Decision Report 202410937

Summary

C complained about the care and treatment provided by the board to their late parent (A). Additionally, C complained about the nursing care that A received and the boards handling of C's complaint.

We took independent advice from a consultant geriatrician and a senior nurse.

We found the care and treatment of A to be reasonable. We did not uphold the complaint. In relation to nursing care and treatment, we found unreasonable care in a number of areas including but not limited to, failures in wound care, a delay in administering pain relief, shortcomings in the documentation of cannulation attempts, inaccuracies in key nursing documentation, errors in medication administration and inaccuracies in fluid balance.

While communication with C was compassionate and the timeframes were reasonable, the board’s investigation did not fully identify or address several significant failings in A’s care, resulting in an incomplete and unreasonable response to C’s complaint. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings we identified in nursing care and 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:

• The board should complete a Datix incident report (if not already completed) and identify appropriate learning action.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaints Handling Procedure. The complaint investigation should fully identify and address failings relevant to the complaint.

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.