Summary
Miss C was suffering from a severe headache with associated flashing lights that was not relieved by painkillers. Following referrals from her GP she twice attended an out-patient clinic at St John's Hospital where on both occasions she was reviewed by staff and sent home with medication. She had a computerised tomography scan two days after the second appointment which showed that she had a brain abscess. She was transferred to another hospital for emergency surgery, followed by another operation to further drain the abscess. Miss C raised a number of concerns about the care and treatment she received while attending St John's Hospital, in particular, that the delay in undertaking investigations necessary to diagnose her condition may have led to a more serious outcome and unnecessary prolonged pain and distress.
When Miss C was transferred back to St John's Hospital, she was unhappy with the care she received, in particular the attitude of staff on the ward. Miss C also complained to us about the delay in diagnosing her condition and the way the board handled her complaint.
I took independent advice from a general medical adviser and a senior nursing adviser. On the initial diagnosis of Miss C's condition, my medical adviser said that there were sufficient red flag symptoms for Miss C's condition, which was deteriorating over time, to prompt clinicians to investigate further. Although it is not possible to know if an earlier operation would have improved the outcome for Miss C, I found that the board failed to give her the care and treatment she could have reasonably expected. I found that in terms of infection control on the ward, there was an unreasonable level of uncertainty from medical staff. I also found that there was inadequate communication with Miss C and her family. There had also been errors in relation to one of Miss C's prescriptions and her discharge medication which, whilst my medical adviser said would not have caused any harm, further reduced the confidence of Miss C in the ability of the ward to care for her. I am also critical that whilst the board apologised, they did not explain how these errors occurred in the first place. During my investigation, the board also failed to send copies of information sent by them to Miss C's GP. I was also critical of this, as this was relevant information given that Miss C also complained about poor communication between the board and her GP following her discharge from hospital.
In terms of the nursing care she received, my nursing adviser said that whilst there are notes documenting regular interaction between nursing staff and Miss C, some of the notes were poorly completed, so I have concerns about record-keeping. There was also a breach in nursing protocol in relation to the disposal of a used syringe. The board has accepted that this protocol had been breached and has assured us that action will be taken to address this.
Although there were some aspects of the board's complaints handling that could have been better, on balance I considered that Miss C received a reasonable level of service in this regard so did not uphold her complaint about the way her complaint was dealt with.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Miss C for the failings identified in this complaint;
- (ii) report back to the Ombudsman on the outcome of the review of the discharge prescribing and drug ordering procedures at ward level and on any action taken to prevent similar errors occurring in the future;
- (iii) remind nursing staff of the need to maintain full and accurate nursing records in line with NMC guidance;
- (iv) explain how they will monitor compliance to protocols and ongoing improvements in relation to the safe disposal of clinical waste;
- (v) report back on the outcome of the review of infection control procedures to evidence that learning and improvement has occurred; and
- (vi) report back to the Ombudsman on the action taken as a result of this case in relation to communication to improve the service provided.