Source · SPSO (Scottish Public Services Ombudsman)

Greater Glasgow and Clyde NHS Board - Acute Services Division

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 201800023 Sector Health Category clinical treatment / diagnosis Decided 01 March 2019

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Full decision

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs  A) at Vale of Leven hospital. Mrs A had been admitted with a fractured hip after a fall and remained in hospital for four months before her death. Ms C complained about a number of medical issues, including the timing of the diagnosis of the hip fracture, hydration and nutrition, diagnosis of dementia and end of life care.

We took independent advice from a consultant physician. We found that whilst the documentation of the initial assessment of Mrs A should have been more detailed, her care and treatment was reasonable. We found that Mrs A's hydration and nutrition was managed appropriately and in line with national guidelines, that the diagnosis of dementia was appropriately handled and that her care was holistic and reasonable given her declining health. We did not uphold Ms C's complaint; however, we made a recommendation to the board regarding the documentation of the initial assessment.

Recommendations

What we said should change to put things right in future: Patients with an unwitnessed fall should have a full neurological (nervous system) and musculoskeletal (muscles and bones) system examination documented on admission.

Related reading

View Decision Report 201800023 as a PDF (24.93 KB) Updated: March 20, 2019

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