A DAMNING report into the care of an elderly woman has revealed hospital staff failed to ensure she had enough to eat and drink in the lead up to her death.
The woman, named only as Mrs A, was in good health when she was admitted to Edinburgh Royal Infirmary for hip surgery, but died the week following her discharge after receiving poor treatment at the hospital.
The Scottish Public Services Ombudsman (SPSO) found that nursing staff did not ensure her nutritional needs were met - leaving her to suffer weight loss and dehydration and develop a bedsore.
Mrs A's diabetes was also mismanaged, resulting in her blood glucose levels falling to dangerously low levels. Her discharge from hospital was also not properly planned.
The ombudsman report stated: "Even though she had suffered a hip fracture and had dementia, Mrs A was in a good state of physical health before her admission to hospital. At the time of her admission, she was well-hydrated, with normal glucose levels and without any pressure ulcers.
"She did not, however, receive appropriate care there in terms of nutrition or the provision of a specific care plan."
It added that medical advisers involved in the investigation were "very critical" of Mrs A's care - especially the fact that she became dehydrated.
The report stated: "There was no evidence in the records of a specific care plan to meet Mrs A's hydration needs and it was not clear whether nursing staff attempted to assist Mrs A to drink."
The ombudsman added that there was no evidence that nurses provided "maximum assistance" during Mrs A's mealtimes and they failed to refer her to a dietician quickly enough when she began to lose weight.
Mrs A was admitted to the hospital on January 5, 2013 and passed away on January 30 - a week after being released.
Her daughter complained to the ombudsman, raising concerns about the standard of care her mother received.
The watchdog has now upheld the complaint, saying the poor care Mrs A received "undoubtedly compromised her recovery".
NHS Lothian has now been given seven recommendations, including issuing reminders to staff on the need to keep clear and accurate records and promptly arranging suitable advice and treatment for patients.
The health board has also been instructed to take steps to ensure older patients admitted with a fracture are assessed for specialist rehabilitation and review its policies and procedures for dealing with patients with diabetes.
It has also been told to ensure discharges are carried out in line with national guidelines.
Melanie Johnson, executive nurse director at NHS Lothian, said: "I would like to publicly apologise to Mrs C for the failings in this case and offer our sincere condolences following the death of her mother.
"We accept the report from the ombudsman and we are taking the recommendations very seriously indeed."
A GP practice at the health board was also criticised in another SPSO report looking into the death of a man who suffered a heart attack in July 2013, just days after complaining to a nurse about chest pains.
The 51-year-old, named only as Shawn, was given antacid tablets by a nurse practitioner (NP) at Slateford Medical Practice in Edinburgh.
The ombudsman said: "My nursing adviser ... was critical of the NP's actions, as was my medical adviser, and I concluded that the level of service provided to [Shawn] was not reasonable.
"I took the view that the NP should have referred him to another health professional for further assessment, and possibly for a test to check that his heart was not the cause of the problems."
Shawn's sister, who did not want to be named, described the outcome of the investigation as "bittersweet", saying: "I'm very happy with the ombudsman report and the way they have handled everything, but it's tragic to think that the outcome for my brother could have been different if people had done their job properly."
She added: "We only went to the ombudsman after months of letters and phone calls back and forth with the practice - all of which has only added to our pain.
"This won't bring Shawn back, but at least it gives us some closure now."
Slateford Medical practice was unavailable for comment.
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