Health

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.

Summary
Miss C, who had a previous history of mental illness, had a psychotic episode and was taken by ambulance in the early hours of the morning to the emergency department at Wishaw General Hospital.  An initial mental health assessment was carried out identifying that she was seriously unwell and should be assessed by a doctor as soon as possible.  However, she was not assessed for over three hours.  A junior doctor examined her, took blood tests and contacted the on-call psychiatrist for advice.  The psychiatrist said that out-patient follow-up may be the best option and that they would review Miss C after her blood tests were done.  A couple of hours later, Miss C's parents were told that she was being admitted to the hospital for assessment.  However, Miss C was agitated, received sedation and was restrained by the police.  Later that morning her parents were told that she had been detained under mental health legislation.  She was transferred to Monklands Hospital as there were no beds available.

Miss C’s mother (Mrs C) complained that if Miss C had initially been properly assessed by a psychiatrist and admitted to Wishaw General Hospital, then the police would not have become involved and she would not have been detained.

As part of my investigation of Mrs C's complaint, I obtained independent advice from advisers in emergency medicine and psychiatry.  My adviser in emergency medicine considered that the triage nurse in the emergency department had appropriately assessed Miss C.  He said that the delay in assessment by a doctor was not ideal but, unfortunately, was not unusual in a busy emergency department at night.  My adviser found that the junior doctor's assessment was thorough and of a good standard, but that the junior doctor failed to recognise the severity of Miss C's illness.  Due to a lack of detail in Miss C’s records, my emergency medicine adviser could not state definitively that she required hospital admission but, in his opinion, it was highly likely that she did.  He said that the junior doctor should have questioned the advice of the on-call psychiatrist and insisted on an urgent psychiatric assessment in the emergency department, escalating this to a consultant if the request was refused.  He also said that when Miss C's condition deteriorated and three doses of sedatives were required, she should have been thoroughly re-assessed.

My psychiatric adviser considered that Miss C's psychiatric assessment was unduly delayed and that her condition was allowed to deteriorate during this delay.  He said that it had been unreasonable for the on-call psychiatrist to say that out-patient follow-up may be the best option for Miss C, and he also considered that the standard of note-keeping was inadequate.  In view of all of these failings, I upheld this aspect of Mrs C's complaint and made recommendations.

Mrs C also complained that the board's handling of her complaint was inadequate.  Having carefully considered their initial response to her complaint, I do not consider that it was an adequate response to the issues she had raised about Miss C's treatment, as they failed to show how these had been investigated.  After this, Mrs C met staff from the board, then wrote to them.  The board's response again did not acknowledge their failings or address all of Mrs C's concerns about Miss C's treatment in the emergency department.  Therefore, I also upheld this aspect of the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mrs C for the failure to provide reasonable care and treatment to Miss C in hospital on 18 September 2013;
• remind medical and nursing staff in the Emergency Department that acute mental health patients are high-risk patients;
• take steps to try to put a low threshold in place for the involvement of senior medical staff in decision-making regarding the discharge of such patients;
• take steps to ensure that the assessment and management of acute mental health presentations is discussed during the induction programme for new junior doctors in the Hospital's Emergency Department;
• take steps to ensure that it is emphasised in the induction programme of junior on-call psychiatrists that it should normally be the case that acute mental health patients attending the Emergency Department following an emergency should have a thorough psychiatric assessment;
• remind relevant psychiatric staff that patients being considered for discharge directly from the Emergency Department should have their follow-up and circumstances taken into consideration;
• consider if there should be a change to the process to allow the member of staff carrying out the triage to consider direct referral for psychiatric assessment in high-risk cases;
• emphasise to relevant staff involved in the complaint the importance of keeping accurate records that would be fully adequate for the purposes of later scrutiny;
• consider if there should be a protocol for emergency tranquilisation in the Emergency Department;
• issue a written apology to Mrs C for the failure to satisfactorily respond to her complaint; and
• make the staff involved in the handling of Mrs C's complaint aware of our decision on this matter.

Summary
Mr A was elderly and had several serious health problems, including a form of dementia.  He was admitted to the Royal Edinburgh Hospital from his nursing home due to worsening behavioural problems, including agitation and aggression.  His mental health assessment showed that he lacked awareness and insight into his problems, and had trouble with communication.  This, plus his aggression, meant that he was a risk to himself and other people.

Mr A was mobile with the help of a walking stick when he was admitted to hospital.  He fell two days later and suffered bruising, then fell again a few days later, and broke his hip.  He was transferred for surgery but died two days after the operation.

