Health

Summary

Mrs C, who works for an advice and support agency, complained on behalf of Mrs B about the care and treatment provided to Mrs B's late father (Mr A) by Lanarkshire NHS Board at Hairmyres Hospital (the hospital).  Mr A had diabetes and had been admitted to the hospital to have his leg amputated.  Mrs C complained that his diabetes was not properly monitored or managed following the surgery.  She said that this led to the development of diabetic ketoacidosis (DKA - a serious problem that can occur in people with diabetes if their body starts to run out of insulin).  She also complained about the actions of nursing staff.

We took independent advice from three advisers:  a consultant in acute medicine, a diabetes specialist nurse and a general nursing adviser.  In relation to Mrs C's complaint that the Board did not provide reasonable treatment to Mr A, we found that there were a number of serious failings, which were that the board failed to:

1. adequately monitor Mr A's blood glucose and respond to both hypo-glycaemia (low blood sugars) and hyper-glycaemia (this occurs when people with diabetes have too much sugar in their bloodstream);
2. manage Mr A's diabetes and insulin administration in line with the board's protocol;
3. recognise and respond in a timely manner to his deterioration; and
4. recognise the possibility of heart problems whilst he was in the medical High Dependency Unit (HDU).

The advice we received also highlighted a number of other failings:

1. When Mr A was transferred to the medical HDU overnight, he was not seen until the following morning.  This was an unreasonable delay given the severity of his illness and the complexities of managing DKA in a patient with known cardiac problems (aortic stenosis – tightening of one of the valves in the heart and impairment of the heart as a muscle).  This would have made providing the large quantities of fluid as part of DKA management potentially difficult.
2. Mr A was transferred out of medical HDU despite signs that he was starting to deteriorate.  There was then a delay in reviewing him when he was transferred back to the surgical ward.  We found that Mr A should have subsequently been readmitted to medical HDU or to coronary care.
3. Mr A should have had a review of his antibiotics during his second deterioration, as he had already been on his antibiotic regime for three days and would have probably needed different antibiotics and review of any microbiology results.
4. There was a failure to measure/chart his respiratory rate when he was deteriorating.

    

In view of these failings, we upheld Mrs C's complaint that the board did not provide reasonable treatment to Mr A.

Mrs C also complained that the board did not provide reasonable nursing care to Mr A in the hospital.  She said that nursing staff did not respond reasonably to alerts from another patient's visitors about Mr A's condition and that nursing staff did not reasonably record the actions they took in relation to this in Mr A's medical notes.

We found that the actions of a nurse when Mr A's condition deteriorated had been unacceptable and unreasonable.  The nursing documentation in relation to this matter was also inadequate and we upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board did not respond reasonably to Mrs B when she complained to them about these issues.  We upheld this aspect of the complaint, as the board failed to identify the serious failings referred to above.  We considered that this was both unreasonable and that it called into question the adequacy of the board's complaints handling at the time.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs B:

We are asking The Board to improve the way they do things:



Summary
Mrs C complained about the care and treatment provided to her late husband (Mr C) by Fife NHS Board (the board).  Mrs C's complaint related to delay in diagnosing that Mr C had lung cancer and the treatment provided to Mr C.  Mrs C complained that the standard of care Mr C had received had been poor.

We took independent advice from a consultant respiratory physician.  We found that Mr C was high risk for lung cancer, given his history as a former smoker with a background of heavy exposure to asbestos, and presenting with a cough and breathlessness.  There were also concerning features in Mr C's radiology results and his case was complex.  Despite this, Mr C was removed from an expedited cancer referral pathway without his case being discussed at a lung cancer multi-disciplinary team (MDT) meeting and without consideration given to a tissue biopsy being carried out.  There was also no evidence that there had been any discussion with Mr C to enable him to make an informed decision about his future treatment.  We also considered that that the board did not appear to have followed national standards and guidelines in Mr C's case.

