Summary
Mr A was elderly and had several serious health problems, including a form of dementia. He was admitted to the Royal Edinburgh Hospital from his nursing home due to worsening behavioural problems, including agitation and aggression. His mental health assessment showed that he lacked awareness and insight into his problems, and had trouble with communication. This, plus his aggression, meant that he was a risk to himself and other people.
Mr A was mobile with the help of a walking stick when he was admitted to hospital. He fell two days later and suffered bruising, then fell again a few days later, and broke his hip. He was transferred for surgery but died two days after the operation.
His daughter (Mrs C) believed that Mr A's fall risk had been poorly assessed when he was admitted, and that he was not properly cared for after the first fall so the second fall was not prevented. She was concerned that he was over-sedated and not eating or drinking enough, and that the management of his diabetes was inadequate. She also felt Mr A's aggression had not been handled well and that he was blamed for his behaviour, when it was actually the result of his illness.
I obtained independent advice from a nursing adviser, who noted that the board's policy is to complete a falls risk assessment for all elderly patients and to review the patient's falls care plan if they fall. The board's complaint investigation report said that this was all done, but my adviser found no evidence to support this and considered that the standard of record-keeping and falls prevention practice was poor overall. I agreed with this view and, therefore, upheld the complaint and made recommendations.
Regarding Mrs C's complaint about sedation, my adviser said that the appropriate medication and dosage was prescribed and that quick action was taken when adverse effects were noted. My adviser also considered that the board's response letter was balanced and did not blame Mr A for his behaviour.
However, the advice I received was critical overall of the standard of nursing provided to Mr A. The record-keeping was inadequate and did not include care plans for Mr A's personal care or communication difficulties. There was also a significant failure to monitor Mr A's blood glucose levels appropriately and a failure to adequately monitor his nutritional intake. I noted that the board's complaint response states that blood glucose levels were not monitored following Mr A's admission and I was critical of their failure to act on this. I upheld the complaint and made several recommendations.
Redress and recommendations
The Ombudsman recommends that Lothian NHS Board:
- remind all staff that a falls risk assessment is a requirement on admission of an elderly patient;
- review the complaint investigation to establish why statements about Mr A's care not supported by the clinical record, were included in their formal response;
- review their admission procedures for elderly patients to ensure that a Malnutrition Universal Screening Tool assessment is recorded;
- remind all staff involved in Mr A's care of the importance of regular and accurate blood glucose monitoring for diabetic patients;
- remind all staff involved in Mr A's care of the importance of accurate and comprehensive care plans, which meet all a patient's needs; and
- apologise to Mr A's family for the failures identified in this report.