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Tayside NHS Board

  • Report no:
    201805020
  • Date:
    February 2020
  • Body:
    Tayside NHS Board
  • Sector:
    Health

Summary

Mrs C complained to me about the care and treatment that her mother (Mrs A) received from Tayside NHS Board (the Board). In May 2017, Mrs A was diagnosed with renal cell carcinoma (a type of kidney cancer) and she was referred for kidney surgery to treat it. Following her kidney surgery in August 2017, Mrs A developed excess fluid around her lungs and an infection; and her condition continued to worsen. In late September 2017, Mrs A was discharged home for end of life care and she died the next day. 

Mrs C complained that the Board failed to provide Mrs A with reasonable clinical care and treatment in relation to her kidney surgery. We took independent advice from a consultant urologist (a clinician who treats disorders of the urinary system). We found that the decision to refer Mrs A for kidney surgery was unreasonable. We found there was a low risk the renal cell carcinoma would harm Mrs A; and she was at exceptionally high-risk from kidney surgery.

Mrs C also complained that the Board failed to give Mrs A reasonable care and treatment in response to her worsening condition after her kidney surgery. We found there was an unreasonable delay in recognising Mrs A had a haemothorax (a collection of blood in the lung cavity) but it was then treated appropriately.

Mrs C raised concerns that the Board failed to provide Mrs A with reasonable nursing care. We took independent nursing advice. We found a number of failings in Mrs A's nursing care in relation to the prevention of pressure ulcers (an injury to the skin and underlying tissue, usually caused by prolonged pressure), diabetes management and nutritional care.

Mrs C complained about Mrs A being discharged home for end of life care without appropriate pain relief. We found Mrs A was not prescribed enough hours of pain relief medication; and she should have been given a syringe driver (a machine that delivers continuous pain relief medication), as otherwise a carer would have had to give her hourly injections. 

Mrs C raised concerns about the Board's communication with Mrs A and her family about her condition and treatment. The Board acknowledged inadequacies in their communication; and we found that their communication was unreasonable overall. We found that the Board had appropriately apologised to Mrs C for this and we asked them to provide us with evidence of the action they had taken to address this.

We upheld all aspects of Mrs C's complaint. We made a number of recommendations to address the issues identified. 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.
 

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

What we need to see

(a) (b) (c) and (d) 
  • The decision to refer Mrs A for kidney surgery was unreasonable and there was a failure to evidence a robust multi-disciplinary team meeting (MDT) outcome and consent process; 
  • There was an unreasonable delay in diagnosing and treating Mrs A's haemothorax; 
  • There were failings in Mrs A's nursing care; and 
  • Mrs A was discharged home without appropriate pain relief 

Apologise to Mrs A's family for the failings in her medical and nursing care.

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:  19 March 2020

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

Complaint number

What we found

Outcome needed

What we need to see

(a)

The decision to refer Mrs A for kidney surgery was unreasonable

In similar circumstances, full consideration should be given to non-surgical treatment options for patients with renal cell carcinoma, in accordance with the relevant guidance

Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 20 April 2020

(a) The urology MDT outcome; and the discussion and/or record-keeping was inadequate
  • All potential treatment options should be discussed by urology MDTs and then clearly recorded to facilitate proper engagement with the patient.
  • Urology MDTs should provide and record an expert opinion on patient management and treatment

Evidence that the Board's urology MDT approach ensures MDT meetings are appropriately recorded and an expert opinion on management and treatment is given.

 

By: 20 April 2020

(a) The consent process for Mrs A's kidney surgery was unreasonable. There was a failure to discuss and record the risks of Mrs A not having kidney surgery, as well as the non-surgical treatment options

Patients should be fully advised of:

  • the risks relating to both having and not having surgery, and
  • any non-surgical treatment options.

Those discussions should then be
clearly recorded as part of the
consent process

Evidence that this has been fed back to relevant medical staff in a supportive manner that encourages learning.

The SPSO thematic report on informed consent may assist in encouraging learning for staff in this area: http://www.valuingcomplaints.
org.uk/spso-thematic-reports

By: 20 April 2020

(b) There were unreasonable failings in diagnosing and treating Mrs A's haemothorax Patients should be given timely comprehensive assessments and an appropriate diagnosis

Evidence that this case has been used as a learning tool for relevant medical staff, in a supportive way that encourages learning, to help ensure that an appropriate and timely diagnosis is reached in cases such as this

By: 19 May 2020

(c) There were a number of failings in the nursing care provided to Mrs A in relation to pressure ulcer prevention Patients should receive nursing care to prevent and manage pressure ulcers in line with relevant standards and the Board's own guidance

Evidence that the Board have reviewed the training needs
of nursing staff in relation to the diagnosis, grading, prevention and management of pressure ulcers.

By: 19 May 2020

(c) There were a number of failings in the nursing care provided to Mrs A in relation to managing her diabetes Patients should receive nursing care in relation to managing their diabetes in line with relevant standards and the Board's own guidance

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

By: 19 May 2020

(c) There were a number of failings in the nursing care provided to Mrs A in relation to nutritional care Patients should receive adequate nutritional assessment and care planning in accordance with relevant standards

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

 

By: 19 May 2020

(d) Mrs A was discharged home for end of life care with insufficient pain relief medication Patients discharged home for end of life care should be given sufficient and appropriate pain relief medication with clear instructions on how it is to be administered and by whom
  • Evidence that appropriate guidance/protocols are in place for palliative pain relief; and
  • Evidence that the findings on this complaint have been fed back to relevant medical staff in a supportive manner that encourages learning.

 

By: 20 April 2020

We are asking the Board to improve their complaints handling:

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

The Board's own complaints investigation did not identify or address all of the failings in Mrs A's medical and nursing care

The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement

Evidence that the Board have reviewed why its own investigation into the complaint did not identify or acknowledge all the failings highlighted here and what learning they identified and what changes (if any) they will make.

By: 19 May 2020

The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened.

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

The Board acknowledged there were times when Mrs A's bed table was left out of reach

The Board said they had discussed the need to ensure that bed tables are left within easy reach of patients with relevant nursing staff

Evidence that this was discussed with relevant nursing staff and whether any changes will be made as a result.

By: 20 April 2020

(e) The Board acknowledged their communication with Mrs A's family about her condition and treatment was unreasonable The Board confirmed that they had shared learning with relevant staff

Evidence that the learning was shared with relevant staff.

By: 20 April 2020

Updated: February 19, 2020