Overview
The complainant (Mrs C) raised a number of concerns about the nursing care provided to her mother (Mrs A) after she was admitted to the Royal Infirmary of Edinburgh (the Hospital) for hip surgery. Mrs C said that nursing staff had failed to adequately monitor Mrs A's condition and delayed in referring her to specialists. Mrs A died a week after she was discharged from the Hospital.
Specific complaint and conclusion
The complaint that has been investigated is that staff failed to provide Mrs A with an appropriate standard of nursing care (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- issue a written apology to Mrs C for the failure to provide reasonable and appropriate care to Mrs A in relation to nutrition, fluid, diabetes, pressure ulcers and her discharge from hospital;
- issue a reminder to the relevant staff involved in Mr C's care of the requirement to: keep clear, accurate and legible records; promptly provide or arrange suitable advice, investigations or treatment where necessary; consult colleagues where appropriate; and, refer a patient to another practitioner when this serves the patient's needs;
- take steps to ensure that older adults admitted with fracture are assessed for specialist rehabilitation, including review by a consultant geriatrician;
- review their policies and procedures for patients with diabetes admitted to orthopaedic wards to ensure that adequate systems in the management of their care are in place;
- review the process for referral to the tissue viability nurse;
- take steps to ensure that discharge planning in relevant cases is in line with the Scottish Intercollegiate Guidelines Network guidelines for hip fracture in older people; and
- confirm to me that the matter will be discussed at the Orthopaedic Consultant's next annual appraisal.
The Board have accepted the recommendations and will act on them accordingly.