Health

Summary

C complained about the nursing care and treatment provided to their late parent (A). A had a fall during an admission to hospital. Their condition deteriorated and a large intracranial (brain) bleed was identified. A died shortly after. C complained that the nursing staff provided unreasonable care and treatment as they did not put the correct safety measures in place, given A's frailty and instability on their feet.

The board said that A was reviewed by physiotherapy who assessed A as being safe and able to mobilise independently with a walking stick. The board said that nursing staff carried out care rounding and that A was checked 30 minutes prior to their fall. Following the fall, it was noted that A was able to get up with assistance and an assessment was completed by nursing staff. When checked later, it was found A had become unconscious. The board carried out a scan of A’s head and found a large intracranial bleed.

We took independent advice from a registered nurse. We found that there was a lack of documentation and documented evidence of action taken by staff in response to cognition and mobility. Care rounding documentation was not completed to a reasonable standard or carried out to the prescribed frequency. When A’s needs changed, the care rounding was not increased. We found that the nursing staff failed to complete the mobility risk assessment, consider the use of bedrails and identify A required more help when their condition changed. We noted that the care provided by nursing staff when the fall happened and after the fall was reasonable.

We also found that the Significant Adverse Event Review that was carried out after the fall was not carried out in line with national guidance. The Duty of Candour process should have been followed in this case and it was unclear from the documentation whether this had been activated or not. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified by the investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• SAERs should be completed in line with the national framework and the board’s own protocols.
• Assessments, evaluations, and intervention bundles should be completed in line with guidance. Nursing documentation should include evidence of action taken due to changes observed, such as, change in cognition, change in mobility, use of oxygen, and factors that may impact safety such as the ability to use a call bell.
• The frequency of care rounding required for a patient should be prescribed and recorded accurately in the care rounding documentation. Once prescribed, the care rounding should be completed within the frequency identified. This should be recorded in the documentation to demonstrate care rounding has happened. Frequency of care rounding should be reflective of need. When there are changes in need, the frequency prescribed should change to meet the patients needs.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late partner (A) who was admitted to hospital due to abdominal pain, severe lower back pain, weight loss and reduced appetite. A CT scan identified a left hepatic vein thrombosis (a blood clot in the vein draining the liver). A was commenced on anticoagulant (blood thinning) medication. A further CT scan showed that A had new thrombus in the portal vein (the main vein draining into the liver). Following discussion with haematology (specialists in conditions of the blood), A’s anticoagulation medication was changed.

Several days later A complained of a headache and vomiting and was given pain medication. The following morning A was found to be unresponsive by nursing staff. Levetiracetam (an anticonvulsant medication) was administered and A was taken for a CT scan which showed extensive intracerebral haemorrhage (bleeding into the brain tissue). Protamine (medication that partially reverses the effects of the anticoagulation medication) was administered and advice sought from neurology (specialists in conditions of the nervous system) who said that on review of the scans, the extent of the bleeding was not survivable. A died shortly after.

C complained that the board unreasonably failed to warn A of the risks of anticoagulation medication and unreasonably administered protamine and levetiracetam shortly before A's death. C complained that the board unreasonably failed to include anticoagulation medication on the death certificate and failed to communicate to A’s family that it was a cause of death.

We took independent advice from a consultant in acute medicine. We found that the use and timing of both levetiracetam and protamine was reasonable. We did not uphold this part of C's complaint. However, we found that the board failed to warn A of the risks of the anticoagulation medication before commencing the treatment. We also found that the board unreasonably failed to include the anticoagulation medication on the death certificate and failed to communicate that it was a cause of death to A’s family. Therefore, we upheld these parts of A's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients prescribed anticoagulation medication should be given appropriate information on the risks and benefits of anticoagulants, in line with relevant clinical guidance and this should be clearly documented within the patient records.
• Relevant information about a patient’s death should be effectively communicated to their family.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, a support and advocacy worker, complained on behalf of their client (A) that the board unreasonably prescribed A with Flutiform (a type of medication to treat asthma). A presented to hospital with symptoms of severe asthma and was admitted to the high dependency unit for management of their symptoms. Following assessment, A was prescribed with Flutiform. A’s symptoms improved and they discharged themselves from hospital.

