Health

Summary
Mr A, who was suffering from lung cancer, had an operation at Aberdeen Royal Infirmary to remove his lung.  During the operation, Mr A suffered from hypoxia (a deprivation of oxygen).  He was transferred to intensive care but did not regain consciousness and died one week later.  Mr A's daughter (Miss C) complained about the care and treatment provided to her father.

In investigating, I took independent medical advice from a consultant anaesthetist, as well as considering the board's own investigation of the complaint.

Miss C complained that the consultant anaesthetist failed to provide a reasonable level of care to Mr A prior to and during his surgery.  The adviser said that surgery should not have proceeded when it became apparent there was a problem with monitoring carbon dioxide levels in Mr A's blood, and that it was concerning that the consultant anaesthetist had needed advice on methods to maintain blood oxygen levels and treat hypoxia.  The adviser also noted that the board's own investigation had acknowledged shortcomings in the communication between the surgeon and the consultant anaesthetist during surgery, and that the consultant anaesthetist had not been assertive enough in their decision-making.  I considered that the performance of the consultant anaesthetist fell below the reasonable level of care from a specialist doctor who has achieved consultant grade.

Miss C also complained that her father's suitability for surgery was not appropriately assessed.  The adviser said that the tests used for Mr A were generally acknowledged to have limitations and other tests should have been considered which may have prompted more investigation ahead of surgery.  The board said that their investigations found no problems with Mr A's pre-operative assessment.  I found this to be inaccurate and I was critical of the board for failing to identify that the assessment could have been more robust and to act upon this accordingly.  I also found that the failings in the
pre-operative assessment meant that neither Mr A nor his family were able to have an informed discussion about the risks of surgery.

The board acknowledged that there were significant failures in their post-operative communication with the family.  It was obvious to staff how unwell Mr A was after his operation, but despite this, it was not until around 36 hours later that someone from the surgical team properly discussed matters with the family.  This was the most distressing part of this case.  All other issues relate to technical problems, and the difficulties of high risk surgery, but this issue relates to the basics of human kindness and interaction with a family in distress.  This contributed significantly to a breakdown in trust between Mr A's family and some medical staff.  Although the board recognised that the communication was inadequate, I was not convinced that they have taken sufficient action to ensure this does not happen again.

I upheld all of Miss C's complaints and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• provide evidence of the actions taken by the consultant anaesthetist to improve their non-technical skills and their subsequent appraisals;
• provide evidence that the consultant anaesthetist has continued to practice without significant subsequent complaints or concerns being raised;
• provide evidence that the consultant anaesthetist has revalidated with the General Medical Council, if this has been achieved as part of the five year cycle since this operation;
• review its pre-operative assessment procedure for lung cancer surgery, to ensure that cardiopulmonary exercise tests and echocardiograms are included for appropriate patients;
• review their lung cancer pre-operative assessment procedures to ensure FEV1 and the Diffusing capacity of the lung for Carbon Monoxide DLCO are calculated prior to surgery in order that post-operative lung function is taken into account;
• review their consent procedure for lung cancer surgery to ensure that it informs the patient what level of risk the operation will incur for them;
• review their procedures to include a requirement for a member of the surgical or anaesthetic team to speak to either the patient or their family at the first available opportunity following an adverse incident that requires admission to Intensive Care Unit;
• review the findings of the Anaesthetic Department Morbidity and Mortality meeting to identify if, and why medical staff declined to support the consultant anaesthetist in his meeting with the family; and
• remind staff that notes are taken of any meetings with family or patients following adverse events.

Summary
Ms C had been referred to a consultant plastic surgeon then to a consultant general surgeon to undergo a surgical procedure on her buttocks.  She has suffered from internal and peri-anal abscesses for a number of years and had previously undergone treatment to drain these on a number of occasions.  Ms C said that she had been assured that she would not suffer from any issues with continence following the operation, as this was a significant concern for her prior to undergoing surgery.  Following the operation, Ms C found that she was incontinent.  As a result she had to undergo a colostomy procedure, which has had a significant impact on her personal life, resulting in her having to give up work.

I took independent advice from a consultant colorectal surgeon, who said that incontinence was a well-recognised side-effect of the procedure Ms C had.  Ms C said that she would never have consented to the procedure had she been made aware of this risk.  I found Ms C's medical notes documented that this was an area of great concern to her, therefore I consider that it was unreasonable that this was not discussed with her and documented prior to surgery, nor did the consent form that she signed mention this as a possible risk of the surgery.

