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Grampian NHS Board

  • Report no:
    201701938
  • Date:
    December 2018
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Summary

Mr C complained on behalf of his late mother (Mrs A) about the care and treatment she received from the Board.  Mr C and his father (Mr B) complained that there was an unreasonable delay diagnosing that Mrs A had bowel cancer.  In relation to an admission at Woodend Hospital towards the end of Mrs A’s life, Mr C complained that the nursing care was unreasonable and that there was an unreasonable delay diagnosing internal bleeding.

We took independent advice from a consultant gastroenterologist, a registered nurse and a consultant geriatrician. 

In relation to Mr C’s complaint about delay in diagnosis of cancer, we found that inadequate investigations were carried out.  We concluded that if the relevant clinical guidance regarding investigations had been followed, then Mrs A’s cancer would have been diagnosed in 2013 rather than 2016.  We noted that a number of failings contributed to the delay, including a failure to review the quality of previous investigations performed. 

We concluded that the failings in the investigation of Mrs A’s bowel symptoms likely had a significant impact on her ability to survive her illness.  In addition to this, we also concluded that it was likely that with correct treatment Mrs A would not have had prolonged and profound anaemia and may not have developed a myocardial infarction.  Finally, we were critical of the Board’s investigation of the complaint and concluded that they had failed to provide a full and accurate response to the family. We upheld this complaint.

Following surgery in Aberdeen Royal Infirmary to remove a tumour in her bowel, Mrs A was transferred to Woodend Hospital for a period of rehabilitation.  Mr C raised a number of concerns about the nursing care Mrs A received at Woodend Hospital.  We found a number of failings in the nursing care Mrs A received during this admission.  We were critical of the monitoring of Mrs A’s condition and found there was no care plan for the management of her diabetes.  Furthermore, there were failings in pressure ulcer management and also in falls prevention.  We also found failings in stoma care, noting there was no care plan or fluid balance monitoring.  Finally, we noted that there was little evidence of family involvement in care planning and limited records of communication.  We concluded that the nursing care was unreasonable and upheld the complaint.

Mr C also complained that there was a delay in diagnosing internal bleeding during the admission to Woodend Hospital.  We found that medical staff reviewed Mrs A’s condition reasonably during the admission and we did not identify an unreasonable delay in the diagnosis.  While we recognised that there were issues with the nursing observations, we did not consider that these impacted on the ability of medical staff to diagnose Mrs A’s condition.  We did not uphold this aspect of Mr C’s complaint.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

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)

There was an unreasonable delay in diagnosing that Mrs A had cancer.

The nursing care provided to Mrs A during the admission in Woodend Hospital was unreasonable.

The Board did not investigate Mr C’s complaint to a reasonable standard 

Apologise to Mr C and Mr B for:

  • the unreasonable delay in diagnosing that Mrs A had cancer;
  • the failings in nursing care during the admission in Woodend Hospital;
  • the poor quality of the investigation of the complaint.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology.

 

By:  22 January 2019

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)

Mrs A was not offered a repeat colonoscopy after an incomplete colonoscopy was performed in June 2013 

Patients who have had an incomplete colonoscopy should be offered a repeat colonoscopy or another appropriate investigation in line with clinical guidelines

 

 

Evidence that the gastroenterology department have carried out an audit of current colonoscopy practice.  This should include:

  • the proportion of incomplete colonoscopies over the last 12 months and the reasons for this;
  • the outcomes of incomplete colonoscopies, including whether repeat or follow on tests were arranged in line with national guidelines; and
  • in cases where the guidance was not followed regarding follow up tests, the action being taken to address this.

Evidence that the Board have developed a local protocol to ensure that the national guidelines are followed when colonoscopy is incomplete so that appropriate follow-up tests are arranged  

 

By:  16 April 2019

(a)

The documentation of the extent of completion of the colonoscopy was inadequate.  It was unclear how it was established that the hepatic flexure was passed or whether a scope guide was used

Patient records should include details of how the extent of completion of a colonoscopy has been established. 

Where a scope guide is used, this should be documented 

Evidence that the Board have taken action to ensure that the extent of completion of colonoscopies are adequately documented.  (For instance, the Board might summarise documentation standards on a poster in the endoscopy department, or incorporate this into the colonoscopy reporting system)

 

By: 19 March 2019

(a)

The incompleteness of the colonoscopy was not documented in the discharge letter from the admission in June 2013.

There was no evidence of senior input into the discharge letter

All diagnoses, operations and procedures relevant to a patient’s admission should be accurately documented in the discharge documentation. 

Discharge documentation should receive appropriate input or review from senior medical staff, and this should be documented

Evidence that the Board have reviewed the discharge documentation practice in place in the Gastroenterology Department to ensure that senior medical staff have appropriate input into discharge documentation

 

By: 19 March 2019

(a)

The quality of the colonoscopy in June 2013 was not reviewed at subsequent consultations in 2014 and 2015. 