A complained that Flutiform worsened their symptoms and should not have been prescribed, as they had previously suffered adverse reactions and informed the nurse of this during their assessment at the hospital. In their response to the complaint, the board said that Flutiform was prescribed in line with relevant guidelines and that there was no record of A having indicated that they had previous adverse reactions to Flutiform.

We took independent advice from a consultant physician in respiratory medicine. We found that whilst there is some record that Flutiform had not worked well for A, there was no evidence of an allergy in the clinical records. Whilst A recalled that they raised concerns about the use of Flutiform during the assessment, the contemporaneous assessment records, clinical records available at the time, and relevant guidelines supported the conclusion that there was no evidence against prescribing Flutiform to A. Therefore, we did not uphold C's complaint.

Summary

C complained about the delay in the practice diagnosing their parent (A)'s cancer. C said that A was seen by a GP with recurring chest infections but was sent away with antibiotics and their initial requests for a chest x-ray were denied. When the x-ray was arranged and the results received by the practice, the GP did not contact A directly to discuss the results. Instead, A received a copy of the report from the reception staff, which was not easy to understand. C said the communication issues regarding the x-ray also led to a delay in an urgent prescription for antibiotics being passed to a pharmacy. C said that the delays in diagnosis limited the treatment options available to A.

C complained that the practice failed to reasonably investigate A’s respiratory symptoms. We took independent advice from a GP. We found that while the majority of the care provided to A was reasonable, there was a missed opportunity to refer A for an x-ray, given their symptoms and the lack of success with previous treatments. Therefore, we upheld this part of C's complaint.

C also complained that the practice failed to inform A of the results of the x-ray in a reasonable manner. We found that the x-ray report should not have been provided to A by reception staff and the findings should have been shared in person or over the phone with the GP, including all relevant information. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to consider a referral for a chest x-ray sooner and for failing to provide the findings from the x-ray in a reasonable manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Clinical staff should communicate with patients in line with GMC guidance in relation to sharing the findings of investigations.
• Patients are referred for further investigations in a timely manner, in line with NICE guidance on suspected cancer: recognition and referral.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their child (A) about the care and treatment A received prior to their surgery. They complained that some procedures had been carried out during the surgery without parental consent. They also said that A had not been examined prior to the surgery and that they had been left with unnecessary scarring. The board stated that written consent had been provided on the day of the surgery and the clinical notes recorded the procedures to be carried out and the risks of surgery had been explained at that time. The board also stated that A had been examined. However, they apologised if the verbal discussion prior to the operation had not prepared C for the outcome and also apologised if some of the scarring following the surgery was unsightly.

We took independent advice from a consultant paediatric urologist (specialist in children's urinary and genital problems). We found that the evidence suggested that the signed consent form had been read by C prior to the surgery and that no unnecessary procedures had been carried out. While there were no records to prove or disprove that A had been examined on the day of the surgery on balance we considered it was likely that A had been examined preoperatively. Although ideally it should have been explained to C during the consent process that there was a possibility that redistribution of the skin could be required during the operation, we found that it was not unreasonable that this was not mentioned. We also found that the care and treatment A had received on the day of the surgery was reasonable and that there was no evidence that the surgery carried out was inappropriate or excessive. Therefore, we did not uphold C’s complaints.

Summary

C complained about the care and treatment provided to their parent (A) when A was admitted to hospital with ongoing pain and mobility issues following a fall. A suffered from significant leg ulcers and had received a package of care while at home. While in hospital, A developed sepsis and did not respond to treatment. A died a few months after admission.

C complained of failings in how A’s leg ulcers had been managed, stating that A’s dressings were being changed less frequently than when A was in the community. C highlighted times when family members had raised the need for A’s wounds to be dressed with nursing staff who repeatedly failed to respond to these requests. C also complained of similar failures to provide catheter care and stated their belief that these were contributing factors in A’s deterioration.

