Summary
Mrs A had a form of dementia and was being looked after at home by her family. When the family became unable to care for her at home, she was admitted to New Craigs Hospital, with the aim of assessing her mental health and finding appropriate medication to enable her to return home. Following falls in hospital, however, Mrs A's physical health deteriorated. She was transferred to Raigmore Hospital, where she was found to have a fractured pelvis and urine retention. Her daughter (Mrs C) made complaints about the admission process and the care and treatment Mrs A received at New Craigs Hospital.
As part of my investigation, I obtained independent advice from a psychiatric nurse, a psychiatrist and an elderly medicine specialist. Mrs C complained that the board should have admitted Mrs A to hospital for mental health assessment earlier. I was critical that, from the evidence available, the community mental health team did not provide enough information and advice about the waiting list and what to do if the situation deteriorated. However, the advice I received was that keeping Mrs A at home whilst waiting for a hospital bed was reasonable in the circumstances. I did not uphold this complaint.
Mrs C complained about various aspects of the nursing care provided to Mrs A in New Craigs Hospital. She was particularly concerned about the assessments of falls risk and of Mrs A's pain, the lack of referrals to doctors, the poor monitoring of Mrs A on the ward, and the use of a wheelchair to transfer Mrs A for an x-ray. The psychiatric nurse adviser was very critical of the nursing care Mrs A received, and concluded that it was disorganised, unsystematic and unreasonable. They noted the lack of a nursing care plan, poor evidence of falls assessments, and no evidence of proper monitoring of Mrs A's pain. The psychiatric nurse adviser found that nursing staff failed to bring Mrs A's first fall to the attention of medical staff until a day and a half later, despite clear evidence of bruising and changes in Mrs A's behaviour. They also commented that it was inappropriate to transport Mrs A in a wheelchair when it was suspected that she had a pelvic fracture. The advice I received clearly shows that Mrs A did not receive reasonable nursing care. In particular, I was concerned that nursing staff did not identify changes in Mrs A's behaviour, assess her falls risk, monitor her pain, or ensure that doctors were aware of the situation, even though Mrs C was raising concerns. I upheld this complaint and recommended an internal review to identify changes.
Mrs C complained about several aspects of Mrs A's clinical treatment, including the way medical staff considered the evidence of her deterioration, and that not enough account was taken of her changing behaviour. She asked whether more scans should have been taken to investigate Mrs A's pain. Overall, Mrs C felt that Mrs A should have been transferred to a medical ward much sooner. The advisers noted that, on admission, Mrs A was mobile and active but, within 48 hours, she was in obvious pain and unable to bear weight. It is clear to me that when x-rays did not identify a fracture, doctors did not do enough to consider what was causing the pain, or causing changes in Mrs A's behaviour and continence. Additionally, I was concerned that doctors did not do enough to relieve her pain. I upheld this complaint.
Mrs C also raised concerns about the record-keeping of the board, particularly with regards to Mrs A's food and fluid intake, falls assessments, the use of hip protectors, and Mrs A's level of consciousness. My psychiatric nurse adviser found that, for all of these areas, the record-keeping was poor. Additionally, they were critical that there was no overall care plan so important issues were likely to be neglected, and that record-keeping was mostly retrospective. It was my opinion that poor record-keeping of Mrs A's care went hand-in-hand with poor care planning and provision, and both were well below reasonable standards. I upheld this complaint.
I also upheld Mrs C's complaint about the board's response to her complaint about Mrs A's care and treatment. I found that the response did not fully respond to Mrs C's questions, was overly defensive and lacking in empathy.
Redress and recommendations
The Ombudsman recommends that the board:
- conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mrs A, in order to identify appropriate improvements in clinical practice; and
- apologise to Mrs C for the failings identified in this report, both in relation to Mrs A's care and treatment and in relation to the response Mrs C received to her complaints.