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Case ref:201507703
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Date:January 2017
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the care and treatment her mother (Mrs A) received in the Glen O'Dee Hospital following a hip operation. The initial plan was for Mrs A to return to her own home following physiotherapy, but after a fall she said she wanted to be discharged into a care home. Mrs C complained that after the fall, staff at the hospital failed to recognise that a screw in Mrs A's hip had become displaced and that a further fall was not recorded in Mrs A's records. Mrs C also said that communication with her and her mother was inadequate and that the board failed to take her views into account when reaching a decision to discharge Mrs A into a care home.
We took independent advice from a physiotherapist, a GP and a nursing adviser. We found that after her fall, Mrs A's physiotherapy treatment continued and she said she was not experiencing any pain. It was only when Mrs A began to feel pain that the situation was brought to the attention of a doctor who referred her to another hospital where she was x-rayed and the displaced screw was diagnosed. While Mrs C believed that there had been a subsequent fall, we found no evidence of this. However, we found that communication between the hospital and Mrs C had been poor as she had not been alerted to the fact that her mother had experienced a fall and we upheld this part of the complaint.
However, we also found that Mrs A had been quite definite in wishing to be discharged to a care home despite her daughter's wishes. While the board took Mrs C's wishes into account, Mrs A had capacity to make her own decisions and the board had to acknowledge this. It was only later that Mrs A changed her mind and agreed to be discharged to Mrs C's home. We did not uphold this complaint.
Recommendations
We recommended that the board:
- apologise to Mrs C for the failings identified in this report; and
- ensure that the nursing staff concerned are fully aware of their responsibilities regarding communication under the relevant section of the Nursing and Midwifery Council Code.