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Case ref:201900247
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Date:June 2021
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Body:Lothian NHS Board - Acute Division
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained to us on behalf of their late relative (A) regarding treatment A received from the board leading up to their death. C said that the board had failed to provide reasonable nutritional care and treatment after A was admitted to the Royal Infirmary of Edinburgh suffering from complications due to poor nutritional intake. They considered that the board had unreasonably delayed in diagnosing the likely cause of this nutritional deficit. C also said that the board had failed to reasonably communicate with A and their family, as they were only informed of the likelihood that A would die with around 48 hours' notice, previously believing A was due to be discharged.
We took independent advice from an appropriately qualified adviser. We found that the board had provided reasonable nutritional care and treatment, with no delay in diagnosis. We therefore did not uphold those aspects of the complaint.
However, we also found that the board had failed to appropriately assess A's likely prognosis and communicate this to them or to their family. As such, we upheld this aspect of the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C and A's family for failing to reasonably identify and communicate their prognosis. 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:
- The board should carry out reasonable and realistic assessments of a patient's prognosis, clearly communicate those assessments to the patient and, where appropriate, to their family, and make a record of these discussions.
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.