Decision Report 201406562

  • Case ref:
    201406562
  • Date:
    September 2015
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    nurses / nursing care

Summary

Mr C complained about the care provided to his late father (Mr A) at Aberdeen Royal Infirmary. Mr A was blind, elderly and frail. He had cancer. Early in 2014 he had had many emergency admissions to hospital and in May 2014 he was admitted again. During his stay he experienced two heart attacks and was noticed to have become increasingly more agitated. Mr A required the lavatory and was assisted there by two members of staff and, at his insistence, he was given privacy. However, he fell and broke his hip. After that his condition declined. Due to this, it was not possible for him to undergo surgery and he died. Mr C believed that Mr A should not have been left unattended and he considered that this contributed to his death.

We investigated the complaint and took independent advice from our nursing adviser. We found that while there was a difficult balance to strike between safety and allowing someone dignity and privacy, in this case, because of Mr A's blindness and medical conditions, he should not have been left alone. We upheld the complaint.

Recommendations

We recommended that the board:

  • provide an update of the actions/action plan they instigated since the complaint in order to ensure that their staff have the skills and resources to manage older people with delirium.

Updated: March 13, 2018