The board accepted that the forms Ms C signed had not documented incontinence as a risk of the surgery.  However, they did dispute whether Ms C was ever given an assurance that there was no risk of this complication from the procedure.  I do not accept that this removes the responsibility from the board in this regard.  Under General Medical Council guidelines, the medical staff responsible for her care had an obligation to ensure that Ms C was able to give informed consent, particularly as she had identified a particular concern before the operation.

I also found that the board failed to respond appropriately to Ms C's complaint about the cause of her incontinence.  Whilst it is possible that the incontinence is a result of a progression of Ms C's on-going condition, it is also possible that it was a result of a complication of the surgery.  Given this, the board's failure to provide adequate information to her before the procedure and later in their complaints responses was unreasonable, so I upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• review the consent forms used for this type of surgery to ensure they accurately reflect the potential complications;
• remind staff of the importance of identifying and documenting that issues of importance to patients have been discussed during the consent process; and
• apologise unreservedly to Ms C for the failings identified in this report.

Summary
Ms C, who works for the Patient Advice and Support Service, brought the complaint on behalf of Ms A. It concerned the delay in Ms A's son's diagnosis with Hodgkin's Lymphoma (a cancer that develops in the lymphatic system).I decided to issue a public report because of the significant personal injustice suffered by the child and his family in delaying the diagnosis. I was also concerned that this case highlighted a potential systemic failure at the GP practice to recognise a 'red flag' symptom of cancer.

The child was taken to the practice in May 2013 with a painful swelling on the left side of his neck. He was seen by a doctor who took blood for testing and prescribed an antibiotic. The child returned to the practice later that month and was seen by a different doctor. A chest x-ray referral form was completed and a note made that blood tests were to be repeated in one month as some of the earlier results were abnormal. Further antibiotics were prescribed.

However, no appointment was made with the practice for the further blood tests and no chest x-ray appointment was allocated to the child at the local hospital. The child returned to the practice in October 2013 when he was seen again by the first doctor who immediately referred him for a chest x-ray and for further blood tests. Further consultations took place regarding the child's continuing pain and though a referral was made, it was not an urgent referral and the child was advised to wait for a forthcoming appointment in early November. After this appointment and following further investigation, he was diagnosed with Hodgkin's Lymphoma.

I took independent medical advice on this complaint from a GP adviser. They referred to the Scottish referral guidelines for suspected cancer and commented that they would expect a doctor to be aware of the significance of a left supraclavicular (above the collarbone) node and its potential as a sign of an underlying cancer. They said it would have been reasonable practice to refer the child at an earlier stage and considered that this delay suggested a lack of clinical knowledge on the part of the practice doctors. Although it was considered beneficial to carry out blood tests and an x-ray, the adviser said that this should not have delayed the referral being sent when the child first presented with a lump.

This case also highlighted the way referrals were processed by the practice at that time. The practice were unable to say whether the letter requesting an x-ray had been lost at the practice and never posted; lost by Royal Mail; or lost within the records office at the local hospital. They apologised for the delay in the child receiving his x-ray acknowledged that ideally, the referral should have been followed up. They said that there had not been a robust system for following up referrals or test requests.

The practice explained that in order to prevent such incidents happening again, the process had been changed so that the referring doctor now gives the referral letter to the patient and instructs them to go directly to the hospital. They also advised that a register had been introduced on their computer system for the daily recording of all referrals and test requests. They said that this is checked each week and updated with results or other information received, with any entry that has not been actioned for more than two weeks being flagged for immediate attention. They considered that the new system worked well and would prevent a recurrence of the circumstances the child experienced. I asked the adviser about the new system introduced by the practice to monitor referral and test requests and they commended it and agreed that this would adequately address the issue of the chest x-ray request that arose in this case.

I am concerned that the events in this case suggest a gap in the clinical knowledge of both practice doctors who saw the child, as neither identified the significance of the supraclavicular lump.I appreciate that one of the doctors has now retired, but the other continues to practice. It is important that this matter is addressed without further delay as a learning priority, and I made a recommendation about this.

