• Report no:
    201607746
  • Date:
    April 2018
  • Body:
    Lanarkshire NHS Board
  • Sector(s):
    Health

Summary

Mrs C, who works for an advice and support agency, complained on behalf of Mrs B about the care and treatment provided to Mrs B's late father (Mr A) by Lanarkshire NHS Board at Hairmyres Hospital (the hospital).  Mr A had diabetes and had been admitted to the hospital to have his leg amputated.  Mrs C complained that his diabetes was not properly monitored or managed following the surgery.  She said that this led to the development of diabetic ketoacidosis (DKA - a serious problem that can occur in people with diabetes if their body starts to run out of insulin).  She also complained about the actions of nursing staff.

We took independent advice from three advisers:  a consultant in acute medicine, a diabetes specialist nurse and a general nursing adviser.  In relation to Mrs C's complaint that the Board did not provide reasonable treatment to Mr A, we found that there were a number of serious failings, which were that the board failed to:

  1. adequately monitor Mr A's blood glucose and respond to both hypo-glycaemia (low blood sugars) and hyper-glycaemia (this occurs when people with diabetes have too much sugar in their bloodstream);
  2. manage Mr A's diabetes and insulin administration in line with the board's protocol;
  3. recognise and respond in a timely manner to his deterioration; and
  4. recognise the possibility of heart problems whilst he was in the medical High Dependency Unit (HDU).

The advice we received also highlighted a number of other failings:

  1. When Mr A was transferred to the medical HDU overnight, he was not seen until the following morning.  This was an unreasonable delay given the severity of his illness and the complexities of managing DKA in a patient with known cardiac problems (aortic stenosis – tightening of one of the valves in the heart and impairment of the heart as a muscle).  This would have made providing the large quantities of fluid as part of DKA management potentially difficult.
  2. Mr A was transferred out of medical HDU despite signs that he was starting to deteriorate.  There was then a delay in reviewing him when he was transferred back to the surgical ward.  We found that Mr A should have subsequently been readmitted to medical HDU or to coronary care.
  3. Mr A should have had a review of his antibiotics during his second deterioration, as he had already been on his antibiotic regime for three days and would have probably needed different antibiotics and review of any microbiology results.
  4. There was a failure to measure/chart his respiratory rate when he was deteriorating.

     

In view of these failings, we upheld Mrs C's complaint that the board did not provide reasonable treatment to Mr A.

Mrs C also complained that the board did not provide reasonable nursing care to Mr A in the hospital.  She said that nursing staff did not respond reasonably to alerts from another patient's visitors about Mr A's condition and that nursing staff did not reasonably record the actions they took in relation to this in Mr A's medical notes.

We found that the actions of a nurse when Mr A's condition deteriorated had been unacceptable and unreasonable.  The nursing documentation in relation to this matter was also inadequate and we upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board did not respond reasonably to Mrs B when she complained to them about these issues.  We upheld this aspect of the complaint, as the board failed to identify the serious failings referred to above.  We considered that this was both unreasonable and that it called into question the adequacy of the board's complaints handling at the time.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs B:

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

(a) and  (b)

The Board did not provide Mr A with reasonable treatment.

The nursing documentation in relation to the actions of the nurse when Mr A's condition deteriorated on 4 October 2016 was inadequate

Apologise to Mrs B for failing to provide Mr A with reasonable treatment and for the inadequate nursing documentation.  The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology.

 

By:  25 May 2018

 

We are asking The Board to improve the way they do things:

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

(a)

The Board failed to adequately monitor Mr A's blood glucose and respond to both hypo- and hyper-glycaemia

The Board should reflect on the findings in this report and ensure patients with erratic blood glucose have their capillary blood glucose checked and recorded regularly and at a frequency appropriate to their specific circumstances and condition

Evidence that relevant staff have been informed of this and that consideration has been given to any training requirements to support staff in carrying out these checks.

 

By:  25 July 2018

(a)

The Board failed to manage Mr A's diabetes and insulin administration

Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to diabetes management in hospital, including recognising diabetic emergencies and advice on who they can contact if they have concerns, including at the weekend

Evidence that staff have the appropriate level of skill and access to guidance, support and training.

 

By:  25 July 2018

(a)

There was a delay in reviewing Mr A when he was transferred to the medical HDU

Admissions to the medical HDU should be seen on arrival by medical staff

Evidence this matter has been considered and a decision taken to act (or not), that includes reasons for the decision.

 

By:  25 June 2018

(a)

Staff failed to recognise the possibility that Mr A had heart problems in medical HDU on 5 October 2016

Medical HDU should ensure that electrocardiograms are routinely and appropriately reviewed for patients who have deteriorated or been admitted overnight

Evidence that this matter has been considered and, where appropriate, action has been taken and any changes disseminated.

 

By:  25 June 2018

(a)

Mr A was transferred out of the medical HDU on 6 October 2016, despite signs that he was starting to deteriorate

Patients who are deteriorating should not be discharged from the medical HDU without a clear plan

Evidence that this matter has been fed back to staff in a supportive way that encourages learning.

 

By:  25 June 2018

(a)

There was a delay in recognising and starting treatment for possible sepsis

Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to the consideration of sepsis and on reviewing antibiotics previously prescribed

Evidence that staff have the appropriate level of skill and access to guidance, support and training.

 

By:  25 July 2018

 

 

(a)

There was a delay in reviewing Mr A when he was transferred back to the surgical ward in the late afternoon of 6 October 2016

Patients who have been transferred out of a HDU environment to a general ward should be reviewed on arrival in the ward or as close to that time as possible

Evidence that this matter has been considered and a decision taken to act (or not), that includes reasons for the decision.

 

By:  25 June 2018

(a)

There was a failure to measure/chart Mr A's respiratory rate

Nursing and medical/surgical staff should be competent, appropriately skilled, and able to access guidance, support and training in relation to early warning scores with regard to the importance of respiratory rate

Evidence that staff have the appropriate level of skill and access to guidance, support and training.

 

By:  25 July 2018

(c)

The Board's investigation into Mrs B's complaint failed to identify a large number of the failings we have referred to in this report

The Board should reflect on the findings in this report and ensure that complaints are investigated appropriately

Evidence that relevant staff have been informed of this and that consideration has been given to any training requirements to support staff in investigating complaints.

 

By:  25 July 2018