Decision Report 201405550

Summary

Ms C's mother (Mrs A) had been admitted to Stirling Community Hospital for palliative care (care provided solely to prevent or relieve suffering). Ms C complained that one day her mother was very distressed, saying she had been forced to get out of bed and stand, despite her begging them not to make her do so, as she had not been out of bed for a long time. Ms C said her mother, therefore, fell on the floor and had to be moved back into bed by a hoist. The board told Ms C that two staff members were moving Mrs A from her bed to a chair, but as she sank down towards the floor, they helped her to the floor, and from there they transferred her back to bed with a hoist. Ms C said her mother would never have agreed to stand or sit, feeling so ill that she simply wanted to lie down all the time.

We considered the medical records, which showed that staff wanted to assess Mrs A's mobility needs to see whether it might be possible to meet her wish to return home. The records also said that Mrs A had sat up on occasion. We took independent advice from our nursing adviser, who considered that, although we could not know whether Mrs A had wanted to be moved on the day in question, it was appropriate that staff should try to move her and also, when she moved towards the floor, that they should assist her in doing so, to prevent any injury. We did not uphold this part of the complaint.

Ms C also complained about the communication with the family during the admission. The records showed no discussion about necessary end of life planning issues after a certain date - for example, discussions about where Mrs A might want to die. Our adviser considered such discussions were important. In the absence of documentation to show that such discussions took place, we upheld the complaint. The board themselves had already acknowledged that communication could have been better and had taken action to help prevent a recurrence. Our adviser considered that such action was appropriate, and, therefore, we decided against making any recommendation for further action.