The advice we received was that this represented serious failings in Mr C's care and treatment and that if such action had been taken, this could potentially have resulted in a different outcome for Mr C.  As such, we upheld this complaint.  The board have told us they now have systems and processes for patients in a similar situation to Mr C which they say are significantly different from what was previously in place and are willing to have their lung cancer service independently audited and peer reviewed.  In view of the failings we identified, we made a number of recommendations to address this.

Mrs C also complained about the palliative nursing care Mr C received following his cancer diagnosis.  We took independent nursing advice.  We found that although the board had taken action following Mrs C's complaint, the advice we received was that there were serious failings in the nursing care provided to Mr C following his cancer diagnosis which had not been identified or addressed by the board.  There had been a failure to comply with professional and clinical standards for practice which would be expected of the nursing staff and the palliative care provided had fallen below the standards which Mr C and his family should have reasonably expected.  We upheld this complaint and made a number of recommendations to address the issues identified.

Mrs C also complained that the board's handling of her complaint was inadequate.  We were satisfied there were failings in how the board responded to Mrs C's complaint and upheld this part of her complaint.  We made recommendations to address these failings.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C:

We are asking The Board to improve the way they do things:

Evidence of action already taken
The Board told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

Summary
Mrs C complained about the care and treatment she received from Queen Elizabeth University Hospital Glasgow (the hospital).  Mrs C was concerned about delays in the time taken for her to receive spinal surgery to address her medical condition (incomplete cauda equina syndrome).  In addition, Mrs C complained about the level of care provided during her two admissions by physiotherapy and nursing staff.  Mrs C also raised concerns about the aftercare arrangements made at the time of her discharge from the hospital.

We took independent advice from three clinical specialists:  a consultant neurosurgeon, a physiotherapist and a nurse.

We found that the board failed to provide neurosurgery to Mrs C within a reasonable time.  We noted that there had been unexpected repair works at the hospital that impacted on theatre availability; however, there is clear guidance on the need for surgery to be performed on an emergency basis in cases of incomplete cauda equina syndrome to minimise the risks associated with this condition.  In these circumstances, we considered it was unreasonable for the board not to have provided the surgery, or arranged for this to take place at an alternative hospital site.  We considered that it was likely that the delay would have impacted on Mrs C's poor outcome following the surgery.  Our investigation also highlighted that there was no evidence of communication with Mrs C about the risks of the delays while she was on the neurosurgery ward, and that documentation in the relevant medical records was of a very poor standard.

Our investigation identified failings in the care and treatment provided to Mrs C during her admissions.  We found that Mrs C's care while in hospital and on discharge did not appear to have been planned in a co-ordinated and multi-disciplinary way.  We found that Mrs C did not receive an adequate level of physiotherapy care.  We also had concerns about the level of continence care provided to Mrs C, the management of her pain and wound care based on the evidence in the nursing records.

We found that there were failings in discharge planning and aftercare arrangements for Mrs C.  We considered this was not planned in a co-ordinated and multi-disciplinary way.  Our investigation also found there was inadequate patient information provided to Mrs C on discharge, and referrals for aftercare were not made.  We noted that this likely contributed to Mrs C's difficult and distressing experience returning to her home.

We upheld Mrs C's three complaints and made a number of recommendations to address the issues identified.  The board have accepted these recommendations and we will follow-up on these recommendations.  The board are asked to inform us of the steps that have been taken to implement these recommendations by the dates specified.  We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm the recommendations have been implemented.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C:

We are asking the Board to improve the way they do things:

Feedback
Complaints handling
I agree with Adviser 3's comment about the Board's handling of this complaint.  The Board did not investigate this complaint in a sufficiently detailed and analytical manner.  They appeared defensive of, and failed to take account of the gaps in, nursing practice as evidenced in the nursing notes.  While printed nursing records are lengthy, and consideration has been given to how they might facilitate assessment and care planning, it was nonetheless difficult (on the basis of this investigation) to understand the priorities for Mrs C's care. This must cause difficulty in personalising the care to meet individual patient need and for nurses, working different shifts, to be clear about the care plan.

