Summary
C complained about the nursing care provided to their late parent (A) whilst in hospital. They complained about a lack of adherence to infection control, poor staff attitude and breaches of uniform policy. C also complained that A had been issued a zimmer frame without appropriate assessment and guidance, and that staff inappropriately handled A when transferring them to a hospital trolley. C also raised concerns about the management of A’s medicines. A did not receive their prescribed medications and were able to self-administer after medicine was left in their possession.
Through the board’s own investigation of the complaint, they identified appropriate improvements to areas including staff behaviour, infection control, breaches in uniform policy, and moving and handling. C was unhappy with this response and brought their complaint to this office.
We took independent advice from a senior nurse adviser. We found that the nursing care provided to A had been unreasonable. The board were unable to evidence basic nursing care in A’s case due to poor documentation. We identified significant failures highlighting that appropriate assessments did not appear to have been carried out for A or documented during the admissions. Therefore, we upheld C's complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.
What we said should change to put things right in future: Nursing documentation should be completed to the required standard.
Patients should be issued mobility aids after proper assessment and instruction provided.
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 202305480 as a PDF (26.85 KB) Updated: September 17, 2025