Decision Report 201504531

Summary

Mrs C, who works for an advice agency, complained on behalf of her client (Mrs B) who was concerned about the care and treatment given to her late mother (Mrs A) in Aberdeen Royal Infirmary. Mrs A had multiple sclerosis and was fed through a tube. Before her death in late 2014, she had been admitted to hospital on a number of occasions, mainly with breathing difficulties.

In mid-November 2014, Mrs A was admitted to hospital again, this time with diarrhoea and vomiting. Tests showed that her feeding tube was displaced and that she had colitis (inflammation of part of the large intestine) with a possible perforation (penetration of the organ wall). The situation was discussed with Mrs B and her mother and it was agreed that no surgery would be carried out. After being given antibiotics, Mrs A was noted to be improving although during her stay in hospital she also required treatment for a cyst.

Mrs A was discharged home in late November, but died later the same day. Mrs B believed that her mother had not been fit for discharge. She also complained that Mrs A had not been provided with appropriate care and treatment during her hospital admission and had not received a reasonable standard of nursing care.

We took independent advice from consultants in obstetrics and gynaecology and in gastroenterology, and from a nurse practitioner. We found that all of Mrs A's clinical care had been reasonable and appropriate but that aspects of her nursing care (particularly concerning washing and showering which led to a doctor asking the family to wash Mrs A) had not been, so we upheld that aspect of the complaint. Nevertheless, we found that Mrs A had been fit to go home on the day of discharge. While her death was unexpected, because of the number of diseases and conditions from which she suffered, there was no action that could have been taken to have prevented this.

Recommendations

We recommended that the board:

• make Mrs B a formal apology for the shortcomings identified in Mrs A's nursing care;
• advise us of the actions taken to ensure that patients with mobility issues can access shower facilities; and
• bring this complaint to the attention of the doctor who approached family members to wash Mrs A in order for the doctor to reflect on it as part of their appraisal/training plan.