Summary
Mr A, who had Alzheimer's disease (the most common cause of dementia), was admitted to a specialist ward at Royal Cornhill Hospital for assessment and treatment. He had been displaying very challenging behaviour, and was no longer safe to be looked after at home. He was sectioned under the Mental Health (Scotland) Act, and he remained in this hospital for the next ten months. During this time his behaviour became more stable and he was transferred to a dementia assessment ward at Glen O'Dee Hospital. This move was against the wishes of Mr A's partner and welfare power of attorney, Ms C. Mr A died six weeks after being transferred, following a rapid deterioration in his physical condition.
Ms C raised concerns about a range of aspects of the nursing care that Mr A received in both hospitals. In relation to his time at Royal Cornhill Hospital, she was concerned about Mr A's risk of falls and the staff response to this, his skin care, his oral health care, and provision of social activities for Mr A. She also raised concerns about communication with Mr A’s relatives, particularly with Ms C, given her position as his welfare power of attorney and his Named Person under the Mental Health (Scotland) Act.
In relation to the care and treatment Mr A had in Glen O’Dee Hospital, Ms C complained about the forms of restraint used to keep Mr A safe from falls, the lack of sufficient encouragement and assistance to mobilise him, and the impact of this on his skin care. In relation to Mr A’s medical care, she was concerned that Mr A developed a sore throat that was not properly assessed, and this led him to stop eating and drinking.
When Ms C complained to the board, they identified no significant failings with the care and treatment given to Mr A, either in Royal Cornhill Hospital or Glen O’Dee Hospital.
During my investigation I sought advice from a psychiatric nursing adviser and a psychiatric adviser, who both identified failings in Mr A’s care and treatment.
This case has raised significant failings, particularly in the most standard elements of nursing care: effective care planning; keeping a patient safe; monitoring their condition; providing appropriate food and nutrition; record-keeping; and communication with relatives. Caring for Mr A was not always made easy by Mr A’s challenging behaviour, but the planning and communication around his care were all the more necessary because of his behaviour and incapacities. I am also particularly critical of the way the board handled this complaint and their lack of focus on their failings and ways to improve their services. I upheld all Ms C’s complaints and made several recommendations.
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 Mr A, in order to identify appropriate improvements in clinical practice, and explore how complaint handling failed to identify these issues;
- provide an action plan setting out improvements identified in the above Significant Event Analysis, with explanation of how they would be met, along with changes that have already taken place since these events;
- remind staff of the need to ensure that changes to visiting hours are mutually agreeable to staff, patients and relatives, and are recorded wider staff awareness;
- conduct a nursing audit in the appropriate ward to assess the current practices in relation to record-keeping, food, fluid and nutrition and vital signs monitoring;
- provide evidence that any actions identified from the nursing audit are implemented in full;
- conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mr A, in order to identify appropriate improvements in clinical practice, and explore how complaints handling failed to identify these issues;
- draw together the findings from both Significant Event Analyses to identify any shared issues on the continuum of care and in complaints handling, to be addressed by the Board; and
- apologise to Ms C for the failings identified in this report, both in relation to Mr A's care and treatment and in relation to the responses Ms C received to her complaints.