Mid Scotland and Fife

Summary
Mr and Mrs C complained about the management of Mrs C's pregnancy, leading up to the stillbirth of their baby.  Mrs C experienced increased blood pressure during pregnancy, as well as slightly raised urine protein levels.  These can be signs of pre-eclampsia (a condition that can affect pregnant women, particularly during the second half of pregnancy, which can lead to serious complications for both mother and baby).

About 38 weeks into Mrs C's pregnancy, a plan was made for induction in a week's time.  In the meantime, Mrs C was admitted overnight for monitoring of her high blood pressure, and she also attended a follow-up appointment where a cardiotocography (CTG) was carried out.  The CTG showed some problems of loss of contact and deceleration of heartbeat, but staff thought this was due to Mrs C's movements, and she was discharged.  Sadly, when Mrs C returned two days later for the induction, her baby was found to have died (he was stillborn the next day).  Mr and Mrs C gave consent for a post-mortem examination, which showed Mrs C's placenta had not been functioning properly, which was consistent with pre-eclampsia.

Following discussion with the consultant in charge, Mr and Mrs C complained to the board.  While the board had begun carrying out a routine review of Mrs C's care (which they do for all stillbirths), they also carried out a further clinical review of the care (the REI review) in response to the complaint.  This review found that there was no clear diagnosis made between gestational hypertension (high blood pressure) and pre-eclampsia for Mrs C.  It found that the local guidance about when to measure urine protein levels (a test for diagnosing pre-eclampsia) differed from the National Institute of Health and Care Excellence (NICE) guidelines about this.  The REI review also found there was a lack of continuity of care, and the way that records were kept made it difficult to identify trends in blood pressure recording and blood results in this case.

Following the REI review, the board put in place an action plan for improvement, including amending their guidelines to be consistent with NICE guidelines.  However, the results of the REI review were not shared with Mr and Mrs C.  While the board intended to share the results, they felt it would be easiest to do this in a meeting.  A complaint response had already been drafted before the REI review was finished (indicating that the management of Mrs C's pregnancy was reasonable), and the board simply added a line stating that a review had been carried out and inviting Mr and Mrs C to contact them for a meeting.  The rest of the letter was not updated to include the outcomes from the REI review.

After taking independent clinical advice from a midwife and two obstetrics and gynaecology consultants, we upheld Mr and Mrs C's complaint about the management of her pregnancy.  We found the board failed to conduct further tests to clarify Mrs C's diagnosis (between high blood pressure and pre-eclampsia), contrary to NICE guidance.  We also found the board had failed to recognise abnormalities on two CTG recordings.  We did not uphold Mr and Mrs C's complaints about the continuity of care, their involvement in the REI review or the bereavement support made available to them, although we gave the board some feedback on these points.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

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

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

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

Feedback
Complaints handling:  It was good practice by the Head of Midwifery/Nursing to escalate this complaint for a multi-disciplinary REI review (due to her concerns about the draft complaint response).  However, the results of the REI review were not reflected in the final complaint response, and were never provided to the family (other than an offer to meet and discuss the results, which was not followed up when the family did not get in contact).  If the Board had shared the REI review results and made appropriate apologies, this complaint might have been resolved earlier.

Response to SPSO investigation:  The Board responded promptly to our enquiries.

Points to note:  The professional advisers raised several points for the Board's consideration:

• In relation to continuity of care, Adviser 2 suggested the Board could consider how often women undergoing surveillance for high blood pressure are booked to see their own consultant (for example, in an antenatal clinic), so that decisions could be made with more continuity.
• In relation to the REI review, Adviser 3 suggested the Board may wish to review their guidance on clinical reviews prompted by complaint investigations, to ensure that families who wish to be involved in a review have this opportunity.
• In relation to support following a stillbirth, Adviser 1 said it is good practice for maternity units to have at least one member of staff who has specialist knowledge and training in bereavement care, and recommended that the Board should seriously consider and agree the business proposal for a bereavement midwife.

