Summary
Mr C complained about the care and treatment provided to his mother (Miss A) during two admissions to the mental health unit at Forth Valley Royal Hospital. In relation to Miss A's first admission, Mr C had concerns about the monitoring and treatment of blood pressure and the treatment provided to Miss A by a psychiatrist. In relation to her second admission, Mr C had concerns about medical care, nursing care and issues around communication. Mr C also complained about the gap in community psychiatric care in the period between the two admissions.
We took independent advice from a nurse and a consultant psychiatrist. We found that there were failings by nursing staff in the monitoring of Miss A's blood pressure and upheld this aspect of Mr C's complaint. However, we noted that the board had acknowledged this failing and had introduced a new system for recording observations. Overall, we found that the medical treatment provided to Miss A during her admission was reasonable and did not uphold these complaints. However, we noted that one letter sent to Mr C contained unhelpful language and we made a recommendation in light of this.
In relation to the gap in community psychiatric care in the period between the two admissions, we found that the board had not followed the clinical management plan in place once Miss A's psychiatrist left the community mental health team. Therefore, we upheld this aspect of Mr C's complaint. We did note, however, that the board had apologised for this failing and had put a new appointment system in place to address this issue.
In relation to Miss A's second admission, neither adviser identified any failings in medical care, nursing care or communication. Therefore, we did not uphold these aspects of Mr C's complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to Miss A and Mr C for the failure to appropriately monitor Miss A's blood pressure and the content and tone of the letter sent to Mr C. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future: Blood pressure monitoring should be carried out in line with the instructions by the medical team.
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.
Related reading
View Decision Report 201605078 as a PDF (13.04 KB) Updated: December 2, 2018