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Case ref:202203153
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Date:May 2024
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained that the board failed to provide their spouse (A) with reasonable care and treatment during an in-patient admission to hospital for a fractured hip. C who is A’s Power of Attorney also complained that the board failed to communicate adequately with them and A’s family.
We took independent advice from an orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found that the board had failed to provide A with adequate care and treatment, particularly in relation to pressure care management. We found that the board had failed to maintain a reasonable standard of care records. We also found that the board failed to communicate adequately with C and A’s family. Therefore, we upheld C’s complaints. Additionally we found that the board failed to adequately investigate C’s complaint and made a recommendation to address this.
In response to our enquiries during our investigation, the board sent us a detailed list of actions that they have taken to address and learn from the failings we identified. We considered that these were reasonable, but that further learning could be identified.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for failing to provide A with reasonable care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
- Apologise to C for the failings in communication identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
- Apologise to C for the failings in the board’s complaint handling identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
- Provide C with a copy of the action plan (redacted to remove any personally identifying or otherwise sensitive details) and an update on the progress of implementation.
What we said should change to put things right in future:
- All relevant documentation including the nursing notes should be completed in accordance with the relevant policies and guidance.
In relation to complaints handling, we recommended:
- Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure.
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.