SPSO Individual Decisions

Mrs C complained about several aspects of the nursing care that had been provided to her mother (Mrs A) at Western Isles Hospital and about the nursing staff's communication with the family. We took independent nursing advice. We found that while some aspects of nursing care were reasonable, the board had already carried out their own review which had identified a number of failings with care and communication and apologised for these. We found that there had been poor practice in relation to the use of a hoist when lifting Mrs A. We therefore upheld Mrs C's complaint.

Mrs C complained that the medical practice failed to identify that her father (Mr A) had cancer. Mr A had multiple health issues and regularly attended the practice but it was not until the family eventually took him to hospital that he was diagnosed with an aggressive tumour. He died nine days later. The practice noted that there had been no change to Mr A's longstanding symptoms other than some worsening in the weeks before he died, and they did not consider that his cancer could have been detected much earlier or would have responded to treatment. We took independent medical advice from a GP who noted that the practice had arranged relevant investigations including chest x-rays, scans and blood tests. Although Mr A's liver function test results were noted to have been abnormal in the month prior to diagnosis, the practice had already arranged a colonoscopy and the adviser did not consider that further tests were indicated at that stage. When the tests were repeated two days prior to diagnosis, they showed a significant deterioration and the practice took appropriate steps to upgrade an existing ultrasound scan referral to urgent. The adviser noted that the hospital may have separately arranged investigations themselves around this time when Mr A self-presented with his family. However, we found that the practice had by then already taken reasonable and prompt action when they identified the deterioration in Mr A's liver function results. We therefore concluded that the practice did not unreasonably delay taking steps to have Mr A's cancer diagnosed and we did not uphold the complaint. Related reading View Decision Report 201508703 as a PDF (11.38 KB) Updated: March 13, 2018

Mr C has a diagnosed personality disorder and post-traumatic stress disorder (PTSD). He complained that the practice had refused to come to his home for a house call in relation to physical symptoms he was experiencing including a cough. When the practice initially declined the house call request, Mr C said that his PTSD had rendered him housebound. He later asked for a mental health referral. The practice advised that they needed to see him at a consultation at the surgery before this could be made and Mr C also complained about this decision. In addition, Mr C complained that his complaint to the practice had not been handled properly. After taking independent advice from a GP, we did not uphold either of Mr C's complaints about his care. We found that Mr C had been seen recently at the practice and that it was reasonable to ask him to attend for an assessment of his physical symptoms. The GP adviser also considered that it was reasonable to require a face-to-face consultation before making a mental health referral. We also took independent advice from a mental health adviser. The mental health adviser said that the practice's approach was reasonable but highlighted the fluctuating symptoms of PTSD and considered that their approach may need to change in future. These comments were drawn to the practice's attention. However, we found no evidence that Mr C had been provided with information about the Patient Advice and Support Service and the final response to Mr C's complaint did not include information on how to progress his concerns if he remained dissatisfied. We upheld this aspect of Mr C's complaint.

Mr C complained that he received poor wound care following surgery. He said this resulted in his wound splitting open at home and he had to be readmitted to Western Isles Hospital. Mr C experienced protracted pain and distress due to the condition of his wound. We took independent advice from a nursing adviser and found that the risk of infection had been discussed with Mr C as part of the consent process before his surgery. We also found that the nursing records, including assessments and charts, were of a reasonable standard and demonstrated that Mr C's wound was appropriately monitored and treated before his initial discharge from hospital. Related reading View Decision Report 201507560 as a PDF (10.91 KB) Updated: March 13, 2018

