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Case ref:201902265
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Date:August 2020
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Body:Shetland NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
Ms C complained about the care and treatment her late mother (Mrs A) received at Gilbert Bain Hospital. Mrs A had widespread bladder cancer and she was admitted to the hospital because she was experiencing pain and discomfort. Medical staff decided it would be appropriate to try to insert a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag). Ms C raised concerns that the decision to try to insert a urinary catheter was unreasonable; and that medical staff should have stopped the attempts sooner, as Mrs A was in pain and shouting for them to stop.
We took independent advice from a general surgeon. We found it was reasonable that medical staff tried to insert a urinary catheter. However, we found that the repeated and distressing attempts to do so were unreasonable. We considered that the first attempt to insert a urinary catheter should have been carried out by a more senior member of medical staff. We considered that Mrs A should have been given better pain relief/sedation before any further attempts were made. We also considered that medical staff had failed to recognise Mrs A's distress and to respond to her clear withdrawal of consent. We upheld this complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Ms C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/information-leaflets
What we said should change to put things right in future:
- Patients, at the end of their life, should only undergo invasive procedures and interventions if they will ease their distress or pain. When such procedures are carried out, it should be by medical staff with an appropriate level of expertise; with appropriate consent from the patient; and only after adequate pain relief has been administered.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.