Fife: Health board says sorry after Ombudsman findings

The Scottish Public Services Ombudsman looked into the case after a concern was lodged by family member, named as C, who complained about the care and treatment to their late parent, described as patient A, who suffered dementia and was experiencing worsening delirium following a urinary tract infection.

Patient A was admitted to hospital by an out-of-hours doctor who had visited them at home and C's sibling had accompanied A in the ambulance but was told that they were unable to stay with A in hospital due to COVID-19 visiting restrictions.

After being transferred to a side ward, A fell from the bed later that evening, which resulted in a head laceration and right hip pain. A head CT and hip x-ray were undertaken which confirmed a right hip fracture.

A was transferred to an orthopaedic ward but it was decided A would not survive an operation due to the fall and hip fracture trauma. The patient died a few days later.

The SPSO ombudsman said they took independent advice from a consultant geriatrician and a senior nurse in falls prevention.

The findings report stated: "We found that a reasonable level of information from A's family was recorded and taken into account by medical staff, that the assessment of A's delirium was reasonable and that it is common practice for a doctor to try and speak directly with a patient with significant dementia or delirium to allow them to assess the individual's capacity.

"We also found that it was reasonable to transfer A to a side room, that the action taken by medical staff following the fall was reasonable, as was the communication with the family," stated the report.

"Furthermore, that the pain relief was reasonable and was a priority of staff who saw A.

"However, we found that there were a number of failings in the nursing care and treatment provided to A. We found that it was unreasonable that no family members were allowed to stay with A, that there was a lack of information documented in the nursing records and a lack of completed paperwork in relation to assessments that should have been carried out on A.

"Whilst nursing staff's immediate attendance and commencement of the post fall assessment and escalation tool was reasonable, we also found that there was a delay in contacting the family and failure to use a straight lift. Therefore, we upheld this part of C's complaint.

"C also complained that the board failed to carry out a reasonable investigation into A's fall in hospital. We found that a serious adverse event review (SAER) should have been carried out instead of a local adverse event review (LAER). Therefore, we upheld this part of C's complaint."

The health board was told to apologise to C for the specific failings identified in respect of the complaint.

Responding to the case, NHS Fife's Director of Nursing, Janette Keenan, said: “We always aim to provide patients with the best care and treatment possible.

”This particular case was complex and while we note that the Ombudsman’s findings that much of the care we provided was appropriate, we accept also that there were areas where care could, and indeed should, have been better.

“We have written to family in this case to formally apologise. The actions identified by the Ombudsman are also in the process of being enacted in full.”

In a separate case, the SPSO ordered a Fife Medical practice to say sorry after a complaint was lodged about the care and treatment provided to their relative, described as A.

The complainant, known as C, said that A had attended the practice frequently within a year and was later diagnosed with an aggressive form of cancer and A died shortly after.

C believed that A's concerns were not properly taken into account when they attended the practice and that A should have been referred sooner for investigations. The practice provided a detailed reply to C, stating their view that A's concerns had been investigated appropriately, and that there had been no indication for a cancer referral.

The SPSO said they took independent advice and found that there was no reason to suspect cancer as a possible cause of A's symptoms.

However, they added: "As symptoms persisted, an urgent cancer referral should have been considered. We found that it was highly unlikely, given the aggressive nature of A's cancer, that the delay in A's diagnosis had any impact on the outcome of A's disease.

"Although A's initial treatment was reasonable, we found that there were failings in care in that the practice should have made an urgent referral for A sooner. We therefore upheld this complaint."

The practice was told to apologise to C and A's immediate family, for the failure to make a referral for A in line with the Scottish Government guidelines.