Decision Report 201508660

Summary

Mrs C's elderly mother (Mrs A), who suffered from dementia, was a patient in the Royal Alexandra Hospital. During her admission, members of Mrs C's family visited to find Mrs A naked and lying in a wet bed. Her pyjama top had been removed and her drip displaced, soaking the bed. The family complained and were advised that on two occasions in the hours before the incident, Mrs A was noted to be settled. They concluded that she had removed her top herself. Mrs C was unhappy with this as she believed that given her illness and debility, Mrs A could not have done this. She complained to us because she felt that the board had failed to investigate her concerns appropriately. She was also unhappy about the way they communicated with her.

We took independent nursing advice and we found that the board's investigations had been poor. There was no documentation in Mrs A's medical records to confirm that she had been settled, the incident had not been noted in the file and no statements had been taken from staff who were present on the ward at the time. While it was possible that Mrs A could have removed her top, the board made an assumption that she had done so. There was no mention of Mrs A wearing pyjama bottoms and this was both unacceptable and undignified. The board's complaint response, given the seriousness of Mrs C's complaint, was not a reasonable one. We upheld the complaints.

Recommendations

We recommended that the board:

• make a formal apology;
• emphasise to staff the importance of taking full and timely records;
• review their internal investigations process and consider whether this requires to be audited; and
• review the need for staff on the relevant ward to receive specific training and education regarding distressed behaviour in people with dementia.