Points to note on best practice
In line with the views of Adviser 2, I would ask the Board to consider the following points about delivering best practice in the care of patients presenting with cauda equina syndrome:

• patient representation on the Cauda Equina Forum;
• patient information developed for people who are at risk of developing cauda equina syndrome and for those with incomplete cauda equina syndrome for issue at the time of diagnosis;
• to ensure that the diagnosis of cauda equina syndrome is recorded, explained to the patient and communicated clearly across the multi-disciplinary team;
• training arranged for all members of the clinical team to ensure that; the diagnosis of cauda equina syndrome, the prognosis and the importance of personalised co-ordinated postoperative management are understood;
• a clear pathway to urology;
• a clear pathway to pain services; and
• a governance reporting system for cases who have poor post-operative outcomes related to cauda equina syndrome.

Points to note on the development of the information leaflet
The Board is asked to consider the following suggestions from Adviser 2 for further improvement:

• page 2:  It is important to treat cauda equina syndrome as an emergency not urgently;
• page 3:  the symptoms of cauda equina syndrome can also occur gradually, often related to spinal stenosis;
• page 4:  women may also have sexual dysfunction related to vaginal numbness;
• page 7:  links to patient support groups such as; www.caudaequina.org,  www.ihavecaudaequina.com or www.caudaequinauk.com might be included; and
• the inclusion of guidance on when and where to seek help should symptoms deteriorate.

Summary
Mr C complained about the care and treatment his late wife (Mrs C) received from the Emergency Department at Monklands Hospital (the hospital) when she attended with abdominal pain.  Mr C was concerned that Mrs C had been discharged home during the early hours of the morning without being assessed properly and that she was in pain.

We took independent advice from two clinical specialists, including a consultant in emergency medicine and a consultant in emergency general surgery.  We considered that the clinical assessments and record-keeping by two different doctors who reviewed Mrs C fell below a reasonable standard.  In addition, we found that there was no evidence to demonstrate that Mrs C had been offered pain relief despite it having been documented that she was experiencing moderate to severe pain.

We also found that a significantly abnormal blood test result had been overlooked by the board on three separate occasions:  at the time Mrs C was discharged from hospital; when providing clinical information to the Crown Office and Procurator Fiscal Service's forensic pathologist; and when investigating Mr C's complaint.  We considered that, had a more senior doctor overseen Mrs C's care, and due attention been given to this test result, she would have been admitted to hospital which may have avoided her death.

In terms of Mrs C being discharged home during the early hours of the morning, we considered this unreasonable given Mrs C was an elderly, frail woman with multiple health problems.  We were critical that hospital staff did not communicate with Mr C about the discharge and that the paperwork which prompts such discussions had not been completed appropriately.

We upheld both complaints and made a number of recommendations to address the issues identified.  The Board have accepted the recommendations.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

We are asking the Board to improve the way they do things:

Summary
Mr C, who works for an advocacy and support agency, complained on behalf of Mr A about a number of issues relating to Mr A's discharge to a nursing home following an admission to Newton Stewart Hospital.  First, Mr C complained about the length of time it took clinicians to tell Mr A that an operation to help with a complex medical condition was not going to be possible for him despite it being initially proposed.  Had Mr A known that the operation would not be possible, Mr C said Mr A would not have allowed himself to be discharged to the nursing home.  Instead, when Mr A was discharged, he believed that he would be able to return home after a short time in the nursing home following the operation.  Second, Mr C said that Mr A had not been given the option to return home with a funded care package before being discharged to the nursing home.  Third, Mr C said that board staff had failed to explain clearly to Mr A the financial repercussions of his discharge to the nursing home before discharge and then, given his mental health issues, unreasonably failed to arrange an advocate for him to help him throughout the discharge process.  Finally, Mr C said that Mr A's time in the nursing home should be considered as NHS continuing care because he was waiting for an NHS funded operation.