Redress and recommendations
The Ombudsman recommends that the practice:

• issue a written apology for the delays in appropriately referring the child to the board;
• ensure that the practicing doctor identifies the diagnosis and referral criteria for signs of cancer as a learning priority; and
• ensure that this case is discussed at the practicing doctor's next appraisal.

Summary
Mrs C was scheduled to have a colonoscopy procedure (examination of the bowel with a camera on a flexible tube) at Hairmyres Hospital.  It had been planned that Mrs C would be under general anaesthetic.  This was because a previous colonoscopy procedure using conscious sedation (to relax and provide pain relief) had been a painful experience for her.  However, the operating theatre was unexpectedly unavailable so the procedure was carried out in the endoscopy unit using conscious sedation.  Mrs C said that she experienced excessive pain and discomfort during the procedure, and continued to experience pain for more than a month afterwards.  Mrs C said that she asked many times for the procedure to be stopped and nursing staff also asked for the procedure to be stopped.  However, the doctors (a senior staff grade surgeon and a consultant colorectal surgeon) continued nonetheless.  Mrs C said she had been left severely traumatised by what occurred.

As part of my investigation, I obtained independent advice from an adviser who is a consultant colorectal surgeon.  Regarding Mrs C's complaint that the colonoscopy procedure went ahead without the general anaesthetic, the adviser said that, as Mrs C had prepared for the procedure and waited a long time that day, it was reasonable for it to be attempted using conscious sedation.  However, it should have been clearly understood that if Mrs C experienced excessive discomfort, the procedure should be stopped immediately and rescheduled to be carried out using a general anaesthetic.  The adviser considered that the consultant had not complied with General Medical Council guidelines on obtaining informed consent and had communicated with Mrs C poorly.  They also found it concerning that these communication failings had not been acknowledged by the consultant or the board.

Mrs C complained that the procedure was carried out without a reasonable level of sedation.  The adviser said that the sedation Mrs C received was not enough to provide her with an appropriate level of comfort.  As it would have been unsafe to increase the sedation given to Mrs C, the procedure should have been stopped.

Mrs C also complained that the procedure was unreasonably continued despite her requests for it to stop.  The adviser said that, in the initial absence of the consultant, it was reasonable for the surgeon to begin the procedure.  However, the adviser considered the consultant made a serious error in not giving the surgeon a clear explanation of Mrs C's previous poor experience of colonoscopy and clear instructions to stop if the procedure was too painful or distressing for her.  There was evidence in Mrs C's medical records that she and nursing staff asked the surgeon to stop and, in the adviser's view, on arriving to find both patient and nursing staff requesting that the procedure should be stopped, it was unreasonable for the consultant to have taken over and continued.  The adviser considered that the evidence clearly demonstrated the withdrawal of Mrs C's consent for the procedure.

I upheld all the complaints.  My investigation identified a number of serious failings including poor communication, poor record-keeping, poor understanding of the consent process, and a failure to stop the procedure when asked by Mrs C.  I was also concerned that the board and the consultant did not appear to have understood, acknowledged or sufficiently appreciated the seriousness of the failings.  Nor had they identified all the learning required or taken sufficient remedial action.  I also noted the similarity of the circumstances of another recent complaint (case 201402959) and have taken the recommendations made in that complaint into account in making recommendations in this case.

Redress and recommendations
The Ombudsman recommends that the board:

• and the consultant apologise to Mrs C for the failings identified in this complaint in relation to poor communication and in obtaining informed consent;
• share with the consultant the comments of the adviser in relation to obtaining informed consent from a patient;
• arrange for the consultant, if they have not already done so, to undergo training and a suitable continuing professional development course to improve their communication skills and understanding of the consent process and to provide evidence of this;
• apologise to Mrs C for the failing identified in this complaint in relation to carrying out the procedure without a reasonable level of sedation;
• and the consultant apologise to Mrs C for the failings identified in this complaint in relation to poor communication, a failure to stop the procedure when asked by Mrs C, a poor understanding of the consent process, and poor record-keeping;
• arrange for the consultant and the surgeon to undertake training, if they have not already done so, to improve their communication skills and an understanding of the consent process, particularly where a patient withdraws their consent;
• bring to the attention of the consultant the comments of the adviser to give consideration to submitting a report about what occurred in Mrs C's case to a local morbidity and mortality meeting;
• review the Global Rating Scale (GRS) data from all of their endoscopy units and reflect on the comments of the adviser in relation to achieving good GRS scores;
• provide evidence that all their endoscopy units have standardised documentation for recording of patient discomfort during colonoscopy, in line with recommended practice;
• provide evidence that all their endoscopy units have standardised guidelines for procedural sedation and for withdrawal of consent;
• consider, if they have not already done so, developing  guidelines for all their endoscopy units in respect of recommendations (ix) and (x); and submit a synopsis of this case together with current standardised documentation and guidelines to their Endoscopy Governance Group in order to provide dissemination of learning and to minimise variability of colonoscopy practice within their hospitals; and
• provide evidence of the action they say has been taken.

