Decision Report 201900126

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received at the Victoria Hospital. Mrs A had been deemed appropriate for discharge home but Mrs C and her family were concerned that Mrs A had lost weight and that her pain was not under control at the date of discharge. Mrs A had to be readmitted to hospital the day after discharge and passed away a number of hours later.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that initially Mrs A had received an appropriate medical review which had determined that Mrs A would be fit for discharge. Mrs A had reported pain while in hospital and additional pain relief had been prescribed to supplement her usual pain relief which she received at home. However, between the period of making the decision that Mrs A was fit for discharge and the actual date of discharge, Mrs A required additional pain relief which had not been resolved at the point of discharge. We found that the staff involved should either have allowed Mrs A to remain in hospital until her pain issues had resolved or discharged her home with additional pain relief. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to ensure that Mrs A's pain relief was under control at time of discharge. 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:

• Staff should ensure that a patient's pain relief is under control or addressed at point of discharge from hospital

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.