Decision Report 201808631

Summary

Mr C complained about the care and treatment that his late father (Mr A) received at Aberdeen Royal Infirmary and at a palliative care facility.

We took independent advice from a consultant head and neck surgeon, from a consultant clinical oncologist (cancer specialist) and from a nursing adviser. We found that the surgical and medical care and treatment Mr A received was reasonable.

However, we found failings regarding Mr A's nursing care. In particular, we found that Mr A was not prescribed two hourly position changes at Aberdeen Royal Infirmary and the palliative care facitility when he was at risk of developing pressure damage and that Mr A did not receive care in accordance with the board's policy on adults with tracheostomies (an incision in the windpipe made to relieve an obstruction to breathing). We upheld this aspect of Mr C's complaint.

Mr C also complained about how the board handled his complaint. We found that Mr C was not kept updated regarding a timescale for when he could expect to receive the board's complaint response and the minutes of a meeting. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not prescribing Mr A with care and comfort rounds every two hours; not delivering appropriate tracheostomy care to Mr A in accordance with the board's policy; the delay in responding to his complaint and that he was not kept updated. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .

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

• Patients at risk of developing pressure damage should be repositioned every two hours.
• Patients with a tracheostomy should receive care in accordance with NHS Grampian's Care of the Adult with a Tracheostomy Policy.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found at https://www.spso.org.uk/the-model-complaints-handling-procedures .

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.