Summary
Mrs C complained that the practice failed to take appropriate action when her late father (Mr A) presented to them reporting symptoms of back pain.  Mr A was 81 years old at the time and Mrs C considered that the GPs failed to recognise potential underlying symptoms and arrange appropriate investigations.  Mr C was initially given pain medication and told to return if his symptoms did not improve.  When his symptoms had not improved by the following month, a referral was made to urology for further investigation.  Shortly after this, Mrs C removed Mr A from the practice and took him to live with her.  He was subsequently diagnosed with terminal cancer.

We took independent GP advice, which noted that the GP elected to refer Mr A to urology due to his history of raised prostate-specific antigen (PSA).  This is a protein produced by cells of the prostate gland, levels of which can indicate prostate cancer or other problems with the prostate.  Mr A had been diagnosed two years previously with benign prostatic hyperplasia (BPH) - an enlarged prostate gland - and he was prescribed medication for this.  Mr A’s PSA had last been checked around this time and we were advised that this should have been followed up by the practice with an urgent urology referral, rectal examination, and repeat blood tests.

The next clinical prompt for checking Mr A’s PSA was when he presented with back pain but this was not done.  We were advised that new onset back pain in a man of Mr A’s age should have been a red flag sign and should have prompted further investigations and/or specialist referral.  The practice acknowledged that further investigations should have been carried out, including a check of Mr A’s PSA.  We were also advised that Mr A’s PSA should have been re-checked at the time of referring him to urology and, again, the practice acknowledged that this should have happened.  It was also noted that the referral was sent on a routine basis, when we were advised it should have been given an urgent priority.

We found nothing to link the identified failings to Mr A’s death.  His death certificate recorded gastric cancer and no prostate cancer diagnosis was evident.  However, we were advised that the actions taken by the GPs were unreasonable irrespective of the cause of death.  We found it particularly concerning that their knowledge of Mr A’s history of raised PSA, and lack of follow-up in this regard, did not appear to have prompted a higher degree of suspicion when he presented with new onset back pain.  In the circumstances, we upheld the complaint.  While we were satisfied that the practice had ultimately demonstrated adequate reflection, we considered that there were earlier opportunities for them to have recognised the noted failings.  In particular, they carried out a significant event analysis which did not identify any shortcomings in the care provided.

Redress and Recommendations
The Ombudsman recommends that the practice:

• apologise to Mrs C for the failings this investigation has identified; and
• ensure that the Practice team involved in carrying out significant event analyses have familiarised themselves with the relevant NHS Education for Scotland guidance and report back to the Ombudsman when this has been done.

Summary
Mrs C complained about the care and treatment provided to her brother, (Mr A) by Lanarkshire NHS Board (the board).  Mr A had been experiencing pain in his legs, feet and ankles.  He was referred to the deep venous thrombosis (DVT) service at Hairmyres Hospital (the hospital) by his general practitioner and DVT was ruled out as a cause of his symptoms.

Mr A later had a circulation assessment at one of the board's community clinics (the clinic).  Staff at the clinic were unable to find a pulse in Mr A's foot.  Attempts were made to contact the vascular service at the hospital by telephone but there was no reply and a message was left on an answering service.  Mr A returned home. Five days later, however, one of his toes turned black and Mrs C took him directly to the hospital.

A scan showed that Mr A had a blockage in one of the arteries in his thigh and a procedure was suggested to remedy this.  The procedure was not carried out for a further three days during which time Mr A became increasingly unwell.  This deterioration continued after the procedure and Mr A had to undergo an above the knee amputation of his leg.

During our investigation, we took independent advice from a consultant physician and a vascular surgeon.  While we found no issues with the DVT service examination, we identified that the referral pathway from the clinic to the vascular service had failed.  We found that this and the delay in conducting the procedure meant that the board had failed to take appropriate, timely action to try to save the limb.  While unable to definitively determine that the loss of Mr A's leg was avoidable, we considered more urgent action would have given him the best chance of a different outcome.   We upheld Mrs C's complaint.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

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

We are asking the Board to improve the way it does things:

Feedback for the Board
Adviser 2's comments on the subjectivity of clinical judgement in assessing pulses should be circulated to relevant staff for learning purposes.

Summary
Mrs C complained about the care and treatment her husband (Mr C) received at the Victoria Hospital, Kirkcaldy.