We took independent advice from a consultant in care of the elderly and considered guidance on choosing a care home on discharge from hospital and on hospital-based complex care (ongoing hospital care) in place at the time of the complaint.  We found that when Mr A was discharged, he did not need hospital care and so it was reasonable to discharge him given his clinical needs at the time.  Given this, we also found that the board's decision not to pay the nursing home charges was made in line with the guidance on ongoing hospital care.  In relation to the time it took the board to reach a decision about Mr A's operation, the advice we accepted was that the operation was specialist and complex and so it was reasonable for the decision to take as long as it did.  However, we identified a number of significant failings about the way Mr A was discharged.

We found that the board failed to take all reasonable steps to ensure Mr A was in a position to make an informed decision about the move to a nursing home and that an opportunity for discharge home was missed.  Staff failed to explore with Mr A the option of discharge home with a care package in a reasonable way, and failed to provide clear written information to Mr A about his discharge, particularly around the financial implications of the move.  Staff also let Mr A retain an over-optimistic view about the potential of an NHS-funded operation to improve his health when clinicians considered this was unlikely.  Finally, we found that the board should have offered advocacy services to Mr A given his mental health problems to support him during a complex and uncertain time with extremely significant implications.

We upheld two of Mr C's complaints and made a number of recommendations to address the issues identified.

Redress and Recommendations
What we are asking the Board to do for Mr A:

We are asking the Board to improve the way they do things:

Summary
Ms C complained about the treatment provided to her late mother (Mrs A).  Mrs A was 53 years old when she attended at Aberdeen Royal Infirmary (the hospital) with lower abdominal pain and urinary frequency.  She was discharged with plans for urgent follow-up.  Before this took place, Mrs A was re-admitted via the emergency department.  She was found to be suffering from cancer and procedures to insert plastic tubes into her kidneys to drain urine were necessary.  The procedure, called nephrostomy, is carried out when the tube linking the kidney to the bladder has become blocked.  After the nephrostomies were carried out, Mrs A later began to show signs of infection.  Although antibiotic treatment was started, Mrs A developed sepsis (a severe complication of infection) and died.

Ms C complained that Mrs A had not been prescribed prophylactic antibiotics (antibiotics given as a precaution to prevent, rather than treat, an infection) prior to the nephrostomies.  The board initially responded that there was no requirement to prescribed these and Ms C brought her concerns to this office for investigation.  A short time later, the board advised us that a hospital policy recommending the use of prophylactic antibiotics had been identified.  We suspended our investigation to allow the board to address this matter and a number of further issues Ms C raised.  After the board issued their final response, Ms C brought the complaint back to this office and we restarted our investigation.

We took advice from a consultant urologist.  We found that there had been a failure to follow the hospital policy on prescription of prophylactic antibiotics for Mrs A.  We established that Mrs A had a poor prognosis due to the extent of her cancer.  While prescribing prophylactic antibiotics may­ have prevented her from developing sepsis, it was impossible to definitively determine the effect they would have had.

Although the board latterly acknowledged its policy had not been followed, no apology was offered to Ms C for either the failing itself or for the fact its initial complaint response was inaccurate.  We upheld Ms C's complaint and made a number of recommendations to address the issues identified.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Ms C:

We are asking the Board to improve the way they do things:

Feedback
Complaints handling
Due to new issues being raised by Ms C, this investigation was suspended to allow the Board to respond.  By this time, the Board had recognised that there was, in fact, a local recommendation to prescribe prophylactic antibiotics for patients like Mrs A.  This represented an opportunity for the Board to acknowledge that its original response was inaccurate and apologise.  More effective handling of this complaint could have resolved the matter for Ms C at an earlier stage without the need for this further investigation.  The Board should reflect on this.

Summary
Mr C complained about the care and treatment provided to his late wife (Mrs A).  Mrs A was diagnosed with bladder cancer in April 2015 and Mr C complained that both before and after the diagnosis there were delays in providing necessary appointments.  Mr C also complained that there were unreasonable delays in the treatment of Mrs A's cancer after she had cardiac surgery, and that there were failings in communication between specialists treating her.