Summary
Mrs A, who had dementia, was admitted to Borders General Hospital with sepsis (blood infection).  She was discharged to her care home after a few weeks but was re-admitted two months later for end of life care.  She died in hospital two days later.  Her daughter (Mrs C) complained about several aspects of the care and treatment received by Mrs A during her admissions to the hospital.  She said that, before her first admission to the hospital, Mrs A had been able to walk with the help of a walking stick and could feed herself.  However, by the time of her discharge, she could neither stand nor eat without assistance.  Mrs C said that Mrs A was not helped with personal care, her skin care was not attended to, and she was not helped with eating or drinking.  She said that staff did not consider the needs of Mrs A as a person, despite the care home providing 'Getting to Know Me' documentation when she was admitted.

As part of my investigation I obtained independent advice from a nursing adviser.  The adviser noted that the record-keeping, and particularly the nursing notes, about Mrs A's care was poor.  Documents such as her care plan were not completed properly and other documents that my adviser expected to see (such as a wound chart, and food and fluid charts) were missing entirely.  This meant that there was no evidence to show that reasonable nursing care was provided to Mrs A. The adviser said it was very poor that relevant personal information about Mrs A was lacking from her notes as this information was vital to ensure her care plan was person-centred.  I was advised that Mrs A's care lacked any knowledge of dementia, and I am concerned that her needs and preferences were not taken into account.  I concluded that Mrs A did not receive adequate care during this admission.

Mrs C also complained about communication from staff during Mrs A's first hospital admission.  Despite the family holding welfare power of attorney for Mrs A, she said staff never approached them to discuss treatment or the care plan.  She said the family, who made daily enquiries, were often given misleading information, and she complained that the staff discussed Mrs A with them in the corridor.  The adviser said that they would have expected more information in Mrs A's notes about communication with her family, and that the standard of communication was generally poor.  They considered confidential discussions taking place in hospital corridors to be totally unacceptable practice.  I found that the welfare power of attorney should have been identified and reflected in Mrs A's care plan, and the family should have been updated regularly.  An inspection in 2012 by Healthcare Improvement Scotland (HIS) alerted the board to instances where staff failed to satisfy themselves that a welfare power of attorney was in place, and also instances where staff discussed confidential patient information in corridors.  I was concerned that this was still occurring.

Mrs C was also unhappy about the care Mrs A received when she was re-admitted to Borders General Hospital for end of life care, and about the attitude and communication of nursing staff at that time.  She said that Mrs A, who was close to death, and her grieving family were left alone for two and a half hours.  She said the staff showed no care or compassion and seemed uninterested.  The adviser said the nursing role is to care and support both the patient and their relatives, and that they would have expected staff to assess and provide care to a dying patient at least every two hours.  However, there were long gaps between entries in the nursing records, which I found concerning.  The family's needs were clearly not met and I conclude that the level of support provided was unreasonable.

Mrs C complained about the board's handling of her complaints, one of which did not acknowledge within the correct timescale or automatically treat as an official complaint.  The board also failed to send Mrs C a written follow-up or apology after their meeting with members of the family.  Mrs C considered that the board's investigation missed serious failings and, in particular, a breach in procedures that were put in place after the HIS inspection.  I found that Mrs C's letter was clearly a complaint and should automatically have been dealt with as such, and that it would have been good practice to summarise the key points of the meeting for Mrs C.  I considered that the board's learning from the complaints was vague, and I agreed with Mrs C that the board's action plan was insufficient.  I upheld all of the complaints and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the board:

