Decision Report 202409049

Summary

C complained about the care and treatment that the board provided to their late parent (A). A had Alzheimer’s disease, and C held Power of Attorney for A. A was resident at a care home and was admitted to hospital after experiencing a fall. A stayed in hospital for approximately seven weeks before their death. C raised concerns about the medical and nursing care and treatment that A received, and the board’s communication with C and their family.

We took independent advice from a consultant geriatrician and a registered nurse. We found that the medical care and treatment provided to A was reasonable overall. We did not uphold this aspect of the complaint.

We found that the nursing care and treatment was unreasonable. We identified failings related to nutrition and weight management, a lack of a timely referral to a dietician and inaccurate and incomplete nursing documentation. The board had identified some, but not all, failings during their complaint investigation. We upheld this aspect of the complaint.

We found that there was an unreasonable delay in the board’s communication with C at the start of A’s hospital admission and regarding the use of intravenous fluids to support A. We found that communication from nursing staff was not reasonable, as there was no documented discussion with C about A’s challenging behaviours, refusal of food, fluids and medications, an episode of deterioration or end of life. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified by this investigation. 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:

• Lead nursing staff should monitor and improve nursing services. Lead nursing staff should support staff learning to help staff develop their professional competence. Documentation of the audit should include dates and identify actions for improvement, with a clear plan for monitoring and follow up to ensure the improvement has taken place.
• Medical and nursing staff should communicate clearly and effectively with those close to a patient. Staff should be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.
• Nursing staff should ensure patients’ physical needs are assessed and responded to. Nursing staff should keep clear and relevant records relevant to their practice.

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.