Decision Report 202103709

Summary

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted to hospital but was discharged later that month. Two days after discharge, A was readmitted and died a short time later.

We took independent advice from a consultant in geriatric and general medicine. We found that some aspects of A’s care were reasonable particularly in relation to COVID-19, A’s diabetes, and detailed assessments from physiotherapists and occupational therapists prior to discharge. However, we found that while A’s last blood tests were normal, A was then unwell for several days which could have developed into kidney impairment if levels of hydration in the body became low. A’s blood tests were not repeated prior to discharge. Had A received blood tests prior to discharge, taking into account A’s blood tests on readmission, it is likely that the test would have been abnormal which would have resulted in A remaining in hospital. We considered that the board failed to provide A with reasonable care and treatment. Therefore, we upheld this part of C’s complaint.

C also complained that the board unreasonably failed to consider their concerns in sufficient detail when responding to their complaint. We found that the board’s complaint response did not reasonably address C’s specific concern in relation to the comments of a nurse. We also found that when investigating the complaint there was a lack of attention given to the reasons for readmission and a lack of reflection by the medical team to ensure lessons were learned. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment to A and to appropriately consider and respond to C’s complaint. 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 should be appropriately assessed prior to discharge and any tests required e.g. blood tests carried out in accordance with their symptoms.
• The board should ensure that their complaint investigations and responses appropriately consider and respond to the points raised by the complainant and that, where appropriate, there is reflection on the issues raised by the staff involved, for example discussion at a team meeting/huddle.

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.