C believed nursing staff had failed to provide A with a reasonable standard of care. They complained that A had been confined to bed inappropriately and that no assessment had been made of the impact this would have on A's mental health. C said that there were issues in arranging for suitable equipment to allow A to be transferred out of bed. C also complained about the communication of decisions about A’s care with them, A's next of kin and registered power of attorney. C said that after they complained, the Partnership told them that A was receiving end of life care but that this was not true and was a rationalisation of what had happened after A’s death.
C also noted that the Partnership had been obliged to respond more than once to their complaint, after they had pointed out factual inaccuracies in their response. C suggested that this showed that there had not been a proper investigation into their complaint.
The Partnership accepted that communication with C could have been better. They maintained, however, that A’s care had been of a reasonable standard and that staff had been clear that A was being provided with end of life care. They accepted that this should have been specifically set out in A’s care plan and noted improvements were being made to ensure this going forward.
We took advice from a registered nurse with experience of medicine for the elderly. We found that A’s care and treatment had been reasonable. We did not uphold this aspect of the complaint.
We found that there was failure to communicate with C appropriately. The communication with C fell below a reasonable standard, particularly as C was not informed that A was receiving end of life care. We upheld this aspect of the complaint.
The Partnership acknowledged that staff could have done more to ensure A had the requisite specialist equipment. There could have been better communication between the professionals involved in sourcing the specialist mattress A required. We upheld this aspect of the complaint.
We also found that the handling of C’s complaint fell below a reasonable standard, as the Partnership had issued a response containing factual errors. We upheld this aspect of the complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified in this complaint, which resulted in inaccurate complaints responses being issued. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
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 202106438 as a PDF (26.91 KB) Updated: September 20, 2023