Mrs C said that her husband suffered a fall getting out of bed while on holiday abroad which had caused him to hit his head and lose consciousness for approximately ten minutes.  On arrival home a few days later, Mr C attended the hospital's emergency department.  He was treated as a minor head injury and discharged home the same day with head injury advice.  Mrs C complained that Mr C was not provided with appropriate treatment, and, in particular, that a CT scan was not carried out.

Eleven days later, Mr C returned to the hospital as he had a constant headache.  Mrs C said that, although on this occasion a CT scan was carried out, she had to beg staff to carry it out.  The scan showed Mr C had suffered a brain haemorrhage.  He was transferred the same day to another hospital where he had a craniotomy for an acute subdural haematoma.

Mr C was subsequently transferred back to the Victoria hospital and admitted to a ward.  Mrs C was unhappy with the nursing care Mr C received there.

During our investigation we took independent advice from three advisers:  a consultant in emergency medicine, a consultant neurosurgeon and a nurse.  We found that given his presenting symptoms, an urgent CT scan of Mr C's head should have been carried out when he first presented to the emergency department, and the decision not to do was a significant and serious failing.  We also found that the failure to carry out a CT scan had delayed Mr C's diagnosis and treatment and adversely affected his outcome.  If the diagnosis and treatment had been made sooner there would in all probability have been a significantly improved prognosis for Mr C.  Given this we upheld this aspect of Mrs C's complaint.

We considered, however, that the treatment Mr C received when he returned to the emergency department was timely and was of an excellent standard.  Therefore, we did not uphold this part of Mrs C's complaint.

In relation to the nursing care which Mr C received, the board said they had identified a number of issues where Mr C's care and their communication with Mrs C had at times fallen short of the standard Mrs C expected and they had apologised.  The board said these matters were also addressed with the nursing staff concerned.  We received advice that Mr C's brain injury had caused him to exhibit behaviour which was at times difficult for staff to manage.  While there were many aspects of Mr C's nursing care which were reasonable, we found that he should have been observed for falls better.  We also identified shortcomings in how Mr C's nursing records were kept.  We considered that, on balance, and in the circumstances of this case, the nursing care provided to Mr C was not reasonable and we therefore upheld this aspect of Mrs 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 and Mrs C:

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

Feedback for Fife NHS Board
Complaint Number (c)
Points to note:  Given the comments of Adviser 3, the Ombudsman recommends the Board give consideration to having a dedicated ward/part of a ward where patients who have suffered a brain injury and/or exhibit challenging behaviour can be cared for jointly by acute and mental health teams with appropriate staffing levels. 

When responding to a draft of this report, the Board told me that, having considered it, it would not be practicably possible to deliver the point noted in my feedback.  Even so, they will make every effort to accommodate patients with this presentation within two specific wards of Hospital 1 where they have an acute psychiatric liaison service/unscheduled care team.  The Board have also informed me that the supervision procedure for patients requiring one-to-one intensive supervision is currently under review.  It is ultimately a matter for the Board, and I am pleased that they considered the feedback in relation to their services, seriously.

Summary
Mr C complained to the Ombudsman about the care and treatment he received during a three-week admission to Wishaw General Hospital, when he developed a pressure ulcer which required district nursing care for five months after his discharge.  Mr C said that nursing staff did not take sufficient action to monitor his risk of developing a pressure ulcer.

My complaints reviewer took independent medical advice on Mr C's case from a nurse.  The adviser said that the nursing staff unreasonably failed to recognise that Mr C was at high risk of developing a pressure ulcer and, therefore, failed to provide care/assess Mr C using the SSKIN care bundle (a five-step care plan for pressure ulcer prevention).  The adviser said the Malnutrition Universal Screening Tool or MUST (a way to screen patients to identify and treat adults at risk of malnutrition) was completed inaccurately on all three occasions it was completed.  Had concern about Mr C's weight loss been noted in the MUST and the correct score applied, this would have resulted in Mr C being deemed at high risk of developing a pressure ulcer and a high risk care plan being used.  If the nursing staff had assessed Mr C correctly and used the SSKIN care bundle, it is likely that he would not have developed a pressure ulcer.  The board have acknowledged that they did not carry out visual inspections of Mr C's pressure areas and I am critical of them in this regard.