• carry out a review of nursing care and leadership on the relevant wards, taking account of the failings highlighted in this report;
• further develop their action plan to take account of the criticisms in this report and, in particular, ensure that specific and robust action is taken to address the identified record-keeping failings and the failure to provide appropriate, person-centred dementia care to Mrs A;
• carry out a review of their consent to treatment policy and patient documentation to ensure that the existence of any formal adults with incapacity arrangement is promptly identified, reflected in the care plan, and that appropriate communication with the relevant appointed person(s) takes place;
• take urgent action to address the issue of confidential patient information being discussed by staff in hospital corridors and inform the Ombudsman of the steps taken;
• provide us with a copy of their action plan / strategy for end of life care;
• ensure they have a policy in place to guide staff in what they should do when a patient dies;
• review their handling of this complaint and identify areas for improvement, taking account of their statutory responsibilities as set out in the CIHY guidance; and
• apologise to Mrs C and her family for the failings this investigation has identified.

Summary
Mr C had surgery for bowel cancer and then started chemotherapy to reduce the risk of his cancer recurring.  He suffered significant gastrointestinal side effects from the chemotherapy, including abdominal cramps and diarrhoea.  He went to the emergency department at Victoria Hospital but his oncology consultants (cancer specialists) were not told about his visit.  A week later, Mr C started to have regular sickness and diarrhoea and he visited his GP twice for treatment.  Three days before his second cycle of chemotherapy, Mr C was reviewed by an associate specialist oncologist, who assessed Mr C's diarrhoea as grade 0 (on a scale of zero to five, where grade 5 is the most severe).  The oncologist pre-authorised the administration of the drugs at a reduced dosage and made a note that Mr C's side effects should be observed closely.  Mr C continued to experience diarrhoea and he reported this to the nurses at the chemotherapy unit when he went to receive the second cycle of chemotherapy.  His condition deteriorated over the next few days and NHS 24 referred him to Victoria Hospital, where a scan showed evidence of severe chemotherapy-related inflammation, and possible perforation, of the colon.  Mr C's chemotherapy was stopped and he had an operation on his colon, spending five weeks in hospital.

Mr C complained that his symptoms of chemotherapy toxicity were not recognised within a reasonable time and that he should not have been given another cycle of chemotherapy treatment.

I took independent advice from an adviser who specialises in oncology.  The adviser said that the symptoms Mr C described amounted to grade 2 or 3 diarrhoea.  The board's guidance stated that further treatment should not have been prescribed until the diarrhoea had settled to grade 1 or lower.  The adviser found that the toxicity assessment by the associate specialist oncologist was inadequate and that further chemotherapy should not have been prescribed.  He also said that when Mr C reported his on-going diarrhoea to nursing staff, they should have asked for medical advice before administering chemotherapy.  The adviser said that Mr C should have been able to easily get advice about his problems, for example, from a 24-hour cancer treatment telephone helpline.  He commented that the lack of access to a single point of advice about chemotherapy-related problems resulted in poor communication of these problems to the oncology team treating Mr C.

The advice I have received is that Mr C had considerable difficulty accessing medical advice when he developed problems.  I found that there were failings at almost every contact Mr C had with health care professionals in relation to the second cycle of chemotherapy and that the system in place to ensure he was treated safely was inadequate.  I found that better arrangements were needed to ensure that patients were properly assessed on the day of treatment at the chemotherapy unit, and that the nursing staff must raise any concerns with medical staff.  In view of the failings identified, I upheld the complaint and made recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• bring the failures to the attention of relevant staff and ensure they are addressed as part of their annual appraisal;
• review the governance arrangements of this unit in light of my findings; and
• apologise to Mr C for the failures my investigation identified.

Summary
Mrs A had a form of dementia and was being looked after at home by her family.  When the family became unable to care for her at home, she was admitted to New Craigs Hospital, with the aim of assessing her mental health and finding appropriate medication to enable her to return home.  Following falls in hospital, however, Mrs A's physical health deteriorated.  She was transferred to Raigmore Hospital, where she was found to have a fractured pelvis and urine retention.  Her daughter (Mrs C) made complaints about the admission process and the care and treatment Mrs A received at New Craigs Hospital.

As part of my investigation, I obtained independent advice from a psychiatric nurse, a psychiatrist and an elderly medicine specialist.  Mrs C complained that the board should have admitted Mrs A to hospital for mental health assessment earlier.  I was critical that, from the evidence available, the community mental health team did not provide enough information and advice about the waiting list and what to do if the situation deteriorated.  However, the advice I received was that keeping Mrs A at home whilst waiting for a hospital bed was reasonable in the circumstances.  I did not uphold this complaint.

