Summary
Mrs A, who had dementia, was admitted to Borders General Hospital with sepsis (blood infection). She was discharged to her care home after a few weeks but was re-admitted two months later for end of life care. She died in hospital two days later. Her daughter (Mrs C) complained about several aspects of the care and treatment received by Mrs A during her admissions to the hospital. She said that, before her first admission to the hospital, Mrs A had been able to walk with the help of a walking stick and could feed herself. However, by the time of her discharge, she could neither stand nor eat without assistance. Mrs C said that Mrs A was not helped with personal care, her skin care was not attended to, and she was not helped with eating or drinking. She said that staff did not consider the needs of Mrs A as a person, despite the care home providing 'Getting to Know Me' documentation when she was admitted.
As part of my investigation I obtained independent advice from a nursing adviser. The adviser noted that the record-keeping, and particularly the nursing notes, about Mrs A's care was poor. Documents such as her care plan were not completed properly and other documents that my adviser expected to see (such as a wound chart, and food and fluid charts) were missing entirely. This meant that there was no evidence to show that reasonable nursing care was provided to Mrs A. The adviser said it was very poor that relevant personal information about Mrs A was lacking from her notes as this information was vital to ensure her care plan was person-centred. I was advised that Mrs A's care lacked any knowledge of dementia, and I am concerned that her needs and preferences were not taken into account. I concluded that Mrs A did not receive adequate care during this admission.
Mrs C also complained about communication from staff during Mrs A's first hospital admission. Despite the family holding welfare power of attorney for Mrs A, she said staff never approached them to discuss treatment or the care plan. She said the family, who made daily enquiries, were often given misleading information, and she complained that the staff discussed Mrs A with them in the corridor. The adviser said that they would have expected more information in Mrs A's notes about communication with her family, and that the standard of communication was generally poor. They considered confidential discussions taking place in hospital corridors to be totally unacceptable practice. I found that the welfare power of attorney should have been identified and reflected in Mrs A's care plan, and the family should have been updated regularly. An inspection in 2012 by Healthcare Improvement Scotland (HIS) alerted the board to instances where staff failed to satisfy themselves that a welfare power of attorney was in place, and also instances where staff discussed confidential patient information in corridors. I was concerned that this was still occurring.
Mrs C was also unhappy about the care Mrs A received when she was re-admitted to Borders General Hospital for end of life care, and about the attitude and communication of nursing staff at that time. She said that Mrs A, who was close to death, and her grieving family were left alone for two and a half hours. She said the staff showed no care or compassion and seemed uninterested. The adviser said the nursing role is to care and support both the patient and their relatives, and that they would have expected staff to assess and provide care to a dying patient at least every two hours. However, there were long gaps between entries in the nursing records, which I found concerning. The family's needs were clearly not met and I conclude that the level of support provided was unreasonable.
Mrs C complained about the board's handling of her complaints, one of which did not acknowledge within the correct timescale or automatically treat as an official complaint. The board also failed to send Mrs C a written follow-up or apology after their meeting with members of the family. Mrs C considered that the board's investigation missed serious failings and, in particular, a breach in procedures that were put in place after the HIS inspection. I found that Mrs C's letter was clearly a complaint and should automatically have been dealt with as such, and that it would have been good practice to summarise the key points of the meeting for Mrs C. I considered that the board's learning from the complaints was vague, and I agreed with Mrs C that the board's action plan was insufficient. I upheld all of the complaints and made several recommendations.
Redress and recommendations
The Ombudsman recommends that the board:
- carry out a review of nursing care and leadership on the relevant wards, taking account of the failings highlighted in this report;
- further develop their action plan to take account of the criticisms in this report and, in particular, ensure that specific and robust action is taken to address the identified record-keeping failings and the failure to provide appropriate, person-centred dementia care to Mrs A;
- carry out a review of their consent to treatment policy and patient documentation to ensure that the existence of any formal adults with incapacity arrangement is promptly identified, reflected in the care plan, and that appropriate communication with the relevant appointed person(s) takes place;
- take urgent action to address the issue of confidential patient information being discussed by staff in hospital corridors and inform the Ombudsman of the steps taken;
- provide us with a copy of their action plan / strategy for end of life care;
- ensure they have a policy in place to guide staff in what they should do when a patient dies;
- review their handling of this complaint and identify areas for improvement, taking account of their statutory responsibilities as set out in the CIHY guidance; and
- apologise to Mrs C and her family for the failings this investigation has identified.