Health

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.

Summary
Mr C, who suffered from a hereditary heart condition, had an operation at the Royal Infirmary of Edinburgh to remove a machine implanted in his chest to monitor his heart.  The operation was carried out by a trainee doctor. When the trainee doctor encountered difficulties, he was assisted by a more senior trainee doctor.  Mr C subsequently required a second operation to revise the scar the first procedure had left on his chest.

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

Mr C complained the first operation had not been carried out to an appropriate standard.  He said that the experience had been painful and distressing and  believed the correct procedures had not been followed. Mr C believed the trainee doctor performing the surgery had not been competent to do so, noting that the time taken to perform the operation meant he required additional anaesthesia, as his initial dose had worn off.

The board said they had thoroughly reviewed Mr C's treatment. The board said the tools for cauterising the wound to stop bleeding post-surgery had not been available.  Silk stitches had been used instead, but these may have contributed to the poor healing Mr C experienced. The board said the consultant responsible for supervising the operation was available, but had not been present throughout the operation.  The board acknowledged Mr C's experience fell short of what he could have expected.

The adviser said the board had not adequately explored the conflict between the contemporaneous note of the operation and the conclusions reached by the complaint investigation.  The operation note stated cauterisation had been used to stop Mr C's bleeding, but as the complaint investigation acknowledged, this could not have been performed as the equipment was not available at the time.  The adviser said the operation note's inaccuracy had not been properly explored, nor did the note record the difficulties encountered during the surgery. The adviser said it was unreasonable for a trainee doctor to be allowed to perform the surgery unsupervised, as it was not a straightforward procedure.

The adviser added the board did not address the issue of supervision.  Their complaint response gave the impression a consultant had been present at points during the operation.  The available evidence showed no consultant had been present at any point, nor had they been aware Mr C's procedure was being carried out by a trainee doctor.  The adviser also noted Mr C's consent was not properly obtained and that there were inadequate records of the information provided to him prior to surgery.

I found the board failed to investigate Mr C's complaint thoroughly, although they had accepted the standard of treatment received was unacceptable.  I also found they had failed to deal comprehensively with the service failures Mr C experienced.  I am critical of these failings, which resulted in a misleading formal response being provided by the Board and a lack of evidence that adequate steps had been taken to prevent a reoccurrence.

Mr C also complained that the effect of the first operation had not been recognised by the board.  He had stated to the board that his business had suffered severely whilst he was unable to work and that he had been forced to cease trading.  I was critical of the board for failing to address this issue, even though Mr C raised it twice during his complaint.  I considered the board had to address the impact on him of the failure to carry out his surgery in a reasonable fashion.

Redress and recommendations
The Ombudsman recommends that the Board:

• provide evidence of the actions taken by Doctor 2 to improve their skills and their subsequent appraisals;
• provide evidence that Doctor 2 has continued to practice without significant subsequent complaints or concerns being raised;
• provide evidence that their policy for the supervision of trainees during surgical procedures has been reviewed;
• review the consent forms used for this type of surgery to ensure they accurately reflect the potential complications;
• remind all staff of the importance of documenting consent fully and accurately; and
• provide Mr C with a comprehensive and patient centred response to the issues he has raised concerning the impact of the surgeries on his ability to work and his finances.

Summary
Mr C had a hip replacement operation at Raigmore Hospital.  During the operation, he was aware that the first attempt to insert the implant into his hip had not been successful, and the surgeon had tried again.  This had prolonged the time he was in theatre, and, given the length of time the operation was taking, Mr C had asked for further anaesthesia for the pain.  He found the experience to be very distressing and complained that the board had not provided him with a reasonable standard of care.

I took independent advice from two advisers; one a consultant in orthopaedic surgery (adviser 1) and the other a consultant anaesthetist (adviser 2).  Whilst there were some difficulties during the procedure, of which there is more detail in my full report below, adviser 1 considered that the standard of surgery was reasonable.  However, adviser 2 reported that Mr C was uncomfortable for over an hour until the anaesthetist administered a general anaesthetic, and it would have been reasonable for this to have been undertaken earlier.  Based on this, I upheld Mr C’s complaint about the care he received in his operation.

Mr C was discharged from hospital, and he was given aspirin to take.  However, around two weeks later he was readmitted to hospital with a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs).