Ms C raised concerns that the there was a failure to reasonably inform her of her treatment options prior to having a laparotomy (a surgical procedure that involves an incision being made into the abdominal wall) at Western Isles Hospital. Two ultrasound scans of Ms C's pelvis, carried out six weeks apart, showed she had a cyst on her right ovary. Ms C said she initially understood that she was to have a laparoscopy (a surgical procedure to access the abdomen and pelvis) to treat the cyst and only learned at a pre-operative appointment that she was to have a laparotomy. The board accepted that more explanatory detail could have been provided to Ms C. We took independent advice from a medical adviser who said that the entries in Ms C's medical records indicated that she was always to have a laparotomy, and as she thought she was having a laparoscopy, she evidently had not been given enough information to make an informed choice about her treatment options. Also, it was unclear if the risks of surgery had been explained to Ms C. Therefore, we upheld this part of the complaint. Ms C also complained she had not been provided with reasonable care and treatment. When Ms C had the laparotomy, no cyst was found on her right ovary and she questioned this. The adviser agreed with the board that the most likely explanation was the cyst had ruptured before surgery. The adviser also said that overall, the care and treatment Ms C received was reasonable. We agreed with this and did not uphold this part of the complaint. Ms C further complained that she was not provided with reasonable post-operative care. She said that following the laparotomy she suffered continuing abdominal pain and tenderness. The advice we received was that the symptoms Ms C was experiencing post-operatively were not unusual and would be expected. There was also no evidence she had a post-operative infection. While we did not identify any failings in Ms C's clinical care we considered there were

Mrs C's husband was an adult with incapacity and she was his power of attorney. He was diagnosed with an abscess on his right kidney and had to be transferred by air ambulance to a hospital in another board area. Mrs C accompanied her husband in the air ambulance and arranged to stay in accommodation near to the hospital. She sought to claim back the accommodation expenses from the board but her claim was refused. Mrs C complained that the board acted unreasonably by failing to refund her accommodation expenses. Following our investigation, we established that the board had followed their patient travel policy when reaching a decision on her claim. Section 10.2 of the policy was clear that travelling in the air ambulance did not make an individual an escort for the purpose of the policy and that they would be responsible for their own accommodation and return expenses. Therefore, we did not uphold Mrs C's complaint. Related reading View Decision Report 201507738 as a PDF (11.02 KB) Updated: March 13, 2018

Mr C complained about the care and treatment of his late wife (Mrs C) during several admissions to Western Isles Hospital, following a fall. Mr C said they were initially told there were no breaks or fractures, but he found out over a week later that in fact Mrs C had several rib fractures. He then found out several weeks after this that Mrs C also had a fractured vertebra. Mr C complained about the delay in diagnosing the fractures, and raised concerns about the overall medical and nursing care. He also said staff told him he would be refunded for his expenses when he accompanied Mrs C to a hospital on the mainland, but the board later refused to reimburse him. The board explained that Mrs C was very ill, with a severe chest infection and a number of medical conditions. They said the rib fractures appeared to be old, and would not have changed her treatment. They also said Mr C was not eligible to be reimbursed for his expenses under their travel policy (and they had updated their information leaflet to make this clearer). The board agreed that some aspects of Mrs C's care could have been better, in particular management of her diabetes, and they took actions to improve this. After taking independent medical and nursing advice, we upheld two of Mr C's complaints. We were not critical that staff did not identify Mrs C's fractures on the original x-rays, but we were concerned that there was a delay in the reporting of scans, which meant that staff were unaware of Mrs C's fractures for some time. We also found that staff failed to investigate a new symptom of pain when Mrs C returned to hospital a few days after her fall. Finally, we found there was evidence that nursing staff thought Mr C was eligible for reimbursement under the travel policy (so it was likely they gave him inaccurate information about this).