We took advice from a consultant urologist.  With regards to delays in appointments, we found that there was an unreasonable delay between the results of a biopsy being taken and a subsequent resection.  We also found that there was an unreasonable delay from the time of diagnosis to the time that Mrs A discussed definitive management with a surgeon.  We considered these delays to be unreasonable.  We upheld this aspect of Mr C's complaint.

We also found that there was a delay in Mrs A being provided with treatment for her bladder cancer.  We identified a failure of the urology service to act upon a letter which stated that Mrs A would be suitable to go ahead with treatment for her bladder cancer in a months' time.  We further found that the possibility of Mrs A's condition deteriorating, and her treatment options, were not fully discussed with her, and that there was a delay in Mrs A being offered palliative radiotherapy.  We determined that there were multiple failings in communication between specialists treating Mrs A regarding her condition and treatment.

Mr C also complained about the board's handling of his complaint, specifically that they did not address all of the issues which he had raised.  We considered that the board had failed to address some important questions Mr C had asked, and therefore we upheld this aspect of Mr C's complaint.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to improve the way they do things:

Evidence of action already taken
Greater Glasgow and Clyde NHS Board - Acute Services Division told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

Summary

Ms C complained about the care she received from Grampian NHS Board (the board).  As Ms C was experiencing post-menopausal bleeding, her GP urgently referred her to the gynaecology service of Aberdeen Royal Infirmary.

Ms C's referral was downgraded from urgent to routine by the gynaecology service.  She was offered an appointment six weeks after her GP referral.  Her GP contacted the gynaecology service on two occasions to request an earlier appointment but was told it was unnecessary for Ms C to be seen any sooner.  When Ms C contacted the gynaecology service, they agreed to bring her appointment forward by a week.  Given her concerns, Ms C was told that a consultant gynaecologist would look at her ultrasound scan report.  Ms C received a phone call from a non-clinical staff member reassuring her that she did not need an urgent appointment.

When Ms C attended her appointment at the gynaecology service, an endometrial biopsy was carried out.  When the results were issued, Ms C was diagnosed with endometrial cancer.

During our investigation, we took independent advice from a consultant gynaecologist and from a consultant obstetrician and gynaecologist.  We found that Ms C's referral should not have been downgraded to routine and she should have been seen by the gynaecology service within two weeks of her GP referral.  We found that the target for the treatment of Ms C's cancer was missed by 19 days.  We found that Ms C should not have been given reassurance about the findings of her ultrasound scan report as they could have indicated cancer.  We also found that this reassurance should not have been given to Ms C by a non-clinical staff member.  We upheld Ms C's complaint.

Redress and Recommendations
The Ombudsman’s recommendations are set out below:

What we are asking The Board, to do for Ms C:

We are asking The Board to improve the way they do things:

Summary
Ms C, a support and advocacy worker, complained on behalf of Ms B about the care and treatment provided to Ms B's son (Mr A) when he was admitted to Balfour Hospital (the hospital) following a road traffic accident.  Ms C said that when Mr A arrived at the hospital his spine was not x-rayed despite him reporting pain in his back, and that when Mr A was later transferred to another hospital it was found that he had a spinal fracture.  Ms C also complained that a wound to Mr A's leg was not cleaned appropriately and said this led to infections.

We took advice from an emergency consultant and an orthopaedic surgeon.  We found multiple significant failings in the care and treatment provided to Mr A.  These included a failure to examine and x-ray Mr A's spine; a failure to obtain
x-rays of Mr A's neck, chest and pelvis; a failure to assess and clean a wound in Mr A's arm in a timely manner; a failure to administer antibiotics in a timely manner; and a failure to administer appropriate pain medication.  We also found that the treatment provided was not appropriately documented in the medical records.  However, we determined that Mr A's leg wound was appropriately cleaned and therefore did not uphold this aspect of Ms C's complaint.

