Decision Report 201508786

Summary

Ms C, an advocacy and support worker, complained on behalf of Ms B. Ms B's concerns related to the medical and nursing care received by her mother (Mrs A) at Southern General Hospital. Mrs A had been diagnosed with lung cancer that had spread to her liver. She was admitted to hospital as she was suffering from pain, shortness of breath and confusion. A plan was made for Mrs A's transfer to a special cancer treatment centre but she suffered a fall and fractured her hip before this could take place. An incapacity certificate was completed and after assessment, surgery was carried out to Mrs A's hip, but her condition worsened. Mrs A was transferred to a hospice, where she died.

We took independent advice from a consultant in acute and respiratory medicine. We did not uphold Ms C's complaint about the standard of medical care. We found that the decision to proceed with surgery was reasonable in the circumstances of the case and that whilst pain had been poorly controlled for Mrs A, this was despite the best efforts of the team caring for her.

We also took independent nursing advice. The advice we received highlighted issues with the assessment of Mrs A's risk of falling. We found that Mrs A's cognitive difficulties and other factors had not been properly taken into account, resulting in an inadequate falls prevention care plan at the time of her fall. The advice we received also highlighted issues with the assessment of Mrs A's mobility. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation;
• ensure that all relevant issues, including documented cognitive difficulties, are properly accounted for during the falls risk-assessment process;
• ensure that mobility assessment documentation is appropriately completed and reviewed; and
• ensure that completed incapacity certificates are accompanied by a treatment plan when appropriate.