Health

Summary

Mrs C complained about the management of her child's birth at Aberdeen Maternity Hospital. Mrs C's waters broke prior to labour, and although labour then commenced naturally, she made slow progress and developed a high temperature. In view of this, Mrs C was taken to the delivery theatre and, after a failed attempt with forceps, her baby was delivered via caesarean. Mrs C felt staff should have arranged a caesarean earlier and said she asked for this during her labour. She also raised concerns about the caesarean, in particular that there were retained products of conception (pieces of placenta left in the uterus) which caused ongoing complications and further surgery. Mrs C said the doctor was rude, did not adequately explain her treatment, and lied in their response to her complaint.

The board responded to several letters and met with Mrs C twice to discuss her concerns. They apologised that she felt the doctor had been rude to her, and the doctor attended the second meeting to offer their personal assurance that this was not their intention. The board considered Mrs C's medical treatment was appropriate (although they gave conflicting information about whether Mrs C had asked for a caesarean during her labour). They explained that Mrs C had a CT scan (which uses x-rays and a computer to create detailed images of the inside of the body) after the birth. They said that the CT scan was clear, so staff did not consider there were retained products of conception at that time (although they were sorry Mrs C experienced complications from this).

After taking independent medical advice from a consultant obstetrician and gynaecologist, we did not uphold Mrs C's complaints. We found staff had appropriately discussed Mrs C's treatment options, and there was no evidence that she asked for a caesarean during labour. The adviser said the retained products of conception were quite small, so it was not unreasonable that staff missed these (they also noted that cleaning the uterus too thoroughly can cause scarring and reduced fertility). We also found it was reasonable that staff did not identify Mrs C's retained products of conception during her admission, based on her CT scan and symptoms at the time.

Summary

Mrs C complained about the care she received prior to replacement pacemaker surgery at the Golden Jubilee National Hospital. She was concerned that her premedication had worn off before being taken to theatre and that the anaesthetist had missed the vein when cannulating her (inserting a thin tube into a vein). Mrs C was also in great pain when the anaesthetic drug was administered. When Mrs C came round from surgery, the cannula had been transferred to her other hand, and her hair was stained due to the solution used to cleanse the skin prior to the procedure and she had to have her hair cut. Mrs C also said that she had suffered from tinnitus since the procedure.

We took independent advice from an anaesthetist. We found that the medical records indicated a safe, uneventful anaesthetic procedure and that there were no failings. We were also satisfied that there was no evidence suggesting that failings by the anaesthetist led to Mrs C developing tinnitus.

Summary

Miss C raised her concern about the care she received from Forth Valley Royal Hospital during her pregnancy, labour and postnatal period.

During our investigation, we took independent advice from a consultant in reproductive medicine and surgery, a consultant obstetrician and a midwife. We also received advice on general nursing issues from a nursing adviser.

The board accepted that there had been errors in relation to the initial ultrasound scans Miss C received and, as a result, she had been incorrectly advised that she had suffered a miscarriage. The board had apologised for those errors and had taken action. The advice we received and accepted from the consultant in reproductive medicine and surgery was that it had been too early to diagnose a miscarriage and that there was no evidence consultant advice had been obtained. The adviser also said that there was a failure to record / obtain a complete menstrual history at the time of the scans.

The advice we received from the midwife was that carrying out an ultrasound scan before six weeks gestation would not normally happen. The midwifery adviser also said that it happened in this case in an attempt to meet Miss C's needs, given that she had recently undergone surgery. The adviser said that this was not clinically appropriate.

In the circumstances, we considered that the board had failed to provide Miss C with appropriate care and treatment and we upheld this aspect of the complaint.

We were satisfied that an appropriate assessment had been carried out when Miss C first attended the hospital when she believed her labour had started. However, while the advice we received and accepted from the consultant obstetrician and the midwife was that aspects of her care and treatment were reasonable when she returned to the hospital (in particular, that the obstetrician adviser did not consider that there was an unreasonable delay before the decision was taken to proceed with a caesarean section), we were concerned about a number of communication failings and a failure in record-keeping. We made recommendations to address these failings.

The board had apologised for Miss C's concerns in relation to her postnatal care and had taken action. The advice we received and accepted from the nursing adviser was that the action taken had been reasonable.

Recommendations

We recommended that the board:

• remind staff of the need to record/obtain a complete menstrual history at the time of ultrasound scans;
• bring to the attention of relevant staff the findings of this investigation, in particular the need for experienced medical involvement in a similar situation and the need for further scans;
• consider the suggestion received from the midwifery adviser that additional training in relation to dealing with bereavement surrounding early pregnancies should be provided for midwives who regularly work in this area; and
• remind midwifery staff of the need to maintain full and accurate nursing records in line with Nursing and Midwifery Council guidance.