Mr C complained about a GP during a home visit deciding not to refer his wife (Mrs C) to hospital. Mr C was particularly concerned that Mrs C had been treated with steroids during a recent hospital admission for a chest infection, and this was likely to affect her diabetes. The GP said that, during the home visit, they considered Mrs C was suffering from diabetes and a flare-up of her chronic obstructive pulmonary disease (COPD - a disease of the lungs in which the airways become narrowed). However, they said there was no evidence of a chest infection. The GP said the steroid treatment was important for Mrs C’s COPD (although it had a negative impact on her diabetes control) and they encouraged Mr C to continue this treatment. The GP considered their actions were appropriate. After taking independent medical advice from a GP adviser, we upheld Mr C’s complaint. In relation to Mr C’s concerns about the steroid treatment, we found that the GP acted appropriately by advising Mr C to continue this (as the benefit to Mrs C’s COPD outweighed the impact on her diabetes). However, the adviser explained that Mrs C had lower oxygen saturation levels than when tested 11 days earlier, and the GP should have arranged further investigation of this (which would usually be done in a hospital setting).

Mrs C complained about the mental health care and treatment that her child had received. Mrs C considered that her concerns about autistic spectrum disorders and physical factors had not been taken into account by the board. She was also concerned that her child was not seen soon enough and was not assessed by appropriate staff. While recognising the complexity and severity of her child's condition, the board did not find evidence to support Mrs C's concerns during their consideration of her complaint. After taking independent advice from a psychiatric adviser specialising in child and adolescent mental health, we found that the actions taken by the board were reasonable. There was no evidence that there had been unreasonable delays in the assessment of Mrs C's child, or that the care and treatment provided was inappropriate. The adviser highlighted that the board’s liaison with another service was good and found nothing to suggest that the child had been misdiagnosed. Related reading View Decision Report 201403403 as a PDF (11.06 KB) Updated: March 13, 2018

Mr C complained to the practice that he was concerned that his daughter (Miss A) had been inappropriately prescribed medication for bladder problems. He felt that this was not clinically indicated and was for convenience only, and that Miss A was at risk of side effects from the medication. The practice believed that the medication was appropriate for the symptoms Miss A presented with. We took independent advice from one of our medical advisers, an experienced GP. Our adviser was satisfied from the medical records that, given Miss A's reported symptoms of urinary frequency and medical history, the medication was appropriate. We found that the practice's actions in prescribing the medication was appropriate and we did not uphold Mr C's complaint. Related reading View Decision Report 201404149 as a PDF (10.96 KB) Updated: March 13, 2018

Mr C, who is a solicitor, brought a complaint on behalf of his client (Mrs A) about the service she received after her GP referred her to a psychiatric department. Mrs A complained that the board failed to meet their targets and that her treatment did not meet any reasonable standard of care. She explained that she had requested referral to a psychologist. During our investigation, we took independent advice from a mental health adviser. The adviser said that the Scottish Government's referral-to-treatment waiting time target of 18 weeks did not apply to mental health services. However, Mrs A had received treatment from a community psychiatric nurse (CPN) 12 working days after they received the referral. She was also seen by a consultant psychiatrist ten weeks after the GP referral. Both these appointments fell within the target times. Mrs A was also offered further appointments with a CPN and a senior charge nurse trained in cognitive behaviour therapy (CBT), but Mrs A declined these. The adviser said that there were delays in relation to the referral for a psychology assessment to be carried out and, thereafter, in re-referring Mrs A to the local CBT service. We found that both these periods of delays were unreasonable, but we were satisfied that lower intensity psychological therapy had been progressed from the outset and higher intensity therapy was not initiated because Mrs A declined an appointment with the senior charge nurse trained in CBT. The adviser was also satisfied that the care offered and delivered was reasonable. However, we were concerned that Mrs A had not signed the care plan that had been prepared, and which set out her presenting difficulties, the goals of the nursing care and the interventions planned, and that there was no evidence in the medical records that she had agreed the plan. We were satisfied that it was reasonable to refer Mrs A to a CPN in the first instance and that it had been explained to her that referral to a psychologist was

