Source · SPSO (Scottish Public Services Ombudsman)

Lothian NHS Board - Acute Division

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 201908092 Sector Health Category Clinical treatment / diagnosis Decided 01 October 2021

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Full decision

Summary

C complained about the care and treatment their parent (A) had received from the board. A had a terminal cancer diagnosis and severe arthritis. C complained about a series of admissions A had to hospital. C said A had been discharged without C being consulted, even though they were A’s main carer. This meant A was discharged to a potentially unsafe environment, and did not receive the necessary levels of care.

C said A was readmitted to hospital. A was then discharged to a care home, but was not provided with oxygen. C said that A had required oxygen in hospital and the failure to accept that A required long term oxygen support or to provide A with oxygen meant that A required a further hospital admission.

C said that when A was readmitted to hospital, they received substandard care. A was put on a busy ward, that did not specialise in palliative care or geriatric medicine (medicine of the elderly) and that this type of care was only provided once C intervened.

We took independent advice from a consultant geriatrician. We found that A’s discharge planning was carried out to a reasonable standard. A had capacity and the board’s actions took into account their wishes and included a reasonable assessment of A’s home environment.

We found A was very ill during their final admission and that at times A was dehydrated and eating very little and that this would have been very distressing for C and other family members to have witnessed. We noted that dehydration and low food intake were a common feature of this stage of A’s illness and were not evidence of neglect on the part of staff. We found, based on the advice we received, that communication with A was of a reasonable standard and that their pain and condition was monitored and acted on appropriately.

In terms of A’s discharge without oxygen support, we found that staff gave appropriate consideration how best to manage A’s low oxygen saturation levels and that on discharge A’s own preference was a factor in the decision to discharge A without an oxygen supply.

We did not uphold C's complaints.

Related reading

View Decision Report 201908092 as a PDF (24.77 KB) Updated: October 20, 2021

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