Upheld, recommendations

Summary

Mrs C complained about several aspects of the nursing care that had been provided to her mother (Mrs A) at Western Isles Hospital and about the nursing staff's communication with the family.

We took independent nursing advice. We found that while some aspects of nursing care were reasonable, the board had already carried out their own review which had identified a number of failings with care and communication and apologised for these. We found that there had been poor practice in relation to the use of a hoist when lifting Mrs A. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• provide a further apology, for the inappropriate use of the hoist by staff on the ward; and
• provide Mrs C with a copy of the completed case review showing the action taken to address the concerns raised.

Summary

Ms C complained about the care and treatment given to her father (Mr A) at the Western General Hospital. Mr A, who had cirrhosis (scarring of the liver as a result of continual, long-term damage), deteriorating liver function and liver cancer, was admitted to the hospital for a head scan to investigate possible brain metastasis (a cancer that has spread from its primary site).

Ms C considered that staff gave Mr A inappropriate sedation, which rendered him unconscious, and failed to provide him with appropriate medication for alcohol withdrawal. Ms C believed this led to a sudden deterioration in Mr A's condition and his subsequent death in the hospital.

We took independent advice from a consultant physician experienced in the management of liver disease and cancer of the bile ducts. We found that parts of Mr A's care and treatment were reasonable, in particular that there was no undue delay in carrying out Mr A's head scan and that the palliative care given to Mr A was appropriate.

However, the adviser identified failings in relation to the sedation and medication given to Mr A, in the assessment of his alcohol dependency, and in treating his ongoing constipation. The adviser also considered there were shortcomings in parts of the board's alcohol withdrawal plan (AWP). However, the adviser concluded that despite the failings identified in Mr A's care and treatment, his death was not caused or hastened by these failings. We accepted this advice. Given that our investigation found failings in Mr A's care and treatment, we considered this to be unreasonable and upheld Ms C's complaint.

In the course of our investigation, the board told us they accepted there had been a lack of documentation relating to the sedation administered to Mr A, for which they had apologised.

Recommendations

We recommended that the board:

• apologise to Ms C and her family for the failings in Mr A's care and treatment;
• urgently review and update the AWP, taking account of the comments of the adviser and the relevant National Institute for Health and Care Excellence Guidelines, in relation to the sedation and medication given to patients and the use of validated scores for the assessment of alcohol dependency;
• ensure the comments of the adviser are shared with the relevant staff and acted upon; and
• provide evidence of the action taken to prevent a recurrence of the lack of documentation relating to the sedation administered to Mr A.

Summary

Mrs C complained about the care and treatment provided to her mother (Mrs A) when she attended her GP practice complaining of breathlessness and collapse. During this period, Mrs A also had three admissions to hospital. Shortly after her third admission to hospital, she suffered a heart attack and died. Mrs C said that the practice failed to take Mrs A's symptoms seriously and delayed in taking appropriate action. She also said that the practice should not have prescribed a certain medication in light of Mrs A's heart condition.

We took independent advice from an adviser who specialises in general practice. We found that while the standard of medical care in relation to Mrs A's symptoms was reasonable, there were shortcomings in relation to a referral to hospital and the prescription of medication. While these shortcomings did not contribute to Mrs A's death, we upheld the complaint because of the prescription of medication that should not be given to patients with heart conditions.

Recommendations

We recommended that the practice:

• ensure the relevant GP reviews the issues relating to the medication prescribed, including its contraindications;
• review their systems for sending urgent referrals to ensure there are no avoidable delays; and
• apologise for the failings this investigation identified.

Summary

Mrs C complained about the care and treatment provided to her mother (Mrs A) when she was a patient at the Royal Infirmary of Edinburgh. Mrs A suffered from breathlessness and collapse and had three admissions to hospital.

During her first admission to hospital, tests showed that Mrs A had pulmonary oedema (fluid on the lungs that can indicate heart failure). After Mrs A's second admission to hospital several months later, she was followed up by the respiratory clinic and referred to the cardiology team after further tests showed a heart condition. Mrs A continued to suffer from breathlessness and episodes of collapse. Shortly after her third admission to hospital, Mrs A suffered a heart attack and died.

Mrs C said that staff unreasonably failed to notice the problems with Mrs A's heart and provide appropriate treatment within a reasonable time and that the failure to treat Mrs A led to her death.

