Source · SPSO (Scottish Public Services Ombudsman)

Fife NHS Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201500354 Sector Health Category clinical treatment / diagnosis Decided 01 May 2016

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Full decision

Summary

Mrs C complained to us about the care and treatment provided to her late mother (Mrs A) in the Victoria Hospital. We took independent advice on Mrs C's complaints from a consultant geriatrician and a nursing adviser. Mrs C complained that the action taken in relation to the management of Mrs A's pain was unreasonable, particularly as Mrs A had dementia. We found that although there had been no clear cause of Mrs A's pain, medical staff had made reasonable attempts at diagnosing and managing the cause of her pain and it had been reasonably well controlled. There was also evidence in the nursing notes to indicate that nursing staff undertook very specific assessment and management of Mrs A's pain. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the action taken in relation to fluids and diet. We upheld this complaint, as we found that staff had not completed nutritional screening documentation when Mrs A was admitted and that she had repeatedly received the same types of meals. There was also no evidence that staff had taken action when Mrs A's dentures went missing. That said, we were satisfied that the board had apologised for these failings and had taken action to prevent similar problems occurring.

Mrs C also complained about the communication with the family. We found that this had been of an acceptable frequency and detail. We did not uphold this aspect of the complaint. In addition, we found that the end of life care provided to Mrs A had been reasonable and did not uphold Mrs C's complaint about this.

Related reading

View Decision Report 201500354 as a PDF (11.29 KB) Updated: March 13, 2018

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