Mr C said that he had been suffering pain from his rib cage for a number of years and believed he had a displaced rib. He complained that the board delayed in providing him with treatment or a firm diagnosis. He wanted to be referred to a chiropractor (a practitioner who uses their hands to treat disorders of the bones, muscles and joints) and was unhappy that the board declined to provide this. After taking independent advice from one of our medical advisers, and considering Mr C's medical records, our investigation found that while the treatment given to Mr C took place over a considerable period of time, there were no periods of unreasonable delay. The x-rays carried out were appropriate and timely. Although Mr C wanted to be referred to a chiropractor, our adviser said that physiotherapy was an acceptable, reasonable alternative, and the board had provided this. Related reading View Decision Report 201306310 as a PDF (11.03 KB) Updated: March 13, 2018

Mrs C was concerned by the care and treatment provided to her late mother (Mrs A) by a GP at the medical practice. Mrs C was unhappy that although Mrs A was complaining of pain and discomfort in her leg, the GP failed to consider the possibility of deep vein thrombosis (DVT - a blood clot in a vein). A month later, Mrs A died of a bilateral pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). To investigate the complaint, we carefully considered all the relevant information (including the complaints correspondence and Mrs A's relevant clinical records) and obtained independent advice about Mrs A's care and treatment from one of our medical advisers, who is a GP. We found that the GP's treatment of Mrs A was reasonable and that the records showed why he had not suspected DVT, given the symptoms that Mrs A had at the time. The adviser said that a clinical picture may at the time not be as clear cut as when looking back and considering a matter with hindsight. In the circumstances, the adviser thought that it was reasonable for the GP not to consider DVT. We noted that, since Mrs C's complaint, the GP had clearly reflected on what had happened, and had reviewed local guidelines in attempt to prevent this happening again. Although we did not uphold the complaint, we made recommendations that the GP takes further steps to ensure good clinical practice. We upheld Mrs C's complaint about complaints handling, as we found that timescales were not met when responding to her letters.

Mr C complained to the board that he had concerns about the validity of an application to provide a community pharmacy in his local area. The board responded that the applicant had fulfilled the criteria to allow the application to proceed to the next stage of the approval process. Mr C complained to us that the board failed to address his concerns about the competency of the application. We found that, technically, the board had acted in accordance with the procedures although we did think that they could have provided Mr C with additional information - ie that his concerns would be considered by the committee considering the community pharmacy application in due course. Related reading View Decision Report 201304881 as a PDF (10.88 KB) Updated: March 13, 2018

Mrs C was expecting a baby. When she was 35 weeks pregnant, a routine scan raised concerns about her baby's heart rate and it was suggested that she be flown by air ambulance to the mainland for an emergency caesarean section (an operation to deliver the baby). Mrs C's husband (Mr C) and young child were with her at the appointment, and she asked if they could travel with her. She was told that, whilst Mr C would be permitted to travel with her as an escort, the board would not agree to provide travel arrangements for their child. As there was no-one available locally to look after their child, Mrs C had to travel alone in the air ambulance while her husband and child followed separately on a commercial flight. Because of this, Mr C was not with her for the birth. Mr and Mrs C's baby died three days after being born. Mrs C complained about the board's decision about the travel arrangements. She said that for the return journey, whilst the board arranged return flights for her and Mr C, they could only provide her with the phone number of the airline and a booking reference so that she could make her own arrangements for their child to travel back with them. She did not feel that the board took account of her circumstances or the physical and emotional stress she was under at the time. She also raised concerns about their handling of her complaint. We upheld both of Mrs C's complaints. We found that the board's decisions were made with reference to their patient travel policy, which is primarily designed to reclaim relevant expenses incurred when travelling to and from mainland hospital appointments. This was appropriate for the return element of the travel, and we were satisfied that the policy was correctly applied for that journey. However, the policy specifically says that it does not apply in emergencies, or cases where the patient is being transferred between hospitals. Both of these criteria applied to the outward journey in Mrs C's case, and we c