We took independent advice from a specialist in cardiology. We found that the board missed an opportunity to diagnose the cause of pulmonary oedema, which had been identified during Mrs A's first admission to hospital, and that as a result Mrs A's heart condition was not diagnosed within a reasonable time. This in turn meant that there was an unreasonable delay in referring Mrs A to the cardiology team for further assessment and treatment. However, it was unclear whether an earlier diagnosis would have led to a different outcome, due to Mrs A's medical history. It was our view that a potential opportunity for further treatment was missed and we therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• provide a plan detailing the changes they have made to ensure that appropriate tests and referrals to cardiology are undertaken within a reasonable time;
• confirm the learning gained as a consequence of this complaint and provide details of how this has been passed to and considered by relevant staff; and
• apologise to Mrs C for the failures this investigation identified.

Summary

Ms C, an advocacy and support worker, complained on behalf of Mr A. Mr A was referred by his GP to orthopaedics for a knee problem from which he was suffering. He waited around 13 weeks to be seen and was told he required a replacement knee. Mr A also had an active skin condition which the orthopaedic consultant said would need to be controlled as it increased the risk of infection following surgery.

Mr A was not added to the surgery waiting list. His GP was asked to make a dermatology referral. After a further 12-week wait, Mr A saw a dermatologist and was referred on to a more local facility for phototherapy for his skin condition. The phototherapy was successful but the good effects were short-lasting. Mr A had still not been placed on the waiting list and had to undergo a further pre-assessment and round of dermatology treatment before his surgery took place, meaning that he had to wait 15 months from the time he was referred until he received treatment. We upheld Ms C's complaint.

We found that more could have been done in the chain of communication, and that a degree of difficulty in scheduling surgery around such a skin condition might have been predicted.

We also found a letter between two departments had not been sent to a named consultant and there was no evidence it had been actioned.

Recommendations

We recommended that the board:

• apologise to Mr A for the breakdowns in communication and lack of forward planning.

Summary

Mrs C complained about a delay by clinicians at the Victoria Infirmary in diagnosing that her husband (Mr A) had a cancerous tumour at the site of a previous operation.

Mr A was under two-yearly surveillance following his original surgery. Several years after his original surgery, Mr A reported new symptoms to clinicians and his GP. However, it took six months for a diagnosis of a colonic tumour to be made. Mrs C felt that the diagnosis should have been reached at an earlier stage.

We obtained independent medical advice. We found that Mr A should have been on yearly rather than two-yearly surveillance, in accordance with British Society of Gastroenterology guidelines. Arrangements were made for a procedure to be performed five months after Mr A began to report symptoms, but in the meantime he reported further symptoms. An appointment with a consultant was cancelled due to a change in the consultant's work patterns and this led to Mr A having to attend A&E with deteriorating symptoms.

We found that the clinicians should have arranged further investigations into the cause of Mr A's reported symptoms at an earlier stage. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• share the findings of this investigation with relevant staff and ask them to reflect on their actions; and
• apologise to Mr A and Mrs C for the delay in arranging a medical review for Mr A.

Summary

Mr C complained about the care that was provided to his wife (Mrs A) at the Princess Royal Maternity Hospital when she was admitted for the induction of labour. Mrs A gave birth to a healthy baby. However, Mr C was concerned that Mrs A did not receive appropriate care prior to being moved to the labour ward. He considered that she was not properly assessed and that as a result, she did not have access to appropriate pain relief.

We took independent midwifery advice. While we found that the initial care Mrs A received was reasonable, the advice we obtained was that following this, there was no evidence that assessments were carried out in line with the relevant guidance, particularly the board's own Latent Phase of Labour guideline. The adviser considered that there had been a failure to recognise that Mrs A had progressed into established labour and that she had missed out on the appropriate level of monitoring as a result. The advice we received also highlighted some issues around the way that Mrs A's pain was managed. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C and Mrs A for the failures identified by this investigation;
• draw the comments of the adviser regarding monitoring to the attention of relevant staff for reflection;
• raise awareness of the Latent Phase of Labour guidelines to ensure that they are applied appropriately; and
• draw the comments of the adviser on planning pain relief alongside the patient to the attention of the relevant staff.

Summary

Mrs C complained to us about the care and treatment her son (Mr A) received at Queen Elizabeth University Hospital before his death.