His daughter (Mrs C) believed that Mr A's fall risk had been poorly assessed when he was admitted, and that he was not properly cared for after the first fall so the second fall was not prevented.  She was concerned that he was over-sedated and not eating or drinking enough, and that the management of his diabetes was inadequate.  She also felt Mr A's aggression had not been handled well and that he was blamed for his behaviour, when it was actually the result of his illness.

I obtained independent advice from a nursing adviser, who noted that the board's policy is to complete a falls risk assessment for all elderly patients and to review the patient's falls care plan if they fall.  The board's complaint investigation report said that this was all done, but my adviser found no evidence to support this and considered that the standard of record-keeping and falls prevention practice was poor overall.  I agreed with this view and, therefore, upheld the complaint and made recommendations.

Regarding Mrs C's complaint about sedation, my adviser said that the appropriate medication and dosage was prescribed and that quick action was taken when adverse effects were noted.  My adviser also considered that the board's response letter was balanced and did not blame Mr A for his behaviour.

However, the advice I received was critical overall of the standard of nursing provided to Mr A.  The record-keeping was inadequate and did not include care plans for Mr A's personal care or communication difficulties.  There was also a significant failure to monitor Mr A's blood glucose levels appropriately and a failure to adequately monitor his nutritional intake.  I noted that the board's complaint response states that blood glucose levels were not monitored following Mr A's admission and I was critical of their failure to act on this.  I upheld the complaint and made several recommendations.

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board:

• remind all staff that a falls risk assessment is a requirement on admission of an elderly patient;
• review the complaint investigation to establish why statements about Mr A's care not supported by the clinical record, were included in their formal response;
• review their admission procedures for elderly patients to ensure that a Malnutrition Universal Screening Tool assessment is recorded;
• remind all staff involved in Mr A's care of the importance of regular and accurate blood glucose monitoring for diabetic patients;
• remind all staff involved in Mr A's care of the importance of accurate and comprehensive care plans, which meet all a patient's needs; and
• apologise to Mr A's family for the failures identified in this report.

Summary
Mrs C had previously suffered from mouth cancer and was treated at Monklands Hospital.  After finding an ulcer in her cheek, she contacted the consultant previously in charge of her care, and was seen at Monklands Hospital again, where the ulcer was found to be cancerous.  Mrs C's case was discussed at the multi-disciplinary team (MDT) meeting, who decided to refer Mrs C to the Southern General Hospital for treatment.

However, this was not done until a week later.  The referral was by email from the consultant to his colleagues with details of Mrs C's (and other patients') cases, rather than a formal referral by letter.  It is not clear whether the email was received.  Around this time the head and neck / maxillofacial (the diagnosis and treatment  of diseases affecting the mouth, jaws, face and neck) consultants at the Southern General Hospital decided that, due to lack of capacity, they would no longer accept referrals of patients they considered could be treated locally (such as Mrs C).  It is unclear whether the management team instructed the consultants to do this, or whether the Southern General Hospital was required to accept Mrs C's referral under the existing funding arrangements.  Mrs C was not told that there was a problem with her referral.

Mrs C grew increasingly concerned about the delay, and phoned the consultant at Monklands Hospital several times over the next few weeks to follow this up.  Finally, about a month after the MDT, Mrs C emailed the consultant, outlining her strong concerns, and the consultant phoned the Southern General Hospital and arranged an urgent appointment for Mrs C.  Mrs C said that her treatment from Southern General Hospital staff was excellent from that point on.

Mrs C complained about the delay in the scan and the MDT meeting, as well as the delay in referring her to the Southern General Hospital.  Mrs C was concerned that the delay may have worsened her outcome, as she was initially told that surgery would be performed with the aim of providing a cure.  However, the surgery that she subsequently received significantly reduced her quality of life and gave her a low chance of surviving her cancer.  Mrs C also complained about the lack of communication from Monklands Hospital staff about what was happening.

My investigation found that the delay in arranging Mrs C's surgery was unreasonable, and outwith the national HEAT (Hospital Efficiency and Access Targets) standards.  I found it was unreasonable for the Monklands Hospital consultant to wait one week before referring Mrs C, and also that the email sent by the consultant was not an adequate referral.  I also found that there was a breakdown in the referral process between Monklands Hospital and the Southern General Hospital, which meant that no plans were made for Mrs C's surgery at either hospital until she followed this up repeatedly.  I am concerned that an important decision (not to accept certain referrals) could be made and implemented at NHS Greater Glasgow and Clyde without clear, recorded management approval.  I am also strongly critical of the poor communication between the consultants at both health boards, as they apparently discussed Mrs C's case without clearly agreeing who would be responsible for her treatment (both hospitals appeared to think the other would be responsible).  It was only through Mrs C's courage and perseverance in following up her own appointment that this matter was resolved.

