Decision Report 201602615

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) during his admission to Ninewells Hospital. In particular, Mrs C had concerns that the effects of the medication Mr A was prescribed for delirium were not monitored, and that after a fall whilst in hospital he was given a further dose of this medication. She also complained that he had not been reasonably checked and monitored throughout the night. By the time nursing staff came to check his observations the next morning, Mr A had died.

During our investigation we took independent medical and nursing advice. We found that the effects of the delirium medication were well monitored and that tests were carried out to ensure that there were no rare side effects. Therefore we did not uphold this aspect of Mrs C's complaint. The medical adviser suggested, however, that given Mrs C's concerns, the clinical team could have considered trialling a different medication. They also suggested that while overall the monitoring was reasonable, it would have been good practice to perform a test to check that Mr A's blood pressure did not fall significantly on standing. We made recommendations to address these points.

We found that after Mr A fell on the ward, he was not given any further dose of medication, but was checked thoroughly by medical staff and then reasonably monitored by nursing staff. Therefore we did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• draw the adviser's comments regarding the consideration of trialling alternative medications for confusion if families voice concern, and of documenting these considerations, to the attention of the relevant staff; and
• draw the comments of the adviser regarding the monitoring of blood pressure to the attention of the relevant staff.