Summary
C complained that the board failed to reasonably communicate with their family when their parent (A) was admitted to hospital. A was taken to A&E following a fall at home.
A was moved to a ward following an x-ray and medical review showing that A had broken their hip. A underwent an operation later that day and remained in hospital until their discharge nearly seven weeks later. C also complained about the nursing care that A received.
We took independent advice from a nurse. We found that there was a failure to communicate with the family about the consequences of delirium. We also found that there was a failure to ensure A had access to bread/toast and milk. There was a lack of acknowledgement and details regarding A’s lost dentures, a failure to inform A or C that A had developed a hospital acquired pressure ulcer, poor record keeping and a lack of evidence of appropriate nutritional care interventions being followed. Therefore, we upheld C’s complaints.
Recommendations
What we asked the organisation to do in this case: Apologise to A and C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .
What we said should change to put things right in future: Where appropriate, there should be discussions with family members in relation to diagnosis, treatment and management. An appropriate record of this should also be made.
Blankets should be available for patients on wards, particularly those that care for elderly, frail patients. When wards run out of blankets, there should be a process in place to obtain replacements without delay.
Bread and milk should be made available on the ward in line with the Food in Hospitals specification. Toast should be made available to patients where this has been specifically agreed.
Patients should be changed into nightwear as appropriate or offered a hospital gown where no personal nightwear is available.
Patients experiencing delirium should be given additional assistance to help secure or monitor their personal possessions and in particular, dentures.
Staff should be compliant with the Duty of Candour legislation and inform patients/relatives if they come to harm.
Patient documentation should be completed to an appropriate standard and in line with the required standards of the Nursing and Midwifery Council: The Code in relation to record keeping.
Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring and recording. In addition, this should be appropriately documented.
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 202402369 as a PDF (31.74 KB) Updated: March 19, 2025