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Case ref:201602612
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Date:May 2017
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Body:Tayside NHS Board
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:admission / discharge / transfer procedures
Summary
Miss C said her mother (Mrs A) had a complex medical history and was admitted to the Royal Victoria Hospital with reduced mobility and delirium (a temporary state of mental confusion arising from, amongst other things, infection). Mrs A was discharged to a nursing home eight days later. Miss C complained that Mrs A was not medically fit to be discharged from the hospital. Mrs A died several weeks after her discharge.
We took independent medical advice. We found that Mrs A was medically fit to be discharged and that the care package was reasonable. We therefore did not uphold Miss C's complaint. However, there were shortcomings in the way in which Mrs A was discharged. This included communication about Mrs A approaching the end of her life, meaning that Miss C was unprepared for Mrs A's death. We therefore made recommendations in relation to this.
Recommendations
We recommended that the board:
- review the discharge policy and communication with relatives in light of the failings identified;
- raise the failings identified with relevant staff; and
- apologise for the failings this investigation has identified.