Decision Report 201807032

Summary

Ms C complained about the nursing care that her partner (Ms A) received at Queen Elizabeth University Hospital while she was recovering from brain surgery. We took independent advice from a nursing adviser. We found that the nursing care provided to Ms A was reasonable and did not uphold this aspect of Ms C's complaint.

Ms C also complained about the medical care and treatment that Ms A received. We took independent advice from a consultant in acute medicine and from a consultant neurosurgeon (specialist in surgery on the nervous system, especially the brain and spinal cord). We found that there was a lack of documented medical assessments regarding Ms A's orientation/confused status, and when confusion was identified, this was not appropriately investigated and documented. We also found that there was no consultant medical review prior to Ms A's transfer from Queen Elizabeth University Hospital to another hospital. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Ms A for the lack of documented medical assessments regarding Ms A's orientation/confusion status and the failure to carry out a consultant medical review prior to Ms A's transfer between hospitals. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients recovering from neurosurgery should have documented medical assessments of their orientation and where confusion is identified this should be investigated and appropriately documented.
• Where possible, in-patients should receive daily senior clinical review and these reviews should be 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.