Mrs C complained about various aspects of the nursing care provided to Mrs A in New Craigs Hospital.  She was particularly concerned about the assessments of falls risk and of Mrs A's pain, the lack of referrals to doctors, the poor monitoring of Mrs A on the ward, and the use of a wheelchair to transfer Mrs A for an x-ray.  The psychiatric nurse adviser was very critical of the nursing care Mrs A received, and concluded that it was disorganised, unsystematic and unreasonable.  They noted the lack of a nursing care plan, poor evidence of falls assessments, and no evidence of proper monitoring of Mrs A's pain.  The psychiatric nurse adviser found that nursing staff failed to bring Mrs A's first fall to the attention of medical staff until a day and a half later, despite clear evidence of bruising and changes in Mrs A's behaviour.  They also commented that it was inappropriate to transport Mrs A in a wheelchair when it was suspected that she had a pelvic fracture.  The advice I received clearly shows that Mrs A did not receive reasonable nursing care.  In particular, I was concerned that nursing staff did not identify changes in Mrs A's behaviour, assess her falls risk, monitor her pain, or ensure that doctors were aware of the situation, even though Mrs C was raising concerns.  I upheld this complaint and recommended an internal review to identify changes.

Mrs C complained about several aspects of Mrs A's clinical treatment, including the way medical staff considered the evidence of her deterioration, and that not enough account was taken of her changing behaviour.  She asked whether more scans should have been taken to investigate Mrs A's pain.  Overall, Mrs C felt that Mrs A should have been transferred to a medical ward much sooner.  The advisers noted that, on admission, Mrs A was mobile and active but, within 48 hours, she was in obvious pain and unable to bear weight.  It is clear to me that when x-rays did not identify a fracture, doctors did not do enough to consider what was causing the pain, or causing changes in Mrs A's behaviour and continence.  Additionally, I was concerned that doctors did not do enough to relieve her pain.  I upheld this complaint.

Mrs C also raised concerns about the record-keeping of the board, particularly with regards to Mrs A's food and fluid intake, falls assessments, the use of hip protectors, and Mrs A's level of consciousness.  My psychiatric nurse adviser found that, for all of these areas, the record-keeping was poor.  Additionally, they were critical that there was no overall care plan so important issues were likely to be neglected, and that record-keeping was mostly retrospective.  It was my opinion that poor record-keeping of Mrs A's care went hand-in-hand with poor care planning and provision, and both were well below reasonable standards.  I upheld this complaint.

I also upheld Mrs C's complaint about the board's response to her complaint about Mrs A's care and treatment.  I found that the response did not fully respond to Mrs C's questions, was overly defensive and lacking in empathy.

Redress and recommendations
The Ombudsman recommends that the board:

• conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mrs A, in order to identify appropriate improvements in clinical practice; and
• apologise to Mrs C for the failings identified in this report, both in relation to Mrs A's care and treatment and in relation to the response Mrs C received to her complaints.

Summary
Mrs A had a complex medical history, including heart problems and a low blood count.  She fell ill, complaining of central chest pain, and an ambulance was called.  The paramedics recommended that, due to the possibility of a heart attack, she was taken to Hairmyres Hospital because of the cardiac unit there.  Mrs A was reviewed by a junior doctor in the emergency department, who diagnosed stable angina secondary to anaemia (chest pain due to the blood not carrying enough oxygen).  Instead of the cardiac unit, she was transferred to Ward 2, the hospital's medical assessment unit.  Within 48 hours she was transferred again to Ward 11, then moved to the high dependency unit and, finally, to a side room for palliative care (care provided solely to prevent or relieve suffering) where she died a few days later.

Mrs A's daughter (Mrs C) complained about the care and treatment Mrs A received when she was admitted to the emergency department at Hairmyres Hospital.  In particular, she was concerned that staff did not check Mrs A's medical records to see what her anticoagulation level (INR - a measure of how long it takes blood to clot) should be, and that she was given a high dose of aspirin and other blood-thinning drugs, which seemed to cause major internal bleeding.  She complained that Mrs A was not admitted to a cardiac ward and that she was moved from Ward 2 to Ward 11 when she was very ill.  She also complained about a lack of communication and the junior doctor's failure to listen to Mrs A.

