Dementia patient failed by BGH

A woman whose elderly mother, suffering from dementia, fell five times while she was a Borders General Hospital patient at the end of 2012 is to receive an apology from NHS Borders.

The apology has been sought by the Scottish Public Services Ombudsman (SPSO) who, after an investigation, has delivered a highly-critical report on the level of care received by the patient, who is now dead.

The watchdog has also issued a raft of recommendations in a bid to ensure NHS Borders delivers the specialist care to which people with a cognitive impairment are legally entitled.

The probe identified a significant number of failings in the care and treatment of the patient, who is referred to as Mrs A in the SPSO report published last week.

Mrs A, a resident of a care home, had been admitted to the BGH after a fall on November 20 and discharged on December 4, only to be readmitted two days later and discharged again on December 17.

Her daughter complained about aspects of her late mother’s treatment, believing she had been discharged too soon and had been treated poorly because of her cognitive impairment.

Ombudsman Jim Martin, who took independent nursing and medical advice during his investigation, concluded that Mrs A was not discriminated against because she had dementia.

But he said the failings meant her rights as a patient with dementia had been infringed and that many of these failings related to a failure to provide appropriate care and support to someone with cognitive impairment, or to follow the legislation that provides protection for someone with cognitive impairment who requires medical treatment.

The report states: “Care seemed to be poorly led and coordinated. There was no evidence of a full care plan and, despite the fact Mrs A had been admitted to the hospital because of a fall and had five falls during her stay, there was no completed falls assessment in the clinical records or any evidence of a falls prevention plan.

“There was limited evidence of the involvement of medical staff and communication with the family was sporadic and poor.”

Mr Martin added: “Pain and nutritional assessments were inadequate.”

Mr Martin’s recommendations to NHS Borders include a requirement that national dementia standards should be met and that the presence of cognitive impairment is given due regard in the planning and implementation of care.

The health board has been told to improve record keeping in wards caring for patients with cognitive impairment, to ensure appropriate nutritional care plans are implemented for each patient, to adopt good practice in relation to the prevention of falls and to review its discharge policy.

A health board spokesperson responded: “NHS Borders has accepted the recommendations in the SPSO report and will complete these actions in a timely manner to ensure lessons can be learned from these experiences.

“We have assured the ombudsman’s office that we fully recognise and regret the aspects of the patient’s treatment which did not meet expected standards, and we will take what has been learned from this experience to improve our service in the future.”