Decision Report 201609761

Summary

Mrs C complained about the care and treatment her late husband (Mr A) received at the Western General Hospital during two admissions. Mr A had been admitted to hospital with side effects of chemotherapy that he was receiving for plasmablastic lymphoma (a rare and aggressive form of blood cancer). During his first admission, Mr A had a couple of falls and was later discharged. Mr A was then readmitted and died a short time later. Mrs C complained that communication with the family about Mr A's condition was unreasonable and that nursing staff did not administer his medication properly. Mrs C also complained that the medical care and treatment Mr A received was unreasonable and that the board failed to handle her complaint appropriately.

We took independent advice from a consultant haematologist (a doctor who specialises in medicine of the blood) and from a registered nurse. We found that there had been communication failings with the family during Mr A's hospital admissions, in particular towards the frailty of his condition. Therefore, we upheld this aspect of Mrs C's complaint. However, we noted that the board had acknowledged these failings and had apologised.

In relation to Mr A's medication, we could not find any evidence to show that his medication had been administered inappropriately by nursing staff. Therefore, we did not uphold this aspect of Mrs C's complaint.

Overall, we found that the care and treatment Mr A received was reasonable and we did not uphold this aspect of Mrs C's complaint.

Finally, we found that the board's response to Mrs C's complaint was generally of a good standard. However, they had not kept her informed of delays in their response and they did not address a new issue that was raised. On balance, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to handle her complaint to a reasonable standard. 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:

• There should be proper discussions about advanced care planning with patients and their relatives/carers, where relevant, and these discussions documented clearly.

In relation to complaints handling, we recommended:

• Updates should be provided where the 20 working day timescale for complaints cannot be met; and follow-up correspondence should be carefully reviewed and appropriately responded to.

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.