I obtained independent advice from a consultant physician.  My adviser said that the doctors missed opportunities early in Mrs A's admission to identify the severity and complexity of her conditions, and to reduce the risk and extent of her internal bleeding.  He considered that they failed to carry out the appropriate tests and was critical that, given her symptoms and abnormal blood tests, an early referral to cardiology was not made.  My adviser said that Mrs A was incorrectly given her warfarin (a drug used to prevent blood clots) when it should have been withheld.  As a result, her INR was raised to a high and dangerous level.

The advice I have received is that the staff caring for Mrs A should have considered the potential seriousness of her illness in more detail, and that they failed to properly monitor her condition.  I am concerned that advice from a cardiologist was not sought when Mrs A was admitted to the emergency department.  It was also not sought at a time when, according to my adviser, signs were very suggestive that she had had a heart attack.  I found that better care would have been provided to Mrs A if she had been transferred to the cardiac unit, as she would have received higher levels of monitoring and specialist care at an earlier stage.  I am concerned Mrs A's condition was worsened by the care she received, particularly by continuing to administer warfarin when it should have been stopped.  I am also concerned that Mrs A's medical history was not documented in enough detail and that the target INR level in her records was incorrect, despite it previously having been set at a lower level by board staff due to Mrs A’s condition.

My investigation found that, given the severity of her illness, Mrs A's outcome may not have been different.  However, better care of Mrs A might have increased her chances of survival.  It might also have given her family the reassurance that this outcome was despite good medical care, rather than her chances of survival being reduced by poor medical care.  In view of the failings identified, I upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for the failings identified in this complaint;
• present this case at a departmental Mortality and Morbidity meeting and report back to the Ombudsman on any learning or improvements that are identified;
• ensure that medical staff involved in this case include this case as a significant event analysis in their annual appraisal; and
• make further attempts to contact doctor 1 and ask doctor 1 to include this case in the educational supervision process of their current post.

Summary
Mr A was admitted to Borders General Hospital with a heavy nose bleed and in considerable pain.  He had lung cancer and several other medical conditions, and he was terminally ill.  Mr A was initially admitted to the emergency department and then transferred to the medical assessment unit (MAU).  Mr A's partner (Ms C) said that there were a number of failures in the care and treatment Mr A received in hospital.  She complained that the bedside oxygen equipment did not work, that Mr A was not given adequate pain relief or his own medication, and that he was shown a lack of compassion by nursing staff.  She said that Mr A discharged himself from hospital the day after his admission because of the poor care and treatment he had received, and so that he could receive the medication he needed.  He died at home three days later.

I obtained independent advice from a nursing adviser and a medical adviser who is a hospital consultant in acute internal medicine.  Ms C complained that the medical treatment Mr A received in hospital was unreasonable.  My medical adviser noted that the failure of the oxygen equipment in the emergency department would have increased Mr A's feelings of distress.  The board said they had already made changes to ensure that equipment was checked more often, so I asked to see evidence of this.  I also asked to see evidence of the other positive action the board said they had made following Ms C's complaint.  This was to make sure that patients arriving in the MAU were assessed within sixty minutes, whereas Mr A's medical review took place over two hours after arriving on the ward.

My medical adviser said that there was no record of a pain assessment in the emergency department though, on arrival in the MAU, Mr A was assessed as experiencing severe pain.  My adviser considered that pain relief should have been provided earlier in the emergency department.  There was also no record of pain assessment overnight in the MAU.  The advice I have received is that Mr A, who was in acute pain and terminally ill, appears to have received inadequate pain control and was left in pain for considerable periods.  I noted my medical adviser's comment that he could imagine Mr A's frustration at having been left in pain.  In his view, this led Mr A to discharge himself from hospital, leaving his symptoms untreated and with no investigation into the cause of his pain.  Therefore, he was potentially put at significant risk of harm or death.  I upheld the complaint and made several recommendations.