A colonic cause for Mrs A’s iron deficiency anaemia was not ruled out before iron therapy and capsule endoscopy were performed.

The Board failed to investigate the possibility that the endoscopy capsule had been retained

The quality of colonoscopies should be appropriately reviewed and investigated at subsequent consultations.

A colonic cause for iron deficiency anaemia should be excluded before prescribing iron therapy and performing capsule endoscopy.   

Where a patient reports that they have not passed an endoscopy capsule, investigation should be performed where there is a reasonable clinical suspicion of this complication

Evidence that the Gastroenterology Consultants involved in Mrs A’s care have reflected on their practice in relation to the review and investigation of patients at subsequent consultations and in relation to investigating iron deficiency anaemia.

Evidence that the Board have performed quality improvement work (for instance, development of written guidance or protocol) to ensure appropriate investigations are performed to exclude pathology outside the small bowel and to reduce the risk of a retained capsule.  The Board should provide the SPSO with a copy of any guideline or protocol developed

 

By: 16 April 2019

(b)

Completion of NEWS monitoring charts was inconsistent and not in accordance with guidance.

Mrs A had type 2 diabetes but there was no care plan as to how her condition should be monitored

NEWS charts should be completed to accurately reflect the patient’s condition.  Observations of a patient should be completed in line with the planned frequency in the patient’s records.

A care plan should be in place for patients with diabetes and monitoring should be performed in line with this

Evidence that the Board have reviewed the training needs of nursing staff in relation to:

  • completion of NEWS; and
  • diabetes monitoring.

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned

 

By: 16 April 2019

(b) The assessment and management of pressure ulcer risk was inconsistent and incomplete

Patients should receive nursing care to prevent and manage pressure ulcers in line with relevant standards[1]

 

Evidence that the Board have reviewed the training needs of nursing staff in relation to the assessment and management of pressure ulcer risk.

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned

 

By: 16 April 2019

(b) It was unclear how information was shared when Mrs A transferred between hospitals   

Relevant information about a patient’s care should be transferred with a patient when the patient transfers between hospitals

Evidence that the Board have a clear pathway in place for inter-hospital patient transfers, which details how key information is shared between nurses in both hospitals

 

By: 16 April 2019

(b)

There was no falls prevention care plan in place, despite the risks identified

Where a patient has been assessed as at risk of falling, a falls prevention care plan should be in place

Evidence that the Board have reviewed the approach to falls care planning in Woodend Hospital to make sure that risks are identified, and care plans are developed in conjunction with patients, and their family/carers as appropriate. 

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned

 

By: 16 April 2019

(b)

The management of Mrs A’s stoma care was not reasonable.  There was no stoma care plan in the records 

There was no fluid intake and output measurement in Woodend Hospital for Mrs A, despite her clinical condition 

Where a patient has a stoma a stoma care plan should be in place

Fluid balance charts should be used to measure a patient’s fluid intake and output

Evidence that the Board have reviewed:

  • how stoma nurses advise and support stoma care for patients to ensure that there is a patient centred care plan which can be adhered to by all nurses;
  • the use of fluid balance charts at Woodend Hospital.

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned 

 

By: 16 April 2019

(b) ‘Five Must Dos With Me’ documented do not appear to have informed the care planning.  Mrs A’s family do not appear to have been involved and there are limited records of communication Patients and their family/ significant others should be appropriately involved in care planning

Evidence that the Board have reviewed how the 'Five Must Dos With Me' inform care plans in Woodend Hospital and have reviewed how families and carers are involved and communicated with.

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned 

 

By: 16 April 2019

[1] Since the time of the complaint, the following standards were introduced: Prevention and Management of Pressure Ulcers Standards. Healthcare Improvement Scotland (September 2016)

We are asking The Board to improve their complaints handling:

Complaint number What we found Outcome needed What we need to see
(a)

The Board did not

investigate Mr C’s

complaint to an

acceptable

standard

The Board’s complaint handling

monitoring and governance system

should ensure that failings (and good

practice) are identified and learning

from complaints are used to drive

service development and

improvement

Evidence that SPSO's findings on this complaint

have been fed back in a supportive manner to

the staff involved in investigating Mr B’s and Mr

C’s complaints and meeting with the family and

that they have reflected on the findings of this

investigation. (For instance, a copy of a meeting

note or summary of a discussion)

By: 19 February 2019

 

Feedback

Response to SPSO investigation:

Multiple enquiries were needed in order to obtain the records required by SPSO to carry out a full and detailed investigation.  This led to increased work and lengthened the investigation time.  I strongly encourage the Board to review the way evidence and responses are provided to SPSO.  The Board should ensure that all the relevant records are provided to SPSO at the first request.  Where additional enquiries are made by SPSO, the Board should provide the specific information requested and not duplicates of records already provided.

The Board have accepted the recommendations and will act on them accordingly.  We will follow-up on these recommendations.  The Board are asked to inform us of the steps that have been taken to implement these recommendations by the date specified.  We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that the recommendations have been implemented.

Updated: December 19, 2018