I also found that Monklands Hospital staff failed to communicate reasonably with Mrs C about her treatment.  Staff did not return her calls on at least one occasion and, although the consultant phoned the Southern General Hospital to follow up the referral and offered to perform the surgery himself, no-one contacted Mrs C to explain what was being done or to check that the appointment had come through.

In reporting on this complaint, I outlined significant concerns about the way in which both boards provided information during my investigation.  NHS Lanarkshire failed to provide a key piece of evidence relating to this complaint until after my investigation was concluded.  NHS Greater Glasgow and Clyde also provided new evidence at a late stage, which directly contradicted information they had previously given during the investigation.  This caused unnecessary difficulties and delays in completing the investigation, and undoubtedly added to Mrs C's distress.  I also raised concerns at the lack of appreciation both boards have shown of the impact these events have had on Mrs C, and of the value of her complaint.  This case involves a patient who was left without any plans for her cancer surgery for several weeks, as the boards were unable to effectively communicate about, and resolve, an administrative disagreement over who was responsible for the surgery.  In this context, I am disappointed that the boards were not more proactive about acknowledging that Mrs C's experience was unacceptable, and acting to prevent a recurrence.

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• issue a written apology to Mrs C for the failings I found; and
• bring my findings to the attention of Consultant 1, for reflection as part of his next annual appraisal.

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board:

• issue a written apology to Mrs C for the failings I found;
• feedback my findings to all staff involved, for reflection and learning; and
• ensure there is a clear procedure for authorising and recording any decisions not to accept referrals, and that staff are aware of this.

The Ombudsman recommends that both boards:

• conduct a joint significant event analysis to investigate and address the cause(s) of the delay in Mrs C's referral, and share the results with my office and with Mrs C, if she wishes.

Summary
Mrs C complained about her late mother (Ms A)'s interaction with NHS 24, in particular their main out-of-hours telephone service, the Unscheduled Care Service (UCS), and Breathing Space, which is a confidential telephone service for people experiencing low mood, anxiety or depression, and also part of NHS 24.

Ms A suffered from anxiety and depression.  One week after attempting suicide, she telephoned Mrs C and told her she needed help as she could not cope.  Mrs C called NHS 24, describing Ms A as a risk to herself, and an NHS 24 call handler rang Ms A directly.  Ms A was extremely distressed during the call.  She told the call handler that she might harm herself again and that she wanted to be taken away under mental health legislation.  The call was initially classified as 'serious and urgent' but, when no nurse was available to speak to Ms A, a senior nurse advised the call handler to downgrade the call, which set a three hour call back from a nurse practitioner.  They also offered Ms A assistance from Breathing Space whilst she waited for the call back, which she accepted.  The Breathing Space adviser (the BSA) spoke and did breathing exercises with Ms A, but she was still tearful when the call ended.  A nurse practitioner called Ms A around two hours later but there was no answer and the call was closed.  Mrs C called the police a few days later as she had been unable to contact Ms A.  They forced entry to Ms A's home and found that she had completed suicide.  It is understood that she died from an overdose of medication.

In investigating Mrs C's complaints, I took independent advice from a nursing adviser, a mental health adviser and a GP adviser with experience of NHS 24 and out-of-hours work.

Mrs C said that the classification of Ms A's call meant that a suicidal woman needing immediate help instead received a three hour call back.  NHS 24's own investigation report noted that it was unclear why the call was downgraded, and that there seemed to have been a disregard of mental health concerns by the senior nurse.  They also found that following the transfer to Breathing Space, the call should have been closed down within the UCS.  The advice I received was that, given the information taken by the call handler, contact with Ms A should not have been broken.  Allocating a three hour call back and leaving the call open after transferring to Breathing Space was not reasonable and, therefore, I upheld this complaint.