The adviser said that the fact that Mr C developed a pressure ulcer in the hospital which appeared to require district nursing care for five months after Mr C's discharge, suggested that the nursing staff failed to provide Mr C with appropriate pressure area care and they considered the board's failing to be significant.  I, therefore, upheld Mr C's complaint.  I am also concerned that during their own investigation of Mr C's complaint, the board did not recognise the failings in Mr C's care and take appropriate remedial action.

Redress and Recommendations
The Ombudsman recommends that the Board:

• feed back my decision on this complaint to the staff involved;
• ensure that in future nursing staff carry out appropriate assessment and monitoring of patients at risk of developing pressure ulcers;)
• ensure that in future, staff carry out a full and proper investigation of patients' complaints and recognise failings where they exist; and
• provide Mr C with a written apology for the failings identified and offer to meet with him to discuss their learning and actions as a result of his complaint.

Summary
Ms C complained about the treatment she received when she saw a dentist after a bridge that replaced some of her teeth had come off.  She said that the dentist had inadvertently fractured the porcelain when cleaning the bridge.  She said that they then made a temporary repair, but on the following day, part of the bridge shattered.

We took independent dental advice on Ms C's complaint.  The adviser noted the bridge had been in need of replacement, but that there had been a lack of care by the dentist in fracturing the porcelain on the bridge.  We therefore upheld this aspect of Mr C's complaint.  However, we found that, as this had been an emergency appointment, it had been reasonable for the dentist to carry out a temporary repair and then refer Ms C to her usual dentist for further treatment.

Ms C also complained about the care and treatment she received when she saw her usual dentist.  They agreed to refer her to a consultant in restorative dentistry.  The consultant sent a report to Ms C's usual dentist with their findings after examining Ms C.  In their report, they said that she may need to have some teeth extracted, but they would be quite hopeful that another tooth was relatively sound and could be used to support a bridge.  They also suggested that she could have orthodontic treatment for this tooth and implants to replace the teeth that were to be extracted.  However, after receiving the report, Ms C's usual dentist extracted this tooth along with the other teeth supporting the bridge.

We also took independent dental advice on this aspect of Ms C's complaint.  We found that there was no evidence that Ms C had been adequately advised of her options for replacing the original bridge.  Ms C's usual dentist had also failed to record his reasons for extracting what the consultant thought was a relatively sound tooth.  We did not consider that there was evidence that Ms C's usual dentist had provided reasonable treatment to Ms C and we also upheld this aspect of her complaint.

Finally, Ms C complained that the dental practice had failed to reasonably respond to her complaint about the dental treatment.  We found that the practice had acted in line with their policy for handling patient complaints.  In addition, their response about the porcelain fracture on the bridge had been reasonable.  However, the practice had failed to respond adequately to Ms C's comments about unnecessary work being carried out.  In view of this, we upheld the complaint.

Redress and recommendations
The Ombudsman recommends that Dentist 2:

• issues a written apology to Ms C for the failure to record that they adequately advised her of the reasons for extracting tooth 12 or the options in respect of the replacement of the failed bridge; and;
• in the event that they are unable to provide an x-ray showing that it was reasonable to remove tooth 12, they should refund Ms C for the cost of having to have an implant fitted to replace tooth 12, due to the failure to record why they did not follow the advice of the dental hospital or that they had fully discussed this with Ms C.  This should be done on receipt of appropriate invoices when treatment has been completed.

The Ombudsman recommends that the Practice:

• issue a written apology to Ms C for the failure to adequately investigate or respond to her comments about unnecessary work being carried out.

