Overview
Mr C has complained about the care and treatment provided to his late mother (Mrs A) prior to and during her last hospital stay in a hospital (the Hospital) within the Shetland NHS Board (the Board) area. Mr C's mother was admitted to the Hospital on 8 March 2005 and discharged to her care home in the afternoon of 9 March 2005. Mrs A died later in the evening of 9 March 2005. Mr C has also complained that Mrs A should have remained in hospital longer.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the reasons for medication, prescribed for Mrs A's suspected clinical condition at the time, were unclear (partially upheld, to the extent that the reason why medication was prescribed in the community for Mrs A's suspected condition was clear and appropriate but the reasons for the prescribing decisions made following admission to the Hospital were not clear and appropriate);
- (b) medical and nursing staff failed to assess and record the treatment and care requirements adequately throughout this particular episode of care (partially upheld, in relation to the actions of the Hospital);
- (c) Mrs A was not provided with an acceptable level of fluids during her stay in the Hospital (upheld); and
- (d) Mrs A should have remained in the Hospital longer (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) share this report with the staff involved in Mrs A's care, so they can reflect on the findings relevant to the prescription of medication when Mrs A was admitted to the Hospital and identify clear and explicit indications for the use of prescribed and administered medication;
- (ii) ensure thorough assessment, recording and treatment is undertaken for the ongoing care of a patient when health remains compromised and discharge is being considered;
- (iii) ensure nursing staff are appropriately trained to record baseline observations and understand the reasons for recording them;
- (iv) ensure a fluid intake and output record is kept for an unwell patient, where feeding and drinking assistance is required; and explanations are recorded when there is a delay in supporting the early, prompt intake of fluids;
- (v) remind staff of the importance of encouraging fluid intake, when a patient is unable to attend to that aspect of care independently;
- (vi) ensure full consideration is given to any potential discharge plan, when observations continue to indicate a level of patient distress or compromise;
- (vii) ensure appropriate family members are given an opportunity to contribute to the discharge planning process of an unwell relative; and
- (viii) provide Mr C with a full formal apology for the failures in care identified in this report.