| (a) |
Mrs A was not offered a repeat colonoscopy after an incomplete colonoscopy was performed in June 2013
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Patients who have had an incomplete colonoscopy should be offered a repeat colonoscopy or another appropriate investigation in line with clinical guidelines
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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
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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
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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
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| (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
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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
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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
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| (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
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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
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| (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
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| (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]
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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
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| (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
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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
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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
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| (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
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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
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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
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| (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
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