their weight when requested as part of their care plan.
• Patients admitted to hospital should receive reasonable medical care including appropriate and timely medical assessments for feeding and nutrition and delirium and appropriate antibiotic treatment.
• Staff caring for a patient with diabetes should be competent in the monitoring and appropriate recording of blood sugar results and any action taken to address low or high blood sugar.
• Staff involved in wound care should be knowledgeable and competent in wound assessment; wound care and treatment.
• Reporting of deaths and issuing of a death certificate should not be delayed unnecessarily by staff absence.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning.

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.