Mrs C complained that the BSA had not used Applied Suicide Intervention Skills Training (ASIST) during the call with Ms A and took no action to help her.  NHS 24 said that ASIST techniques were not used as the BSA knew that a nurse practitioner would be calling Ms A to make a full clinical assessment of her symptoms.  My mental health adviser said that this explanation was not reasonable as the BSA knew about Ms A's suicide attempt yet did not explore sufficiently the risk of suicide during the call.  My adviser said that the support offered by the BSA was ineffective.  The call recording showed that Ms A became increasingly distressed and my adviser commented that they would have expected the BSA to continue speaking with Ms A until her distress had reduced, instead of ending the call.  I found that Breathing Space did not offer a reasonable service to Ms A so I upheld this complaint and made several recommendations.

Mrs C also complained that there was only one attempt to call Ms A back before closing the call, and that NHS 24 did not contact Ms A's GP.  My investigation found that NHS 24's procedure is to attempt to call patients up to two times before closing the call, unless there is a particular clinical concern.  However, there was enough evidence from Ms A's call to indicate a 'particular clinical concern' and I considered that further action should have been taken, including sharing information with Ms A's GP.  Therefore, I upheld this complaint.

This significant case has raised concerns about how effectively mental health crises are managed by the UCS.  The initial call handling is geared towards physical problems and gathering personal information.  However, the advice I have received highlighted that, for people experiencing mental health difficulties, this is ineffective and can exacerbate their symptoms.  More needs to be done to ensure that mental health is not treated with any less urgency than physical health, so I made a number of additional recommendations to address my wider concerns.

Redress and recommendations
The Ombudsman recommends that NHS 24:

• apologise to Mrs C for the allocation of a three hour call back;
• ensure that this complaint is included for discussion at the next appraisal of the Senior Nurse;
• ensure that all relevant staff are aware of the guidance on transferring calls to Breathing Space to avoid incorrect advice being offered to call handlers in future;
• apologise to Mrs C for the way this call was handled by Breathing Space;
• ensure that the findings of this report are discussed with the BSA for learning;
• ensure that Breathing Space staff are aware of when to use ASIST techniques;
• ensure that all Breathing Space staff are aware of the process to escalate calls;
• apologise to Mrs C for the failure to take appropriate action when Ms A could not be reached;
• ensure that this complaint is included for discussion at the next appraisal of the Nurse Practitioner;
• report to us on the implementation schedule of the new Patient Contact Management system system;
• and then again when the system goes live
• review their guidance for all staff on the management of suicidal thoughts and common mental health problems;
• review their procedures for triaging mental health difficulties, such as panic and depression, for patients who present in crisis; and
• review the questions used in the initial contact process to take mental health into account.

CSummary
Ms C was assessed as low risk during her pregnancy and it was, therefore, considered suitable for her to deliver her baby at the Community Midwifery Unit at Vale of Leven District General Hospital.  After going into labour she was admitted to the maternity unit but her labour was slow to progress.  Several hours after admission, an examination found that her baby was in a posterior position (when the back of the baby's skull is in the back of the mother's pelvis).  This meant that the delivery would be more complicated and would be likely to need a higher level of care than was available at the maternity unit.  Staff called an ambulance to transfer Ms C to the Royal Alexandria Hospital.  The ambulance service was particularly busy so the transfer took longer than expected.  There was also a delay in the ambulance team accessing the building as they did not know the maternity unit.  Ms C was given an episiotomy (a minor surgical cut that widens the opening of the vagina during childbirth) very shortly before she was transferred.  Her baby was unwell at birth and she was transferred to another hospital for specialist neo-natal treatment.

Mr and Ms C complained to the board that the maternity unit did not reasonably explain in advance the transfer arrangements to hospital from the unit in case of an emergency; did not provide a reasonable standard of maternity care; delayed making the decision to transfer Ms C to hospital; contributed to delays during the transfer process; and that the board did not handle their complaint in line with the complaints procedure.

The board conducted a Significant Incident Review following the complaint, identifying a number of failings in Ms C's care, and recommending improvements at the maternity unit.

I took independent midwifery advice on this complaint.  Regarding the information received about an emergency transfer to hospital from the maternity unit, it was clear that Ms C's understanding of the transport arrangements was not correct.  She had also not been given any written information.  The board acknowledged that Ms C should have been given clearer information, and they had amended a leaflet to include the transfer information.  However, my adviser noted that the leaflet should be provided to women before they have chosen where to give birth.

We found several failures in the maternity care provided to Ms C in the maternity unit.  This included a failure to properly assess her on admission or identify a clear plan of care; lack of monitoring throughout her labour; poor documentation, particularly of care planning and regarding handovers between staff; and also the episiotomy was undertaken inappropriately and possibly unnecessarily.  The poor standard of care put Ms C and her baby at unnecessary risk.