Ms C was operated on at the Western Isles Hospital for a labial abscess (a painful swelling caused by a build-up of pus in part of the female genitals). Ms C had undergone a kidney and pancreas transplant in 2007. She complained that although her medical records said that the transplant team should be contacted prior to any surgical procedures, this had not happened. Ms C said that this had placed her at great risk, as the drugs she took to prevent her body rejecting the transplant suppressed her immune system, meaning she was at increased risk of infection. Ms C also complained that she was not provided with reasonable care after the surgical procedure. She was discharged, despite being in great pain, and was then readmitted as the wound had become infected. Ms C suggested that she should not have been operated on in the first place and said her view was supported by the fact that on her second admission she was transferred to another hospital for treatment. We took advice from two medical advisers, a specialist in the management of transplant patients and a specialist in gynaecological surgery (surgery of the female reproductive system). They said that the records showed that attempts had been made to contact Ms C's transplant team. However, the advisers said that the nature of the infection, combined with Ms C's suppressed immune system, meant it would not have been reasonable to delay her operation. They said that a reasonable care plan had been put in place, and the medical record showed that she was free of infection at the time of her discharge. Our investigation found that Ms C had undergone the appropriate surgical procedure for a labial abscess, and that the care she received after the procedure and the decision to discharge her had both been reasonable. We found it would not have been appropriate to delay surgery whilst awaiting the response of the transplant team. Our investigation also found, however, that the attempt to obtain advice from the transplan

Mrs C, who lives on one of the Scottish islands, complained that the board failed to repay her full transport and accommodation costs when she escorted her mother to a mainland hospital for in-patient treatment. Mrs C had intended to stay for four nights, then take her mother home but, as her mother was not well enough to leave hospital on the expected date, Mrs C had to return home alone. She was unhappy that, in these circumstances, the board had not paid her full costs. The board's patient transport policy says that they can only reimburse costs associated with escorting a patient to and from hospital. Mrs C had chosen to stay over, and the board explained that as her mother was not discharged when expected, there was only one approved journey for which an escort was required. They also explained that they can only reimburse accommodation costs when the escort stays and escorts the patient home (provided that the total cost of the stay does not exceed the cost of a second return fare to collect the patient). If the patient is not discharged when expected, accommodation costs cannot be reimbursed, but the board will pay for a second return journey to escort the patient home. We also found that the guidance says that authorised escorts are expected to return home at the earliest opportunity or to stay at their own expense. We noted that the patient travel team had advised Mrs C of the available options before the outward journey. On her return they had said that they would be happy to book a second flight for her to collect her mother, or alternatively if she organised her own flight for this, they would pay her overnight accommodation claim. We did not uphold the complaint as we found that the board had acted in accordance with their procedures. We noted that although they were of the view that they had provided accurate information before Mrs C travelled, the board had also asked the patient travel team to review the guidance issued to patients and GPs,

Mr C complained that the board failed to take reasonable steps to fund travel and accommodation costs for his mother (Mrs A) following his father's emergency transfer to a hospital on the mainland. Mrs A wished to accompany her husband but there was no room in the ambulance, and so she made arrangements to travel to the mainland herself. Mrs A's GP had signed a post-dated escort authorisation form for her. Because of this she submitted an expenses claim, expecting the board to pay her costs, but they refused to do so. Our investigation found that the board's policy says that they will only fund costs when someone is required to escort a patient who needs their support when travelling. This does not apply where the patient has travelled by ambulance, nor where family members to travel to be with someone who had been taken to hospital, and so the GP had incorrectly signed the form. Because of this, we did not uphold Mr C's complaint. In responding to our enquiries, the board also explained that they intended to highlight the requirements of the patient travel policy to all GPs in their area to ensure that the correct information is provided to families in future.