Overview In April 2007, the complainant (Ms C), the mother of four children, was made unintentionally homeless from her home in a village some distance from Perth. Ms C and her partner applied to Perth and Kinross Council (the Council) for rehousing. The family were first accommodated in a bed and breakfast guesthouse in the village but were later allocated the temporary let of a Council house in Perth in August 2007. Ms C and her partner were anxious that disruption to their children's education was minimised. Ms C stated that when she made enquiry of the costs of transport to the village for two of her children, she was told that her outlay would be met. Specific complaints and conclusions The complaints which have been investigated are that: (a) Ms C was not properly informed directly by the Council about the travel costs for two of her children (not upheld); (b) when Ms C asked a NHS Health Visitor working with homeless families, she claims she was assured that travel passes would be issued for her children but that she would have to meet her own costs of accompanying those children (no finding); and (c) the Council's decision to fund Ms C's children's travel costs from the time of her complaint failed to address the substantial costs she had already incurred (not upheld). Redress and recommendation The Ombudsman recommends that the Council inform him of the outcome of their reassessment of policy. The Council have accepted the recommendation and will act on it accordingly.

Summary
Mr C's wife (Mrs A) was admitted by ambulance to Monklands Hospital with increased breathlessness.  While visiting Mrs A, her daughter (Ms B) who is a nurse, reviewed Mrs A's medical records and noticed that it was recorded that Mrs A had been given Amoxicillin, a penicillin antibiotic, earlier in the day.  Mr C said that he had made both ambulance and hospital staff aware that Mrs A was allergic to penicillin and that, previously, penicillin had caused Mrs A to suffer anaphylactic shock.  Mr C said that thereafter Mrs A's condition deteriorated.

Mr C said that although Ms B had immediately informed a member of the nursing staff of the prescribing error, staff had failed to take corrective action and to conduct increased observations of Mrs A.  Mr C said there was also a failure to document the incident in Mrs A's medical records at the time and again when Mrs A was later transferred to the Intensive Care Unit (ICU). Mr C believed there had been unreasonable delay in transferring Mrs A to the ICU where she remained until her death.

Mr C considered that Mrs A had been denied proper treatment for the possible adverse effects of an anaphylactic reaction to the Amoxicillin.  Mr C said that he believed the error in administering Amoxicillin to Mrs A and the lack of an appropriate response could have hastened or brought about Mrs A's deterioration and death.  As a result, Mr C believed that Mrs A had not been provided with a reasonable standard of care and treatment.

The board acknowledged that Mrs A was unreasonably prescribed and administered Amoxicillin when she had a known allergy; that the response of medical and nursing staff was deficient; and there were failures in record-keeping.  The board said that, while Amoxicillin should not have been prescribed or administered to Mrs A, there was no suggestion that an allergic response was seen or was responsible for Mrs A's subsequent clinical course.

During the investigation, my complaints reviewer took independent advice from a consultant in respiratory medicine and a nurse.

Regarding Mr C's complaint that Mrs A was unreasonably given Amoxicillin when she had a known allergy to penicillin, the medical and the nursing advisers said that while what had occurred in Mrs A's case was a human error, the failure by staff to follow drug administration policies was a serious incident and represented serious failings in care.

In respect of Mr C's complaint that staff had failed to take appropriate steps when the prescribing error was reported to them, the medical adviser said that although the board had accepted there were failures in the response of nursing and medical staff to Mrs A wrongly being administered Amoxicillin, these failings fell below an expected standard of care that Mrs A should have received and represented serious failings in Mrs A's care.

Mr C also complained that there was a failure to provide Mrs A with a reasonable standard of treatment. The medical adviser said that the deterioration in Mrs A's condition was due to the worsening of an underlying condition and not to the administration of Amoxicillin.  However, the medical adviser said there were missed opportunities to identify the severity of the deterioration in Mrs A's condition earlier on in her admission and Mrs A should have been referred earlier to the ICU team.  All of which represented a serious failure in Mrs A's care.  I accepted the advice I received.

I was concerned by the serious failings identified in Mrs A's care and treatment and in view of these failings, I upheld all of Mr C's complaints.  I have, therefore, made recommendations to address this.

