Overview
The complainant (Mrs C) raised concerns that the standard of care and treatment provided to her late mother (Mrs A) from two hospitals following a fall was not reasonable and included concerns about communication, treatment decisions, discharge and provision of nutrition and fluids.
Specific complaints and conclusions
The complaints which have been investigated are that:
- the Western General's care and treatment of Mrs A in 2013 was unreasonable (upheld); and
- the Royal Infirmary of Edinburgh's care and treatment of Mrs A in 2013 was unreasonable (upheld).
Redress and recommendations
The Ombudsman recommends that Lothian NHS Board (the Board):
- ensure that any recorded assessment of a patient is accurate and a reliable source on which to base the planning of care and supervision;
- ensure that the presence of cognitive impairment is given due regard in the planning of care, and that the level of observation, supervision and support provided to people with delirium and/or dementia is appropriate for their impaired capacity;
- take steps to ensure that communication with relatives or carers of patients with cognitive impairment is proactive and systematic;
- ensure the failures identified are raised with relevant staff;
- review their practice in relation to the pre-operative provision of nutrition and fluid in light of Nursing Adviser 2's comments;
- ensure that clinical practice, decision-making processes and clinical records in relation to DNACPR decisions are in line with the relevant policy; and
- apologise to Mrs C for the failures identified in this investigation.
The Board have accepted the recommendations and will act on them accordingly.