Mr C attended the hospital's accident and emergency department (A&E) during the night, as he was concerned that he might be experiencing a repeat of a chest condition he had had some years previously. After discussion with a nurse, he was shown to a phone and advised to speak to the person at the other end, who turned out to be from the out-of-hours GP service, NHS 24. NHS 24 advised him to return home, and that they would phone him within an hour to assess his condition. Mr C felt that his situation had not been taken seriously and he left. NHS 24 phoned him three times at home, but Mr C felt too distressed to answer their calls. In the morning, he saw his GP, who diagnosed a chest infection. We explained to Mr C that it is NHS policy that someone should only attend A&E if they have an emergency and that, if they need to see a GP outside their practice's opening hours, they should phone NHS 24. NHS 24 then assess, by phone, whether the patient needs to see a GP and, if so, whether they should travel to the out-of-hours GP, or whether the out-of-hours GP should visit them at home. The papers we received from the board showed that, when Mr C arrived at A&E, the nurse considered whether he did need emergency care and spoke to a doctor, who decided that this was a matter for NHS 24, rather than A&E. We did not uphold the complaint because the hospital appropriately established that Mr C needed to contact NHS 24, rather than themselves, then helped him contact them. We also noted that the board said that, because of Mr C's complaint, if someone arrived at A&E but needed to contact NHS 24, staff now made the phone call themselves, giving NHS 24 the relevant details. NHS 24 would then phone the patient back. They believed this would improve their service for patients, and we welcomed the board's use of a complaint as an opportunity for learning and improvement. Related reading View Decision Report 201203271 as a PDF (11.59 KB) Updated: March 13, 2018

Ms C has a clinical need for a hysterectomy (surgery to remove the womb), and was to be referred to hospital for treatment. Her social and domestic circumstances meant that she did not wish to be treated at the local hospital. She discussed this with her GP and her GP requested she be referred outwith the board's area for her operation. The medical director reviewed the request, but declined it on the basis that the procedure could be carried out locally. Ms C appealed, and the chief executive reviewed the decision and also declined it as he agreed with the medical director's decision. As part of our investigation, we asked to see the protocol that the board use to consider extra-contractual referral (ECR - where a person is referred for treatment elsewhere). We found that the protocol did not say that the medical director could decline an ECR - rather, an ECR panel should have considered and decided on Ms C's request. We upheld Ms C's complaint, as we found that her request had not been reasonably considered by the board in line with their protocol, which was that such requests should initially be considered by an ECR panel.

Mrs C, who is an advocacy worker, complained on behalf of her client (Mr A) that the board did not make information about NHS continuing healthcare publicly available. Mr A had disputed the grounds on which his late father was considered liable for care home fees, as he felt that his father's placement related to health needs rather than social care needs. At the time of the placement, Mr A was not told that the NHS could fund care costs in care homes. Our investigation found that Mr A's father had been placed temporarily in the home for respite care, and he did not require an emergency hospital admission. The decision was then taken to make the care home placement permanent and health board staff were not asked to contribute to any assessments. The board accepted that at the time of the placement they had not made information about NHS continuing healthcare publicly available. They had since done this, and had apologised to Mr A. Related reading View Decision Report 201101410 as a PDF (11.12 KB) Updated: March 13, 2018

Mr C had a history of skin cancer and suffered from a back condition. He complained that the board failed to: make a full and accurate diagnosis of his back condition, provide him with appropriate treatments including alternative therapies, and explain the prognosis. Mr C also complained that the board failed to provide him with a report containing this information to allow him to claim appropriate benefits. In addition, Mr C complained that the board failed to ensure that there was adequate communication between different departments in the board and medical professionals from other boards on the diagnosis and treatment of his condition. We did not uphold Mr C's complaints. After looking at the clinical records and taking advice from one of our medical advisers, we found that hospital staff did diagnose Mr C appropriately. They also made recommendations for treatment and made him aware of what his condition was and the outlook for it. Mr C had told us that he asked specific staff for a report for benefit purposes at consultations. The board said Mr C did not ask staff for such reports, and we found no mention of this in the clinical records. In addition, the board said that staff were only required to complete reports sent to them by the relevant benefits agency. We also found evidence in Mr C's clinical records that hospital staff did communicate adequately and in reasonable time, both within the board and with relevant staff from other health boards, about the diagnosis and treatment of Mr C's condition. Related reading View Decision Report 201100704 as a PDF (17.14 KB) Updated: March 13, 2018

