• Case ref:
  • Date:
    December 2018
  • Body:
    Lothian NHS Board - Acute Division
  • Sector(s):
  • Subject:
    hygiene / cleanliness / infection control
  • Outcome:
    Upheld, recommendations


Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C also complained about the personal care that Mrs A received and the communication from nursing staff.

We took independent advice from a nursing adviser. We found that:

• the number of ward moves that Mrs A experienced was unreasonable in view of her reduced cognitive function and delirium (sudden confusion)

• the board had failed to keep adequate records regarding the risk assessment and decision making for Mrs A's ward moves and how Mrs A and her family were informed of the ward moves

• the board failed to adequately assess and document Mrs A's care needs. In particular there was no care plan in place to cover Mrs A's personal hygiene needs

• a “Getting to Know Me” document was not in use during Mrs A's admission to St John's Hospital.

In light of the above we upheld Mrs C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for the number of ward moves that Mrs A experienced, the failure to keep adequate records regarding Mrs A's ward moves, the failure to adequately assess and document Mrs A's care needs and complete a 'Getting to Know Me' document. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

  • The movement of patients with cognitive impairment between wards should be in line with national standards and guidance.
  • The reason for moving patients to another bed, room or ward should be clearly documented and shared with the patient and/or their representative in accordance with Standard 15 of the Care of Older People in Hospital Standards.
  • Nursing assessments and care plan documentation should clearly document the care needs and preferences of patients.
  • The 'Getting to Know Me' document should be completed and used to inform a person-centred care plan.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.