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise for the failings identified in complaint (a) in relation to the prescribing and administration of   Amoxicillin when Mrs A had a known allergy to penicillin;
• ensure the comments of Adviser 1 and Adviser 2 in complaint (a) about the action that requires to be taken to avoid a repetition of what occurred are brought to the attention of relevant staff and to report back on the action taken;
• carry out a review of the Action Plan and the Board's policies on drug administration in view of the comments of Adviser 1 and Adviser 2 referred to at paragraphs 31, 34 and 35 and to report back on the action taken;
• provide my office with an update on the work of the Patient Safety Programme;
• apologise for the failings identified in complaint (b) in relation to the failure to take appropriate action when it was reported that Mrs A had wrongly being administered Amoxicillin;
• ensure the comments of Adviser 1 and Adviser 2 in complaint (b) are brought to the attention of relevant staff and to report back on the action taken;
• carry out a review of the Action Plan in view of the comments of Adviser 1 referred to at paragraph 55 and to report back on the action taken;
• provide evidence to show how they encourage staff to report early when errors occur and how they share the learning from such errors with staff;
• apologise for the failings in Mrs A's treatment identified in complaint (c);
• ensure the comments of Adviser 1 and Adviser 2 in complaint (c) are brought to the attention of relevant staff and to report back on the action taken; and
• carry out a review of the Action Plan in view of the comments of Adviser 1 referred to at paragraphs 95; 96 and 97 and to report back on the action taken.

Summary
Mrs C's child (Child A) had been suffering from vomiting and headaches and was referred to a paediatrician at Forth Valley Royal Hospital in January 2014.  The paediatrician saw Child A on three occasions from January 2014 until July 2014.  In August 2014, Child A collapsed at home and was admitted to Forth Valley Royal Hospital as an emergency.  Child A was diagnosed with a brain tumour. They underwent lengthy and difficult surgery to remove the tumour, but it was impossible to remove it completely.  Mrs C said that despite the evidence of Child A's deteriorating condition, the paediatrician failed to record their symptoms and carry out appropriate tests, referrals and investigations.  Mrs C also said that the paediatrician failed unreasonably to consider a serious cause of Child A's symptoms.  As a result, Mrs C believed that Child A's brain tumour should have been detected much earlier and that they suffered unnecessarily.

During the investigation, my complaints reviewer took independent advice from a specialist in paediatrics and a specialist in paediatric neurosurgery.  The first adviser considered that Child A should have been referred for a brain scan in April 2014 (at the least) and that the paediatrician's failure to consider that Child A may have a brain tumour and arrange appropriate scans and referrals was below an acceptable standard of care.  I accept that advice.  I am particularly concerned about the paediatrician's failure to act in July 2014 given that they had documented their awareness of headaches in addition to ongoing vomiting.  The second adviser said that it was likely an earlier diagnosis would have meant a smaller tumour and a shorter, less challenging operation.  My view is that these failures led to a significant personal injustice to Child A.  The unreasonable delay meant that an opportunity to completely remove the tumour was missed, and in this respect I note that Child A required additional treatment (chemotherapy) with significant risks and was left with neurological defects.  In addition, Child A's collapse was very traumatic for them and their family.  Given the evidence and information available to the specialist about Child A's condition (from January 2014 onwards), I am extremely concerned about their failure to properly assess and investigate Child A's symptoms, and their failures raise questions about their competence.  In view of the failings identified, I upheld the complaint about the clinical care and treatment provided and made recommendations.  However, I did not make recommendations that relate directly to the paediatrician because they are no longer an employee of the health board.

Redress and recommendations
The Ombudsman recommends that the board:

• ensure that all relevant healthcare professionals are aware of the guidelines relating to the diagnosis of brain tumours in children and young people (the HeadSmart programme); and
• apologise to Mrs C for the failures identified.

Summary
Mr A, who suffered from schizophrenia (a long-term mental health condition that causes a range of different psychological symptoms), was admitted to the Clinical Assessment Unit (CAU) at Forth Valley Royal Hospital (the hospital).  Mr A had been suffering from a sore throat, a cough and a wheeze in his chest.

Mr A was treated for an infection and the possibility was raised that he may have chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed).  The day after his admittance, Mr A was reviewed and was transferred to a medical ward.  Mr A died the following morning.

Mr A's mother (Mrs C) complained that Mr A did not receive reasonable care and treatment and that the board failed to take into account his lack of capacity to understand how ill he was.  She also complained that the standard of record-keeping was not adequate and that she was not able to obtain accurate information from staff about what had happened to her son.  In addition, she complained that she was given unclear information about whether a SAE (significant adverse event) investigation by the board into Mr A's death would be carried out.

