Summary
Mrs C complained about the way her late mother Mrs A had been treated while in hospital. Mrs A, who had dementia, was admitted to Borders General Hospital on 20 November and discharged on 4 December 2012. She was readmitted on 6 December and then discharged again on 17 December 2012. Mrs C was concerned about aspects of her mother's treatment while in hospital and that she was discharged too soon. She felt that Mrs A had been treated poorly because of her cognitive impairment. I sought independent expert advice from a nursing adviser and a medical adviser. I did not find that Mrs C had been deliberately discriminated against because of her dementia. However, my investigation identified a significant number of failings in her care, many of which related to a failure to provide appropriate care and support to someone with cognitive impairment or to follow the legislation that provides protection for someone with cognitive impairment who requires medical treatment. As a result of these failings, it is likely that, taken together, the failings were such that Mrs A's rights as an NHS patient and a dementia patient were infringed.
Care seemed to be poorly led and coordinated. There was no evidence of a full care plan and, despite the fact that she had been admitted to the hospital because of a fall and had five falls during her stay, there was no completed falls assessments in the clinical records or any evidence of a falls prevention plan. There was limited evidence of the involvement of medical staff and communication with the family was sporadic and poor. Pain and nutritional assessments were inadequate. There was also a specific incident of which I am critical when Mrs A required but was not provided with adequate pain relief and this meant her journey to the care home on 4 December was very uncomfortable. While the report identifies a number of medical and nursing failures, I did not uphold a complaint about physiotherapy and occupational therapy. There was evidence in the records of appropriate physiotherapy involvement and while I am critical that an occupational therapy assessment was only carried out after prompting by the care home, I found that overall care in these areas had been reasonable.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) monitor practice to ensure national dementia standards are being met including specifically that the presence of cognitive impairment is given due regard in the planning of care, and that the level of observation, supervision and provision of support provided to people with delirium and/or dementia is appropriate for their impaired capacity;
- (ii) ensure that staff comply with adults with incapacity legislation, in particular completing section 47 certificates and accompanying care plans;
- (iii) take steps to ensure communication with relatives and carers of patients with cognitive impairment is proactive and systematic;
- (iv) ensure that falls prevention clinical practice is administered within the Hospital in line with recognised good practice and Board policy;
- (v) ensure that nutritional care is carried out in line with national policy and that nutritional care plans are developed, implemented and evaluated for each patient as appropriate;
- (vi) explore all options to implement an observational pain assessment tool for use with patients with cognitive impairment;
- (vii) undertake an audit of record-keeping in wards caring for patients with cognitive impairment to ensure compliance with record-keeping guidelines and a reasonable standard of practice;
- (viii) review their discharge policy to ensure: its continued relevance in light of the failings arising from this case; it meets the needs of people with cognitive impairment and the need to fully involve the family in decision-making; a more systematic approach to discharge planning; and pre-discharge assessments are clearly identified at an early stage and carried out within a reasonable time to inform follow-up care;
- (ix) ensure the failures identified are raised as part of the annual appraisal process of relevant staff and address any training needs particularly in relation to falls prevention and adults with incapacity legislation; and
- (x) apologise to Mrs C for the failures this investigation identified.