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Grampian NHS Board

  • Report no:
    201800964
  • Date:
    April 2019
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Summary

Mrs C complained about the care and treatment given by Grampian NHS Board (the Board) to her late mother (Mrs A) during the period after she had a coronary artery bypass graft (a surgical procedure to treat coronary heart disease) and an aortic (heart) valve replacement in December 2016, until her death in March 2017.

Mrs A had a history of type 2 diabetes and after her operation she experienced significant delirium and a stroke. Her leg wound also broke down and became infected. Because of her changing and deteriorating symptoms, Mrs A moved on a number of occasions between Aberdeen Royal Infirmary (ARI) and Woodend Hospital. Regrettably, Mrs A’s condition deteriorated and she died in March 2017.

Mrs C was unhappy with Mrs A’s care and treatment and complained to the Board. They said that her case had been a complex one and that although her outcome had been poor, Mrs A had been treated by appropriate specialists and that management decisions made at each stage of her illness appeared to have been reasonable.

We took independent advice from a consultant geriatrician and from a registered nurse specialising in tissue viability. We found that while she was in ARI some of Mrs A’s post-operative problems could have been expected in someone with her complex health and overall frailty. However, insufficient attention had been paid to her symptoms of delirium in relation to her more surgical complications despite them causing Mrs A significant distress. We also found that the Board’s own pressure ulcer prevention and management pathway had not been followed; there were delays in referring Mrs A to the tissue viability team, her wounds were not attended to frequently enough and inappropriate dressings were used.

While we found that Mrs A’s medical care improved when she was initially transferred from ARI to Woodend Hospital for rehabilitation and more attention was paid to her delirium, the nursing care of her leg wound remained extremely poor and caused Mrs A pain and distress which were all avoidable.

Finally, we found that there had been a lack of information given to the family by ARI about Mrs A’s delirium and little to no evidence of discussion between nursing staff and the family. This was an extremely distressing time for Mrs A which was compounded by a lack of information.

We upheld Mrs C’s complaints and made a number of recommendations to address the failings identified.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

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

Complaint number

What we found

What the organisation should do

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

(a)

Mrs A’s post -operative care in ARI fell below a level she and her family could have expected; there was a lack of attention to her delirium management and her wounds and pressure ulcer were not treated appropriately

Apologise to Mrs C for the failure of ARI to give proper care and attention to the symptoms of Mrs A’s delirium and to her wounds

A copy or record of the apology made

 

By: 17 May 2019

(b)

While she was a patient in Woodend Hospital, the attention paid to Mrs A’s leg wound and sacral pressure sore remained poor: no referral was made to Tissue Viability; her leg wound was not dressed with appropriate products; a review did not take place until 16 February 2017; important documentation (the Applied Wound Management Chart) was not completed.  Similarly, her sacral pressure sore did not receive appropriate and reasonable attention

Apologise to Mrs C for the failure of Woodend Hospital to give Mrs A's leg wound and sacral pressure sore the required care and treatment

A copy or record of the apology made

 

By: 17 May 2017

(c)

The level of communication with Mrs A’s family was not what they could have reasonably expected

Apologise to Mrs C for the failure of Board staff to communicate reasonably and appropriately

A copy or record of the apology made

 

By: 17 May 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’s post-operative care in ARI fell below a level she and her family could have expected; there was a lack of attention to her delirium management and her wounds and pressure ulcer were not treated appropriately

Proper care and attention should be given to the symptoms of delirium.  The Board should follow the Health Improvement Scotland (HIS) Standards for the prevention and management of pressure ulcers; staff should have wound knowledge of how to assess and dress a wound appropriately and be aware when to refer to the Tissue Viability Service

 

 

Evidence that the Board are improving the care of patients with delirium. Also evidence that they have taken measures to improve the clinical knowledge of the staff concerned in relation to pressure ulcers, wound management and referrals to the Tissue Viability team

 

By: 17 July 2019

(b)

While she was a patient in Woodend Hospital, the attention paid to Mrs A’s leg wound and sacral pressure sore remained poor: no referral was made to Tissue Viability; her leg wound was not dressed with appropriate products; a review did not take place until 16 February 2017; important documentation (the Applied Wound Management Chart) was not completed. Similarly, her sacral  pressure sore did not receive appropriate and reasonable attention

Proper care and attention should be given to the symptoms of delirium in line with HIS Scotland Standards for the management of delirium.  The Board should follow the HIS Standards for the prevention and management of pressure ulcers; staff should have wound knowledge of how to assess and dress a wound appropriately and be aware when to refer to the Tissue Viability Service

Evidence that the Board are improving the care of patients with delirium. Also evidence that they have taken measures to improve the clinical knowledge of the staff concerned in relation to pressure ulcers, wound management and referrals to the Tissue Viability team

 

By: 17 July 2019

(c)

The level of communication with Mrs A’s family was not what they could have reasonably expected

Particularly where there are capacity issues, staff should communicate with family members in a reasonable and appropriate manner

All staff who were involved in Mrs A’s care and treatment were made aware of the outcome of this report and were reminded of their obligations to communicate clearly with family members

 

By: 17 May 2019

 

We are asking The Board to improve their complaints handling:

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

The Board's investigation failed to identify the significant failures in Mrs A’s care, in particular, in relation to the management of her delirium and her wound/pressure ulcer

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 Mrs C’s complaints 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: 17 July 2019

Updated: April 17, 2019