We took independent advice from a nurse. We found significant failings had occurred with regards to washing and dressing the wounds, and a failure to adhere to the standard of monitoring, risk assessment and record keeping as per the relevant professional Nursing and Midwifery Council (NMC) code. We considered that the nursing care provided was unreasonable and upheld this part of C's complaint.

The adviser also highlighted concerns about the medical care and treatment provided and on this basis we took additional advice from a geriatrician (specialist in medicine of the elderly). We found that the wound care provided lacked a coherent and consistent approach, and in particular, that A’s legs were not examined until a number weeks after admission. We also found insufficient attention was given to wound swab results and blood tests, as well as A’s level of pain and overall condition. We found that the medical care and treatment provided to A was unreasonable and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Nursing staff should act in line with the NMC Code of Conduct, in particular Section 10 relating to documentation.
• Where there is concern about possible infection, such as in a patient with a raised CRP, any wounds should be examined within 48 hours of admission. If there is urgent concern, wounds should be examined immediately.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late parent (A) during two admissions to hospital. C complained that during their first admission A was given insulin that was for another patient and C was not timeously informed. C complained that during the second admission, A was initially diagnosed and treated for sepsis but when a CT scan was later performed a major stroke was discovered. C considered that stroke should have been considered and a CT scan should have been carried out earlier. A was given an infusion of both insulin and glucose to manage diabetes. C complained that A was inappropriately given intravenous (IV) glucose for 38 hours after IV insulin had stopped, noting that A became hyperglycaemic (when the level of sugar in the blood is too high) and then developed seizures. C also complained that nursing records were incomplete and that the board’s incident management and review process did not go far enough to recognise or rectify failings.

We took independent advice from a registered nurse and a consultant specialising in medicine of the elderly. We found that the insulin error should not have happened. In relation to sepsis treatment, it was reasonable to treat the infection in the first instance but when C informed medical staff of A slumping to one side a medical assessment for stroke should have been carried out and a CT scan should have been booked. We also found that it was unreasonable to continue IV glucose after insulin had been stopped, record keeping was inconsistent and incomplete such that it could not be said that nursing care was reasonable and that incident management and review was also unreasonable. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable care and treatment provided to A. In particular in relation to the treatment of A’s constipation, the incorrect administration of insulin, the failure to undertake a detailed stroke assessment and book a CT scan, and the fact that fluids were not reviewed or considered on after A’s insulin infusion was stopped and their blood glucose increased. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the unreasonable incident management of the insulin error, for not recording a Datix incident for the glucose error, that the SAER report was not sufficiently detailed to provide reassurance in regards to the quality of incident management and review and that learning and action in relation to medical care during the second admission was not appropriately considered in the SAER. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for unreasonable record keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Errors in relation to the management of a patient’s care should be appropriately recorded e.g. using Datix. Adverse event reviews should be thorough and should appropriately identify the failings, learning and improvement from the event.
• Patients should receive appropriate treatment including any relevant checks and scans booked in accordance with their symptoms.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide their sibling (A, a prisoner) with medication in a reasonable manner. C complained that the injection for A’s condition was not administered in line with the prescribing consultant’s instructions and that the board’s view that the acknowledged delays did not negatively impact A was unreasonable. C was also unhappy with the way that A’s other medications were managed.

We took independent advice from a GP. We found that there was an unreasonable delay when one of the injections was administered and guidance did not support the board’s view that no detriment would have been caused by this delay. We also found that the record keeping for the other medications administered during that period did not indicate that other medications were provided at regular intervals. This was unreasonable. Therefore, we upheld this part of C's complaint.