The nursing advice I received identified a number of serious failings in Mr A's nursing care and found that, overall, the nursing care Mr A received in the MAU was unacceptable and poor practice.  My nursing adviser found that nursing staff had failed in their duty to appropriately assess, monitor and alleviate Mr A's pain and did not appear to have followed Nursing and Midwifery Council Standards regarding the prescribing of pain relief medication to Mr A.  My nursing adviser considered that Mr A must have been frustrated not to have had his severe pain relieved despite having his own pain relief medicines with him, which he should have been allowed to self-administer.  My adviser also considered that written statements from the nurses involved in Mr A's care showed a lack of compassion for, or understanding of, his situation and feelings.  I am critical of the board for these failings and the lack of compassion shown to Mr A.  I am concerned that he had such a painful and distressing experience, and I also acknowledge the upset and distress this has caused to Ms C.  I upheld this complaint and made the following recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• provide evidence of the action to ensure that oxygen equipment checks are made between patients in addition to standard twice daily checks carried out;
• provide evidence of the action taken to ensure that the assessment of a patient is completed within sixty minutes of the patient arriving in the MAU;
• ensure the comments of the medical adviser in relation to the treatment of Mr A's pain control are brought to the attention of relevant medical staff and they reflect on this;
• apologise to Ms C for the failings identified in Mr A's medical care and treatment;
• reflect again on Ms C's complaint by reviewing what went wrong and what learning has taken place;
• consider implementing learning and development training in early resolution of concerns and complaints for front line nursing staff in the MAU;
• carry out a review of nursing in the MAU to explore the leadership and culture within the ward - to include a review of pain assessment and monitoring of patients in the hospital and, in particular, in the unit; and
• apologise to Ms C for the failings identified in Mr A's nursing care and treatment.

Summary
Mr C complained to the Ombudsman about the standard of care provided to his son (Mr A) in the community and in Stratheden Hospital, where he was taken by his parents in a moment of crisis.  Mr A had been diagnosed several years previously with paranoid schizophrenia, and he had a history of self-harming and attempting suicide.  Mr A was admitted to hospital, but absconded within hours and was found dead on a nearby railway line.  Mr C believed that Mr A's suicide risk was not properly assessed on admission, and that actions were not taken that could have ensured his safety.

I obtained independent advice from a mental health nursing adviser and a consultant psychiatrist adviser.  Both advisers noted the risk assessment in Mr A's medical records that was done when he was admitted to hospital.  They said that the form was unsigned and that important sections were either left blank or completed without much detail.  The form did, however, record Mr A's history of self-harm, suicide attempts and absconding behaviour.  Both advisers said that the assessment should have been collaborative, including Mr A, his parents and all involved staff.  It also should have assessed and discussed the many known factors that increased Mr A's risk of serious self-harm or suicide.  As this was not the case, my advisers considered that this risk assessment was inadequate, and I agreed.

Further to this, on the day after admission, a doctor began the process to detain Mr A under a Short Term Detention Certificate.  My adviser on mental health noted that this showed the doctor must have considered Mr A to be a significant risk to himself, yet did not ensure that Mr A was under constant observation from that time.  Both advisers considered this to be unreasonable.  They said that Mr A's detention was not recorded in his notes so it was not clear if nursing staff knew about the decision to detain him.  My adviser on mental health was also concerned that Mr A was able to leave the ward and hospital without staff realising, which was unreasonable.

Given the advice received, I considered that the care and treatment provided to Mr A in the hospital was below a reasonable standard.  I upheld the complaint and made several recommendations.

Mr C also complained about the medical care and treatment provided to Mr A in the community.  The advice I received is that Mr A's care package was appropriately planned and delivered, and his needs were met.  However, the needs of his parents, who played an essential role in supporting him, were not examined.  Mr C and his wife would have been entitled to a carer's assessment, which would have explored how much choice they had in their provision of care, and the impact on them, including their health, domestic needs and relationships.  I considered this to be unreasonable.  I therefore upheld the complaint and made recommendations.

Redress and recommendations
The Ombudsman recommends that Fife NHS Board:

• review their admission procedures to ensure there is multi-disciplinary involvement in the risk assessment of emergency admissions;
• remind all staff of the importance of accurate contemporaneous record-keeping;
• contact Doctor 1's current employer and ask them to ensure that this report is considered and reflected on in his next appraisal;
• review the risk assessment tools used by staff to ensure they include an adequate review of historical risk factors;
• review the procedures followed during nursing handover to ensure that patients are adequately monitored during this period;
• review the procedure followed for Short Term Detention Certificates, to ensure both multi-disciplinary  involvement, including carers and named persons;
• review their procedures for community care provision to ensure the needs of carers are pro-actively considered; and
• apologise unreservedly to Mr C and his family.