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Case ref:201910934
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Date:February 2022
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Body:Lanarkshire NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Admission / discharge / transfer procedures
Summary
C made a complaint about their late parent (A)'s discharge from University Hospital Hairmyres. C believed that A was not fit to be discharged and that this resulted in A having a fall, and sustaining an injury which then contributed to A's death.
We took independent advice from a physiotherapy adviser and a consultant physician and geriatrician (a speciality focussing on the health care of elderly people). We found that a comprehensive geriatric assessment was not carried out during A's admission. Given that this is a requirement outlined in the Healthcare Improvement Scotland (HIS) Care of older people in hospital standards, we considered it was unreasonable that no assessment appears to have been carried out. This may have provided a more comprehensive view of the issues affecting A.
We also found that A's case was not discussed at a Multidisciplinary team (MDT) meeting prior to A's discharge. If this meeting had taken place, the MDT could have considered whether A would have benefited from further rehabilitation (either in hospital or in the community).
Given that an MDT meeting did not take place prior to A's discharge, and given the lack of a comprehensive geriatric assessment in line with HIS standards, on balance, we considered the decision to discharge A was unreasonable. We upheld C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for not carrying out a comprehensive geriatric assessment during A's admission and for not discussing A's case at a Multidisciplinary team (MDT) meeting prior to their 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:
- Clinicians should have access to MDT meetings including all appropriate specialties to discuss patients on geriatric units who have MDT input.
- Older people presenting with frailty syndromes should have prompt access to a comprehensive geriatric assessment in line with Healthcare Improvement Scotland standards.
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.