Mrs C said that the hospital had not been equipped to meet Mr A's needs. We took independent advice from a nursing adviser. We found that there had been a delay in obtaining an appropriate specialist bed for Mr A. There were also problems in relation to Mr A's bed sheets and in obtaining an appropriate hoist for him. We upheld this complaint. However, the board had apologised to Mrs C for these failings and we were satisfied that they had taken reasonable steps to try to prevent these problems from recurring.

Mrs C also complained about the nursing care provided to Mr A. We found that there had been problems with the meals provided to Mr A and with the buzzer being out of his reach. Again, we upheld Mrs C's complaint but we were satisfied that the board had apologised to Mrs C for these failings and had taken steps to prevent them recurring.

Mrs C complained that there had been no explanation as to why Mr A had not been offered dialysis. She said that dialysis had been mentioned to Mr A over several days as a possible procedure, but that this was then postponed. We took independent medical advice on this aspect of Mrs C's complaint. We found that the decision that Mr A did not require dialysis had been reasonable, but that the communication of this to him and his family had been inadequate. Mrs C complained that there had not been a reasonable standard of communication with family members. In regard to this, the adviser was critical of the record-keeping. We upheld these aspects of Mrs C's complaints.

Finally, Mrs C complained that reasonable arrangements were not in place for the storage and security of personal belongings. We upheld this complaint, as we found that there had been some confusion about where Mr A's belongings were being stored in the hospital. In addition, there was no evidence that Mrs C had been informed of the outcome of an investigation into Mr A's missing watch.

Recommendations

We recommended that the board:

• provide us with evidence that steps have been taken to ensure that medical records are maintained appropriately;
• issue a written apology to Mrs C for the failure to communicate adequately with Mr A and his family;
• ensure that there are adequate systems in place in the hospital for the safe storage of patients' belongings; and
• ensure that Mrs C is informed of the outcome of the investigation into Mr A's missing watch.

Summary

Miss C complained about her labour and delivery at the Princess Royal Maternity Hospital. She said that the labour had been very difficult and that she had not been provided with sufficient pain relief. She also said that she felt the communication had not been reasonable, as she did not recall being offered general anaesthetic and she was unaware that she was going to have a forceps delivery.

During our investigation, we took independent advice from two advisers, an obstetrics adviser and an anaesthetics adviser. We found that the pain relief given to Miss C during her labour and delivery had not followed hospital guidelines, and that this possibly resulted in her having sub-standard pain relief. We found this to be unreasonable care and treatment.

We also found that whilst the record of communication was reasonable, the board had previously acknowledged that the communication was not effective and apologised for this. We upheld Miss C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings in care and treatment identified in this investigation;
• feed back the findings of this investigation to relevant staff, highlighting the importance of following guidelines;
• feed back the findings of this investigation to relevant staff, highlighting the importance of effective communication during labour and delivery.

Summary

Mr C complained about a nurse in the substance misuse clinic within the prison. Specifically, that when he self-referred, the nurse did not provide him with adequate advice, care and treatment for his reported addiction and self-harm issues. Mr C had particular concerns that he had explained to the nurse that he did not wish to be prescribed methadone (a drug used medically as a heroin substitute) as he had had problems with taking it in the past, and that instead he needed a prescription for a different medication used to treat addiction. He said that the nurse had not passed this information to his psychiatrist. Mr C also said that the nurse had not passed on information about his self-harming to the psychiatrist.

During our investigation, we took independent advice from a mental health nurse. We found that there was no evidence that the information Mr C said that the nurse had failed to pass on to the psychiatrist had ever been disclosed to the nurse. However, we found that no proper assessment and care plan had been completed by the nurse when Mr C attended the substance misuse clinic and considered this unreasonable. We also considered that the nurse's record-keeping was insufficient. In view of these failings, we upheld this aspect Mr C's complaint.

Mr C also complained that the board's handling of his complaint had been unreasonable. We identified that, whilst the board's initial complaint response had been sufficient, they did not investigate Mr C's subsequent complaints. We found that this was unreasonable and not in accordance with national complaints handling guidance. Therefore we also upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in relation to record-keeping and lack of evidence regarding proper assessment;
• review their process when a prisoner self-refers to the addictions team to ensure adequate assessment and care planning is carried out where appropriate;
• draw the findings to the attention of the nurse;
• apologise to Mr C for not responding to his additional complaints; and
• draw these findings to the staff involved in the local investigation of Mr C's complaint in order to highlight the importance of investigating and responding to all issues complained about in accordance with national complaints handling guidance.