Scottish Public Services Ombudsman

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  • Report number:
  • Date:
    December 2014
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
  • Keywords:
    Nursing care, risk assessment

The complainant (Ms C) raised concerns that her late mother (Mrs A) developed lithium toxicity during her admission to Pavilion 2, Ayrshire Central Hospital, as a result of inadequate fluid intake.  Ms C was also concerned that Mrs A had a heavy fall during her admission and suffered significant injuries.

Specific complaints and conclusions
The complaints which have been investigated are that Ayrshire and Arran NHS Board (the Board):

  • did not reasonably ensure that fluid intake was adequate (upheld); and
  • did not take reasonable steps to ensure the patient's physical safety (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • identify and address any staff training needs in relation to lithium toxicity;
  • remind nursing staff that action is required to address low fluid intake when the intake for a lithium patient falls below 1.2 litres;
  • issue a written apology to Ms C, acknowledging the failings identified in this report;
  • provide his office with a copy of the six-monthly review of the measures set out in the Quality Improvement Plan for improving falls assessments, fluid intake monitoring and record-keeping.  If the measures of effectiveness set out in the plan were not met, the Board should explain what further action will be taken;
  • provide refresher training for staff involved in Mrs A's care on the requirements of the Falls Management Guideline for In-Patients; and
  • raise the findings of his investigation with the staff responsible for Mrs A's care, for reflection as part of their next performance appraisal.

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201305924 as a PDF (74.79 KB)

Updated: December 19, 2014