Decision Report 201407749

Summary

Mr C, who works for an advice agency, raised a complaint on behalf of his client (Ms B) about the care her mother (Mrs A) received while in Glasgow Royal Infirmary. In particular, Ms B was concerned that staff failed to take account of her advice about her mother's early onset of Parkinson's Disease and that they failed to deal appropriately with Mrs A's mobility issues and the risk of falling while in the hospital. She also complained that the communication between the hospital staff about Mrs A's care was inadequate and that the board's complaint response was inadequate.

During our investigation, we took independent advice from a mental health adviser and a nursing adviser. We were satisfied that Mrs A's risk of falling was reasonably assessed on admission and there were regular and focussed assessments of mobility with involvement from medical, nursing and physiotherapy staff. We also found that the nursing assessments, charts and notes were of a good standard and that Mrs A's medical records were clear about her level of mobility and the assistance required. However, we were concerned that, while the advice we received from the mental health adviser was that Mrs A may have been able to comprehend and recall instructions and that prior to a fall in the hospital she had been assessed as safe and independent with a walking frame, Mrs A's abbreviated mental test score was ineffectively recorded in the medical records. We found that there was a failure to re-assess Mrs A's cognitive state and keep this under review while in the hospital.

We were also concerned that, while the board apologised for the delay in replying to Ms B's complaint, there was a failure to provide updates or provide an explanation for the delay.

Recommendations

We recommended that the board:

• ensure that where a patient presents with confusion and memory impairment, their cognitive state is assessed on arrival to the ward and kept under review;
• ensure that cognitive testing results are effectively recorded in the medical records; and
• remind staff of the importance of adhering to the NHS Scotland complaints procedure.