Decision Report 202308797

Summary

C complained about the care and treatment of their late parent (A) following an admission to hospital with a hip fracture, and about the communication surrounding this. C raised concerns about A’s fitness for discharge, including a lack of rehabilitation in hospital and length of wait for community rehabilitation, as well as a lack of support with food and fluid intake, and a lack of adequate skin care. C also raised concerns about a lack of engagement with them as A’s next of kin and power of attorney.

We took independent advice from a consultant orthopaedic surgeon and a registered nurse. We found that A’s discharge was medically reasonable, and that the level of input from therapists was reasonable. The board acknowledged shortcomings in communication with C around their discharge, and a failure to document the nursing handover with the care home. The board also apologised that the target timescale for community rehabilitation was not met.

We found that there were unreasonable failings in the nursing documentation, person centred care, and pressure care that A received. A’s person centred care plan was not completed, and a documented instruction that A required full assistance with nutrition and hydration was not adhered to.

We identified frequent gaps in skin inspections and repositioning, and inconsistent completion of a pressure ulcer risk assessment. The relevant foot care did not take place in light of A’s diabetes, and there was no referral to podiatry when pressure damage to A’s heel was discovered. We were concerned to note that A’s nutritional needs were not met, and that there was a failure to protect A from pressure damage. We upheld this complaint.

We also identified inconsistencies in the board’s complaint responses and noted that important failings were overlooked. We made recommendations to the board to address these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Food, fluid and nutrition standards should be met. Instructions set out in care plans to be adhered to, and patients to receive the appropriate level of assistance.
• Patients’ person centred needs should be fully considered. Documentation should meet the professional standards required by the NMC – The Code.
• Pressure ulcer prevention standards should be met, and patients protected from healthcare acquired pressure damage.

In relation to complaints handling, we recommended:

• Stage 2 complaint responses should meet the aims of the NHS Scotland Model Complaints Handling Procedure. They should aim to establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response that represents the organisation’s final position. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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.