As a result of some of the failures above, the decision to transfer Ms C to hospital was delayed.  If her labour had been managed properly, she could have been transferred before it was an emergency.  I am critical that the board's SIR did not highlight this delay and that they have yet to apologise for it.

The delay in the ambulance arriving at the maternity unit was due to pressures on the ambulance service and therefore out of the board's hands.  However, the difficulties the crew experienced getting into the building were avoidable, and I am critical of the lack of action from the maternity unit staff.

The board clearly did not deal with Mr and Ms C's complaints within the timescales of their guidance (Guidance to Staff in Dealing with Complaints).  Additionally, the board's final response to their complaints was in the form of notes from meetings, rather than a formal letter clearly stating whether complaints were upheld and providing a meaningful apology.

I upheld all of the complaints.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  ensure that the leaflet entitled 'Having your baby at the Vale of Leven CMU' is given to women before they have made a decision about where they would like to give birth, and revise the wording of the leaflet as appropriate; 30 November 2015
• (ii)  consider the need to review the NHS Greater Glasgow and Clyde Obstetric Guidelines, in line with National Institute for Health and Care Excellence Guidelines on Intrapartum Care (2014); 30 November 2015
• (iii)  reflect on the findings of this case, and consider whether the provision of aromatherapy at the Unit should be offered on a 24 hour basis; 30 November 2015
• (iv)  extend the use of the new tool for handover of care, so that it is applied to telephone handovers when transferring care from the Unit to Royal Alexandria Hospital; 30 November 2015
• (v)  consider implementing a system for staff rotations from the unit to Royal Alexandria Hospital on an annual basis, if this is not already in place; and 7 January 2016
• (vi)  apologise to Ms and Mr C for the failings identified in this report, and the distress this caused them and Baby C. 30 October 2015

Summary
Mr C complained to the board following treatment he received at Raigmore Hospital.  He was admitted for a haemorrhoidectomy (surgery to remove haemorrhoids) and flexible sigmoidoscopy (a procedure to look inside the back passage and lower part of the large bowel).  Polyps (small growths on the inner lining of the bowel) were found and removed during the sigmoidoscopy.  Mr C was readmitted two days later, after experiencing considerable pain, and it was found that he needed emergency surgery for two holes in his bowel.  Mr C said he was told that, if this second operation was not successful, he would need more surgery and a temporary colostomy bag.  He said that the procedure caused him further pain, stress and anxiety.

Mr C said that he consented to surgery for haemorrhoids and to a flexible sigmoidoscopy on the understanding that the sigmoidoscopy was investigatory, and that he was not told polyps may be removed if identified.  He said that, if he had known of the possibility of damage to his bowel, he may not have had the original procedure done.  He was also concerned that, due to annual leave, the surgeon he had seen before his original day surgery did not perform the operation.

In investigating Mr C's complaints, my complaints reviewer obtained independent medical advice from a consultant colorectal surgeon who is experienced in carrying out the surgery Mr C had done.

My adviser noted that the board’s response to Mr C’s complaint said that the risk of bowel perforation from flexible sigmoidoscopy is low but increased with treatment for polyps.  My adviser referred to General Medical Council guidance on consent which says that doctors must tell patients if an investigation or treatment could result in a serious adverse outcome.  He said that, as the risk of perforation (and, therefore, a hospital admission) is a serious adverse outcome, not having discussed or made a record of such a discussion was unreasonable.  He felt the question of whether polyps should have been removed was irrelevant as the consent process was inadequate.

Regarding Mr C's transfer from the care of the surgeon he had seen before his original day surgery to another surgeon, my adviser explained that it was the responsibility of the surgeon in charge of the case on the day to ensure that a procedure's risks had been explained.  He said that the second surgeon should have ensured that the first surgeon had properly discussed the procedure with Mr C but the evidence did not show that this was done.

In light of the clear medical advice, I uphold the complaints and have made recommendations to the board.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mr C for the failings identified in this report; 28 October 2015
• (ii)  consider introducing pre-printed consent forms for common procedures like this to ensure that such rare (but serious) complications are not missed, and report their findings back to the Ombudsman; and 25 November 2015
• (iii)  consider introducing a review of case notes by the operating surgeon (before the day of surgery) where the patient has been transferred from another surgeon's list, to ensure that the operating surgeon is satisfied the appropriate consent is in place, and report their findings back to the Ombudsman. 25 November 2015