Highland health board told to implement recommendations after Scottish Public Services Ombudsman (SPSO) finds ‘significant’ care failings over brain bleed patient who died after hospital fall
A hospital patient who suffered a bleed on the brain after falling in a ward and died several days later experienced “significant and serious” failings in their care, a report has ruled.
The Scottish Public Services Ombudsman (SPSO) issued their findings this week after a complaint was made over “a lack of basic nursing care” towards the patient by NHS Highland.
The health board has been ordered to improve its complaints handling process, but will not need to make any other improvements after the SPSO ruled that it had already implemented measures in response to this incident that have since resulted in “significant improvements to patient care”.
Issuing its report, the SPSO said that a person, referred to as ‘C’, had made a complaint on behalf of their client, person ‘B’, about the “care and treatment” given to B’s late parent while in hospital - who the report only refers to a patient ‘A’. The hospital was not named.
The report said that ‘A’ fell on the ward, suffered a cerebral haemorrhage and died several days later, after which ‘C’ had complained there had “been a lack of basic nursing care, a failure to carry out and record nursing risk assessments and routine observations and a failure to maintain documentation to a reasonable standard”.
‘C’ also complained that the level of communication and information sharing with ‘A’s family was “unreasonable”.
The SPSO report noted that, in response to the complaint, NHS Highland’s health board had acknowledged there had been failings and explained that action had been taken in response.
Issuing its ruling, the SPSO said: “We found that there were significant and serious failings in ‘A’s care in relation to a failure to consider delirium, the absence and recording of regular vital signs monitoring and observations, a failure in fluid balance management, poor record keeping, a failure to move ‘A’ in the ward offering more visibility, a lack of a pharmacology review and a failure to have in place an escalation process for staff concerns.
“Therefore, we upheld the complaint. However, we recognise the learning already implemented by the board which has led to significant improvements to patient care and addressed the failings identified in this case.
“We also provided feedback on the score given on the Serious Adverse Event Review (SAER) report, which was not reflective of the failures identified in this case. SAERs should be reviewed in a timely manner in partnership with the patient and/or their family/carers.”
Following its ruling it recommended that people making complaints “should be kept updated on their complaints in line with the Model Complaints Handling Procedure”.
The SPSO added; “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.”
Responding to the publication of the report, a spokesperson for NHS Highland said: “We fully accept the findings of the SPSO report. The report recognises the learning that has already been implemented which has led to significant improvements in patient care and addressed the failings that were identified in this case.
“In relation to complaints handling, as recommended by the SPSO, a Complaints Training Session has been held with the staff involved.”