Decision Report 202210966

Summary

C’s parent (A) was admitted to the hospital and diagnosed with a urinary tract infection (UTI) and sepsis. A was transferred to the acute medical unit (AMU) that night and died later the next day. C was concerned about the care and treatment provided to A.

C raised a number of complaints with the board regarding the care and treatment that A received, including the provision of oral care. The board accepted that there had been issues with the prescription and administration of anticipatory medication and the care provided to A, and outlined steps that would be taken to prevent any recurrence. C was dissatisfied with the board’s responses and actions and raised their concerns with SPSO.

We took independent advice from a nursing adviser. We found that the investigation already carried out by the board, and the steps taken to address the areas for improvement identified were reasonable and did not require further investigation by the SPSO. However, we found that the action taken did not address the issue of the provision of oral care to A and investigated this matter further.

In responding to our enquiries, the board accepted and apologised that there had been issues with A’s oral care during their admission. Therefore, we upheld the complaint that the board did not provide A with reasonable oral care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not provide A with reasonable oral care. 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:

• Training is delivered to all relevant nursing staff in the Acute Medical Unit regarding mouthcare in palliative care. This should include structured educational or awareness sessions covering common mouth problems in such care (dry mouth, painful mouth, infections, bad breath, changes in taste and drooling).

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.