C also complained that the board unreasonably failed to arrange or rearrange hospital appointments for A. We found that some elements of this complaint were outwith the board’s control, in relation to third party organisations being involved in transportation. Whilst there were instances where A’s transport requests were not sent within the timeframes set out by guidance, overall we considered that the board’s efforts to schedule transport were reasonable. Where an appointment was cancelled due to transport issues, the board took quick action to reschedule the appointment and rearrange transport. This was reasonable. Therefore, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with medication in a reasonable manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Medication should be prescribed in line with specialist advice.
• When there are multiple delays in administering medication action is taken to avoid the issue repeating.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided by the board during and after the birth of their child. Following the birth of their child, C received a perineal (space between the anus and vagina) repair. C complained that the stitching was incorrectly carried out and that this subsequently caused ongoing pain and tightening of the vagina. At a consultation with a gynaecologist (specialist in the female reproductive system) the following year, it was identified that C had a thick band of skin at the vaginal opening. There was also a concern about pelvic floor muscle tightness which indicted vaginismus (an involuntary tensing of the vagina when something is inserted into it). C was referred to physiotherapy. As this was not successful, an operation to remove the thick band of skin was undertaken with the explanation that it was unlikely to improve the tightness of the muscles. C was also referred for psychosexual counselling.

C complained that they did not receive a follow-up after the operation and that they had not received an appointment for psychosexual counselling. The board reassured C that their perineal repair was performed correctly. However, they explained that unfortunately vaginismus can occur after any vaginal repair procedure. They noted that it was not always standard practice to follow up patients after gynaecology surgery but C had been added to the routine waiting list which was approximately one year. The waiting time for a psychosexual counselling appointment was 91 weeks. They apologised for C’s wait.

We took independent advice from a consultant gynaecologist. We found that the perineal repair was reasonable and that the decision to offer physiotherapy, then the operation was reasonable. It was also reasonable to refer C for psychosexual counselling. Offering a follow-up review was not standard after elective gynaecological surgery. We considered that care and treatment, from the birth until the operation, was reasonable. We acknowledged that waiting times had been extended. However, we accepted the advice received. We noted that treatment time standards do not cover routine post-operative reviews or psychosexual counselling. Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment provided to their parent (A) over two admissions to hospital. A attended the emergency department following a fall at home and was treated with painkillers for a pain in their neck. They were admitted to the ward for further monitoring of their fast and irregular heartbeat. A was reviewed the next morning and discharged that day. However, A returned to hospital later that day after another fall. A was reviewed and admitted to the ward where they were later diagnosed with a fracture of a bone in their neck.

C complained that the board failed to diagnose the fracture on the first admission to hospital and about the decision to discharge A. In response to the complaint, the board did not identify any failings with respect to assessment of A, but acknowledged that the communication of their diagnosis and discharge could have been better. With respect to the second admission, the board explained that symptoms of neck fracture are not straight forward and the examinations carried out within the emergency department were appropriate. C was dissatisfied with the response and brought their complaint to our office.

We took independent advice from an emergency medicine consultant and a consultant geriatrician (specialist in medicine of the elderly). In relation to A’s first admission, we found that the initial assessment of A’s condition in the emergency department was reasonable, although there was a missed opportunity for further assessment before A went to the ward. However, the examination and assessment of A’s neck pain on the ward was unreasonable, as was the assessment of A’s suitability for discharge, given the failure to properly assess A’s neck injury, mobility, and cognitive function. We found that the board failed to provide A with appropriate care and treatment during their first admission and upheld this part of C's complaint.

In relation to A's second admission, we found that A’s neurological examination did not include a cervical spine assessment. The board acknowledged in their correspondence with our office that the care provided at this time was not to an acceptable standard. Therefore, we determined that the care provided in the emergency department was unreasonable. We found that the care and assessment provided during A's admission to the ward was reasonable, and there was no delay in arranging further investigations. Given our findings in respect to the care provided in the emergency department, we upheld C's complaint regarding A’s second admission to hospital.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Clinical staff should be familiar with relevant NICE guidelines on the management of suspected cervical fractures. Relevant departments concerned should review their practices regarding the assessment of pain and investigation of potential head/neck injury.
• Patients should only be discharged following appropriate review and assessment of all clinical factors relevant to the decision to discharge a patient from hospital.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.