We had further concerns that the board's own investigation into Ms C's complaint failed to identify the serious clinical failings in this case and made recommendation regarding this.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Ms C:

We are asking the Board to improve the way they do things:

Summary
Mr and Mrs C complained about the management of Mrs C's pregnancy, leading up to the stillbirth of their baby.  Mrs C experienced increased blood pressure during pregnancy, as well as slightly raised urine protein levels.  These can be signs of pre-eclampsia (a condition that can affect pregnant women, particularly during the second half of pregnancy, which can lead to serious complications for both mother and baby).

About 38 weeks into Mrs C's pregnancy, a plan was made for induction in a week's time.  In the meantime, Mrs C was admitted overnight for monitoring of her high blood pressure, and she also attended a follow-up appointment where a cardiotocography (CTG) was carried out.  The CTG showed some problems of loss of contact and deceleration of heartbeat, but staff thought this was due to Mrs C's movements, and she was discharged.  Sadly, when Mrs C returned two days later for the induction, her baby was found to have died (he was stillborn the next day).  Mr and Mrs C gave consent for a post-mortem examination, which showed Mrs C's placenta had not been functioning properly, which was consistent with pre-eclampsia.

Following discussion with the consultant in charge, Mr and Mrs C complained to the board.  While the board had begun carrying out a routine review of Mrs C's care (which they do for all stillbirths), they also carried out a further clinical review of the care (the REI review) in response to the complaint.  This review found that there was no clear diagnosis made between gestational hypertension (high blood pressure) and pre-eclampsia for Mrs C.  It found that the local guidance about when to measure urine protein levels (a test for diagnosing pre-eclampsia) differed from the National Institute of Health and Care Excellence (NICE) guidelines about this.  The REI review also found there was a lack of continuity of care, and the way that records were kept made it difficult to identify trends in blood pressure recording and blood results in this case.

Following the REI review, the board put in place an action plan for improvement, including amending their guidelines to be consistent with NICE guidelines.  However, the results of the REI review were not shared with Mr and Mrs C.  While the board intended to share the results, they felt it would be easiest to do this in a meeting.  A complaint response had already been drafted before the REI review was finished (indicating that the management of Mrs C's pregnancy was reasonable), and the board simply added a line stating that a review had been carried out and inviting Mr and Mrs C to contact them for a meeting.  The rest of the letter was not updated to include the outcomes from the REI review.

After taking independent clinical advice from a midwife and two obstetrics and gynaecology consultants, we upheld Mr and Mrs C's complaint about the management of her pregnancy.  We found the board failed to conduct further tests to clarify Mrs C's diagnosis (between high blood pressure and pre-eclampsia), contrary to NICE guidance.  We also found the board had failed to recognise abnormalities on two CTG recordings.  We did not uphold Mr and Mrs C's complaints about the continuity of care, their involvement in the REI review or the bereavement support made available to them, although we gave the board some feedback on these points.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr and Mrs C:

We are asking the Board to improve the way they do things:

Evidence of action already taken
The Board told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

Feedback
Complaints handling:  It was good practice by the Head of Midwifery/Nursing to escalate this complaint for a multi-disciplinary REI review (due to her concerns about the draft complaint response).  However, the results of the REI review were not reflected in the final complaint response, and were never provided to the family (other than an offer to meet and discuss the results, which was not followed up when the family did not get in contact).  If the Board had shared the REI review results and made appropriate apologies, this complaint might have been resolved earlier.

Response to SPSO investigation:  The Board responded promptly to our enquiries.

Points to note:  The professional advisers raised several points for the Board's consideration:

• In relation to continuity of care, Adviser 2 suggested the Board could consider how often women undergoing surveillance for high blood pressure are booked to see their own consultant (for example, in an antenatal clinic), so that decisions could be made with more continuity.
• In relation to the REI review, Adviser 3 suggested the Board may wish to review their guidance on clinical reviews prompted by complaint investigations, to ensure that families who wish to be involved in a review have this opportunity.
• In relation to support following a stillbirth, Adviser 1 said it is good practice for maternity units to have at least one member of staff who has specialist knowledge and training in bereavement care, and recommended that the Board should seriously consider and agree the business proposal for a bereavement midwife.