Mrs C attended a hospital accident and emergency unit in 2005 with a suspected deep vein thrombosis (DVT). DVT was not, however, diagnosed and Mrs C was sent home. In 2011, Mrs C's health deteriorated and an electrocardiogram (a test that measures the electrical activity of the heart) showed that she had a heart abnormality called a left bundle branch block (LBBB). On reviewing her past medical records Mrs C saw that this was actually diagnosed in 2005 but that no action had been taken. Mrs C is now on numerous medications for angina, heart failure and increased blood pressure. Mrs C complained because she felt that treatment should have been provided in 2005, and that she should have been seen by a heart specialist and had a thorough review of her heart condition. We found that the finding of LBBB in 2005 was picked up by chance and was unrelated to the matter which was being investigated (which related to pain in Mrs C's leg). Also, at that time, Mrs C was not exhibiting any sign of heart problems. The guidelines that were in place in 2005 for dealing with patients with cardiac problems have been updated and replaced by new guidelines that include preventative action to reduce the consequence of further cardiac problems for such patients. We found that the care and treatment provided to Mrs C in 2005 was, therfore, appropriate at the time. Related reading View Decision Report 201102374 as a PDF (17.27 KB) Updated: March 13, 2018

Mrs C made a number of complaints about the care and treatment provided to her mother (Mrs A) when she was admitted to the Western Isles Hospital for two days. We found that although staff had recorded that Mrs A was allergic to plasters, they continued to apply them to her. We were satisfied with the action taken by the board in response to Mrs C's complaint about this. However, we found that the record-keeping in relation to the assessment of Mrs A was not satisfactory and that there was no evidence of a risk assessment. We did not uphold a number of Mrs C's complaints. There was no evidence that staff had failed to use a hoist when lifting Mrs A. We also considered that it was reasonable for staff to decide to keep her in bed rather than hoisting her onto a chair, as she was due to be seen by a doctor. We found that after the initial assessment, there was evidence that the board had listened to the family's views in relation to their mother's care needs. There was no evidence that staff had failed to ensure that Mrs A had a means of summoning help. Mrs C also complained about the board's handling of her complaint. However, we found that it was reasonable to interview her brother about an allegation that a member of staff had been rude to him. There was no evidence that the board had breached confidentiality when they spoke to him. We also found that the board had not blamed the family for the problems that had occurred, but had tried to provide an explanation about how they had arisen. Recommendation We recommended that the board: • remind nursing staff in the hospital of the importance of good record-keeping in relation to the assessment of patients on admission. This should include risk assessment and should involve obtaining information from relatives and/or carers. Related reading View Decision Report 201101188 as a PDF (19.06 KB) Updated: March 13, 2018

Mrs C, who was the manager of a care home, complained to the board about the way one of her residents (Mrs A) was discharged from hospital back to the care home. Mrs C felt that it was inappropriate to have discharged Mrs A as she was in an unkempt state, was agitated; had struggled with ambulance staff; and that Mrs A's safety, along with that of care home staff, was at risk. When Mrs C tried to have the hospital re-admit Mrs A, she was told the bed was no longer available. Mrs C also complained that the board's investigation of her complaint had not included seeking comments from clinical staff who had attended Mrs A following her discharge. We established that Mrs A had been admitted to the hospital for an assessment and that when this had been completed then there was no clinical reason for her to remain in hospital. We did establish that there had been a communication issue between hospital staff in that initially Mrs A's hospital bed was to have been kept available for a time should she not settle back into the care home. However, from a clinical perspective it had been appropriate to discharge Mrs A from hospital. We also found that the board's investigation of the complaint was reasonable and it was for them to decide who should be contacted to provide comments as part of their investigation. Related reading View Decision Report 201101619 as a PDF (14.03 KB) Updated: March 13, 2018