Scottish Public Services Ombudsman

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  • Report number:
    201105263
  • Date:
    April 2014
  • Body:
    Forth Valley NHS Board
  • Sector(s):
    Health
  • Keywords:
    Care of the elderly; diagnosis; consent

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late mother (Mrs A) in Stirling Royal Infirmary (the Hospital) between 21 and 23 February 2011.  This included Mrs C's concerns: that hospital staff incorrectly diagnosed Mrs A with dementia rather than delirium, and failed to obtain proper consent for surgery; about how Mrs A's urinary tract infection was treated; and, about how Forth Valley NHS Board (the Board) responded to Mrs C's complaint.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) the Board failed to explain how their diagnosis of dementia was reached (upheld);
  • (b) the diagnosis of dementia was inappropriately used to obtain consent for an operation (upheld);
  • (c) the approach to managing Mrs A's urinary tract infection was inappropriate (upheld); and
  • (d) there was a failure to accept clinical failings or offer an apology despite the findings of an external review (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • apologise to Mrs C for incorrectly diagnosing Mrs A with dementia, and incorrectly completing a Certificate of Incapacity to obtain consent for Mrs A's operation;
  • apologise to Mrs C for the poor standard of care provided to Mrs A;
  • review their provision of specialist ortho-geriatric care for patients like Mrs A, who commonly present with fractures but have other medical conditions that need to be managed in an orthopaedic ward;
  • apologise to Mrs C for their handling of her complaint, in particular their failure to accept the findings of the external review they commissioned; and
  • carry out a Significant Event Analysis, with reflective commentary, of the care and treatment provided to Mrs A, the handling of Mrs C's complaint, and their response to the external review they commissioned.

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201105263 as a PDF (75.33 KB)

Updated: April 30, 2014