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Decision Report 201707447

  • Case ref:
  • Date:
    June 2019
  • Body:
    Lanarkshire NHS Board
  • Sector:
  • Outcome:
    Some upheld, recommendations
  • Subject:
    nurses / nursing care


Mr C complained about the nursing care and treatment his father (Mr A), who had dementia, received when he was admitted to University Hospital Monklands. He also complained that Mr A had been unfit for discharge on the day of his planned discharge. In addition, Mr C complained about the level of communication with Mr A's family from the board.

We took independent advice from a nursing adviser and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the nursing care Mr A received had been reasonable and we did not uphold this aspect of Mr C's complaint.

Mr A's planned date for discharge was modified due to his deteriorating health. We found that there had been a failure to assess Mr A's mental health and the possible presence for delirium prior to the original date for discharge, and as a result, the consultant geriatrician advised that staff could not be confident, or show, that Mr A had improved to a level where it was safe to consider discharge. We were particulary concerned that a dementia test was not carried out. We found that the board had unreasonably considered Mr A fit for discharge on the date of the planned discharge and upheld this aspect of Mr C's complaint.

In relation to communication, we found that the nursing communication was reasonable but the board had identified some failings. We also found failings in the medical communication in the initial part of Mr A's admission to the hospital. We upheld this aspect of Mr C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mr C and the family for the failings this investigation has identified. 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:

  • Ensure older people in hospital have their cognitive status assessed and documented. Older people in hospital experiencing an episode of delirium should be assessed, treated, and managed appropriately.

Updated: June 19, 2019