Decision Report 202403923

Summary

C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died.

We took independent advice from a nursing adviser and consultant geriatrician (specialist in medicine of the elderly). In relation to nursing care, we found failings with A's nutrition, pressure care, person centred care planning, and documentation. We upheld this part of C's complaint.

In relation to medical care and treatment, we generally found this to have been reasonable and did not uphold this part of C’s complaint. However, we provided feedback to the board regarding starting oral nutrition supplements in line with Scottish Hip Fracture Guidance.

Finally, we found that there were delays in the handling of C's complaint and the board failed to fully address of all C's concerns. The board had acknowledged these failings and taken action to address them. Therefore, we upheld this part of C's complaint but made no further recommendations in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in nursing care provided to A, and the failings in complaint handling. 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:

• Appropriate assessments should be accurately completed in a timely manner to identify patients at risk of or with existing pressure sore damage. Those patients should receive appropriate and timely pressure sore care in accordance with relevant local and national guidance.
• Malnutrition Screening should be completed in a timely manner and repeated as appropriate. Food charts should be completed accurately.
• Person-centred care planning should be completed for every patient, and documentation should support this.