"Poor care of my elderly relative"
About: Inverclyde Royal Hospital / Respiratory Medicine Inverclyde Royal Hospital Respiratory Medicine PA16 0XN
Posted by ElizabethNHS (as ),
93 year old frail relative was admitted to Inverclyde Royal Hospital in Feb 15 with a chest infection. Our relative also suffered from other health conditions. After an acute phase in the main hospital our relative was transferred to the Larkfield Unit for rehabilitation. The care our relative received there was very poor, After an inpatient stay of approx six weeks unfortunately our relative passed away. This was not altogether unexpected. We did voice our concerns to nursing staff when issues occurred at the time. One of the doctors in charge we felt really was not interested in speaking/helping us, however we were very concerned with so many aspects of the care that we requested a copy of the case notes.
Without going into detail we had major issues with personal care (no bath/shower given to patient for the full 5 weeks of his inpatient stay),
oral hygiene was neglected -teeth were obviously not cleaned on a regular basis.
After referring to the case notes we also noted pressure sore chart completed incorrectly.
nutrition- first seen by dietitian 14 days after being admitted to the unit- weight loss during the inpatient stay was greater than 10% in a short space of time. Our relative was not eating/drinking enough. We feel that staff, were aware but Did not escalate the problem, however recorded it in the notes regularly with no action.
A Dieteticn review recommended a prescription of high energy drinks- this instruction was ignored for three weeks despite being recorded in the clinical notes and nursing notes and was only rectified when the dietician realised the mistake .As a family we were unaware of this major error at the time. This error in our opinion definitely hastened death. Despite major weight loss and poor oral intake nobody bothered to implement the instruction to commence drinks and they were not prescribed. We believe this would have given an extra 500calories per day.
Fluid balance charts / food charts were completed to such a low standard it was embarrassing. No evidence of any senior nurse "signing off" these “ complete” charts.
Medicine administration-often as relatives we found tablets on the bedside table not ingested, however they had been signed as given by the nursing staff. Patient was also severely dehydrated however a diuretic continued to be offered and no review of my relatives medication appeared to take place. Also, digoxin levels were not taken..
Observation charts- near end of life - mews scored as 4 (which means four hourly obs-) was checked at 17.20 . next checked 34 hours later! ! ) unacceptable.
Death certificate- delay of 36 hours to obtain said document, and then no cause of death was entered. This caused more distress and delay when registering the death.
This summary is very brief, and we had many more issues.
Our first letter of complaint was submitted to Greater Glasgow and Clyde and acknowledged in early June 15( before we had reference to the case notes). The reply (mid August 15) (delayed and in breach of the guidelines) acknowledged some of the poor standards of care. After receiving and reading the notes I was appalled by the extremely poor level of documentation spanning the complete length of his inpatient stay.
I was so concerned I really believe that it constituted basic institutional neglect that we submitted a further letter of complaint which lead to a face to face meeting with a panel of representatives from the hospital in October where they agreed that poor care was delivered. The written minutes from this meeting have still not been made available to us at the time of writing today.”
Lessons must be learned from this.