There are national guidelines, issued by the Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Health and Care Excellence (NICE), which relate to the use of treatments to prevent VTE (the formation of blood clots in the vein).  These guidelines state that aspirin is not considered an adequate treatment for reducing the risk of VTE for patients in hospitals.

The advice I received from adviser 1 is that the failure to follow the guidelines on treatment following his surgery led to a significant injustice to Mr C in that he suffered a life-threatening condition which required another admission to hospital for treatment.  The surgeon who carried out the surgery had noted in Mr C’s operation note that he should receive anticoagulant therapy but another member of staff had discharged Mr C with aspirin.  However, the surgeon had gone on to tell my complaints reviewer that it was common throughout Scotland for aspirin to be provided for patients who had undergone joint surgery, even though this is against recognised SIGN guidelines.  The board confirmed to my complaints reviewer that there was no specific board policy on this, but that if anticoagulant therapy wasn’t provided to a patient, this should be documented and explained by the clinician taking that decision.

I am very concerned not only that the relevant guidelines were not followed in Mr C’s case, but also about the board’s practice in general.  It remains unclear to me if the board have a coherent policy that is being followed within Raigmore Hospital and beyond.  As a result, an urgent review is required. I also intend to write to the Chief Medical Officer to draw their attention to my concerns about the use of aspirin and its potential implications for patient safety which have come to light in the course of my investigation.

Redress and recommendations
The Ombudsman recommends that Highland NHS Board:

• bring adviser 2’s comments in relation to anaesthesia to the attention of relevant staff;
• review as a matter of urgency the practice to ensure that its surgeons take into account the relevant guidelines on VTE prophylaxis;
• review its standard operating procedures concerning VTE prophylaxis for patients on discharge taking into account the relevant guidelines; and
• apologise to Mr C for the failures this investigation identified.

Summary
Mrs C attended the Golden Jubilee Hospital for a modified Brostrom procedure (ligament repair) on her ankle.  Following surgery, tests showed she had severe nerve damage. This was believed to have been caused by the popliteal nerve block anaesthesia (an injection of local anaesthetic near the nerves that go to the area being operated on) that she received for the surgical procedure.  Mrs C complained that she was not informed the nerve block would be carried out or about the risks. She said that she did not see the consultant anaesthetist before the procedure.  Mrs C complained that her injury was caused during the procedure and that staff failed to carry out the procedure to a reasonable standard.  She said that the nerve damage had had an enormous impact on her life.

As part of my investigation, I obtained independent advice from a medical adviser who is a consultant anaesthetist.  The adviser said there was no documented evidence in Mrs C's medical records of a discussion about the surgical procedure and its possible side effects, whether common but minor side effects, or rare but serious ones.  The adviser noted that the General Medical Council (GMC) guidance on consent issues was clear that patients must be told about recognised serious adverse outcomes, even if they are rare.  Nerve damage was a recognised side effect of techniques such as the nerve block so, even though the risk of permanent nerve damage was very rare, I considered it a failing that Mrs C was not warned about it.  The limited interaction with Mrs C before her operation meant that staff did not obtain her informed consent and I upheld her complaint.  I was concerned that these failings may have been caused by the pressures on the service.  I recommended the board conducted a review to ensure enough time was spent with patients before procedures to obtain consent properly.

Regarding Mrs C's complaint that the procedure was not carried out properly, the adviser noted that there was no record taken at the time of the procedure of the anaesthetist's technique and practice.  This was a significant failing.  However, the adviser said the technique reported later (although without much detail) gave an indication of a reasonable technique by an experienced clinician.  I agreed with the advice that there was limited documentary evidence to indicate that the practice and technique was of a reasonable standard.  Although there was no clear evidence that Mrs C's injury was caused during the procedure due to a failure by staff, the lack of contemporary record-keeping meant there was no assurance of carefully considered practice and technique.  On balance, I upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• bring the failings (related to explaining the risks of a popliteal nerve block anaesthesia) to the attention of relevant staff and ensure they are raised as part of their annual appraisal;
• review the service to ensure there is sufficient time to properly obtain (and document) consent for procedures;
• bring the record-keeping failings (related to carrying out the procedure in an appropriate manner) to the attention of relevant staff and ensure they are raised as part of their annual appraisal; and
• apologise to Mrs C for the failures my investigation identified.

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.