Decision Report 202203015

Summary

C complained about the care and treatment that their spouse (A) received during two admissions to hospital. C complained that the board had failed to provide A with adequate personal care during both admissions and failed to adequately manage their medication during their first admission. C also complained that A had been unreasonably discharged following their first admission and that there had been inadequate preparation for A’s second discharge.

The board apologised for failures in A’s care and for aspects of their communication. They also apologised for a failure to adequately prepare A’s medication prior to their second discharge. They identified learning from these failures. However, C remained unhappy and asked us to investigate.

We took independent advice from a consultant in geriatric medicine and an advanced nurse practitioner. We found that A was unreasonably discharged at the end of their first admission. Therefore, we upheld this part of C’s complaint. However, the board managed A’s medication reasonably and provided adequate personal care during A’s first admission. Therefore, we did not uphold these part’s of C’s complaint.

In relation to A’s second discharge, we found that there had been a failure to provide A with adequate personal care and that they had been discharged at the end of this without adequate preparation. We upheld these parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and to A 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:

• Where a patient has a lack of bowel movements for several days, this should be highlighted and discussed with the relevant nursing, medical and allied healthcare teams.
• Where blood tests have been carried out, the patient’s results should be reviewed prior to their discharge.
• Where there is a delay in a patient being discharged, they should receive any medications they are due whilst waiting to be discharged. Patients should receive all appropriate prescribed medication when they are discharged. All relevant patient discharge documentation should be completed.
• Staff should obtain the precise details of a patient’s usual medication regime for Parkinson’s and act upon this to improve patient care.

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.