As part of my investigation, I obtained independent advice from a senior doctor with experience in acute medicine (adviser 1) and a nursing adviser (adviser 2). I also considered the board's own investigation of the complaint.

The board acknowledged that it was unacceptable that Mr A's observations were not carried out four hourly after his transfer to the medical ward and apologised for this failing.  However , adviser 1 said that there were failings in relation to Mr A's care and treatment throughout his admission to the hospital.  Adviser 1 said that in a patient with type 2 respiratory failure (which Mr A had), the measurement of arterial blood gases (ABGs) to provide information regarding the amount of carbon dioxide in the blood stream and the acid-base status of the patient was important.  Adviser 1 said that Mr A's ABGs should have been rechecked and despite the deterioration in the ABGs there was no plan or comment in the medical records.  In addition, Mr A was not reviewed by a consultant from the respiratory team.

Adviser 1 added that, while it was reasonable that Mr A received treatment for an exacerbation of COPD, other diagnoses should have been considered and treatment for this should have been part of Mr A's management plan.

While the board said that Mr A was deemed to be in a stable position, adviser 1 said that on admission and throughout his admission to hospital he was significantly unwell.

Adviser 2 also indicated that the nursing care Mr A received fell below the standard expected of a patient with a recognised respiratory condition.

I was concerned that, given Mr A's past medical history and in view of his refusal of treatment during his admission to the hospital and that he left the hospital against medical advice, a formal assessment of his mental capacity to understand the seriousness of his illness and ability to make informed decisions was not carried out.

Both advisers said that there was a lack of recognition of the seriousness of Mr A's condition by nursing and medical staff. They said he was not seen by a consultant until over 24 hours after his admission and was not seen again by a senior clinician prior to his death.  I am critical of the failings which meant, that potentially, the opportunity to recognise and treat Mr A was missed.

The board also accepted that there were failings in relation to record-keeping and had taken action as a result of these failings.  However, I am concerned that there appear to be conflicting reports of how Mr A spent his final hours. I consider that this would have added to Mrs C’s and the family’s distress at a very difficult time. I am also concerned that the advice I received, and accept, is that the lack of prescription of oxygen on Mr A's chart was not in accordance with guidance and that the miscalculation which occurred in relation to the national early warning score (NEWS) was in the view of adviser 1 a serious issue.

While the board explained why they decided that an SAE investigation would not be carried out, adviser 1 said that in this case there were issues around the recognition of an acutely ill patient, assessment of mental capacity and escalation and treatment of Mr A's type 2 respiratory failure and that an SAE investigation should have taken place.  Adviser 1 was of the view that there were serious lessons to be learned from this case which needed to be acted on by the board.

Redress and recommendations
The Ombudsman recommends that the board:

• apologise for the failings identified in this complaint;
• bring adviser 1's comments about the frequency of the ABG measurements to the attention of relevant staff and report back on action taken;
• take steps to ensure that, when patients with a known history of mental health problems are formally assessed for capacity, a recognised clinical assessment instrument is used, or alternatively an opinion is sought from the psychiatry service;
• take steps to ensure all patients admitted acutely are reviewed within the timeframe recommended by the Royal College of Physicians;
• take steps to ensure that timely escalation of acutely unwell patients with acidotic type 2 respiratory failure occurs and they are reviewed in person by either a respiratory physician or other clinician with appropriate knowledge and experience;
• bring the failures identified in relation to Mr A's prescription chart and the miscalculation of the NEWS to the attention of relevant staff and ensure they are addressed as part of their annual appraisal;
• carry out an audit of NEWS charts to ensure the documentation is accurate and report back to this office;
• consider the current education and training in place for the care of vulnerable adults in acute care and take any appropriate steps to meet any gaps identified and report back on action taken;
• provide a copy of the completed nursing review referred to at paragraph 43;
• in view of adviser 1's comments, carry out a reflective SAE investigation of this case and provide this office with a copy; and
• review their current significant adverse incident guidance in light of adviser's 1's comments detailed in this report.