Summary

Mr C, who works for an advice agency, complained on behalf of Mr A who was concerned about the care and treatment given to his late wife (Mrs A). In particular, he was concerned that there was an avoidable delay by staff at Forth Valley Royal Hospital in establishing that Mrs A was suffering from breast cancer. While the board accepted that there had been a delay and apologised, they said that Mrs A had suffered from a rare form of cancer which had been difficult to diagnose.

We took independent advice from a consultant breast surgeon. We found that while Mrs A's form of cancer was a very rare variant, opportunities had been missed to diagnose her sooner. There had also been an initial delay in Mrs A being seen and her cytology (examination of tissue samples under a microscope) results had been incorrectly reported. We therefore upheld the complaint and made recommendations.

Recommendations

We recommended that the board:

• make a formal apology recognising the shortcomings we identified; and
• check that the changes they outlined to Mr A are now in place and that all excision biopsies, as well as cytology aspirates and needle biopsies, are formally discussed at multi-disciplinary team meetings.

Summary

Mr C complained that a district nurse had wrongly carried out a procedure to reinsert a catheter at home. The district nurse failed to reinsert the catheter three times and he had to be taken to hospital for the catheter to be reinserted. At hospital it was established that a false passage had been created during the attempts at catheterisation. The hospital successfully reinserted the catheter. Mr C felt that the district nurse had not followed protocols when attempting to reinsert the catheter.

We obtained independent advice on the case from a nurse adviser. She said that there were problems when the district nurse tried unsuccessfully to reinsert the catheter and that contact was made with Mr C's GP for advice. It was decided to arrange a non emergency ambulance to take Mr C to hospital for the catheter to be reinserted. The adviser said that Mr C had suffered a relatively rare but recognised complication of catheterisation and that this did not necessarily mean that there had been a failure in carrying out the procedure. It was also noted that attempts at catheterisation were made in the hospital, and therefore we could not be certain exactly when the problem arose. We did not uphold the complaint.

Summary

Ms C complained on behalf of her mother (Mrs A) who had been a patient in Victoria Hospital. Ms C felt that her mother should not have been asked if she agreed to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) being put on her notes, as her mother was in a state of delirium. Ms C said that she, as next of kin, should make the decision, not hospital staff.

We looked at Mrs A's medical records and we took independent advice from an consultant geriatrician. We found that hospital staff had documented their consideration of Mrs A's situation and their actions to a reasonable standard, and they had acted in accordance with the relevant guidance on resuscitation and DNACPR. The guidance is clear that a patient with capacity can consent to or refuse CPR, and if they lack capacity the decision rests not with the next of kin, but with a legally appointed proxy or with the lead clinician. In general terms, overall responsibility for making a decision about CPR rests with the lead clinician. In the circumstances, we did not uphold Ms C's complaint.

Summary

Mrs C's mother (Mrs A) was admitted to the Medical Assessment Unit (MAU) at Dumfries and Galloway Royal Infirmary via A&E after showing signs of a stroke. Whilst in hospital, Mrs A suffered a major stroke. Mrs C raised a number of complaints about the board, including that they unreasonably failed to give Mrs A a clot buster rtPA (an injection to break down blood clots) and that nursing staff failed to monitor Mrs A appropriately.

We obtained independent medical advice from a consultant physician and a nurse. The medical adviser said that the board unreasonably failed to give Mrs A a clot buster rtPA, although they said that the decision would have been a difficult one and would have had to have been made by a specialist.

In addition, the medical adviser said that when Mrs A was in A&E, the board should have carried out a specific risk categorisation using the ABCD2 score (a risk assessment tool designed to improve the prediction of short-term stroke risk after a 'mini stroke'). Had they done so, this would have shown that Mrs A was at very high risk of progression to acute stroke. The medical adviser also said that Mrs A should have been admitted to an acute stroke unit and given a carotid Doppler (a scan to detect a narrowed artery in the neck, which may cause a stroke). She should also have been monitored continuously by experienced staff, rather than being admitted to the MAU. The medical adviser also said that a plan should have been made for Mrs A's care in the event of a deterioration, which should also have been explicit about what to do if new stroke deficits were detected.

Both advisers said the nursing staff did not monitor Mrs A appropriately or observe her every two hours, as required. The medical adviser said that the scoring system used by staff to monitor Mrs A (the Glasgow Coma Scale or GCS) was not entirely suitable. The nursing adviser said that not taking Mrs A's vital signs for a period of over five hours was a serious failing. We upheld Mrs C's complaints and made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• feed back the failings identified regarding the clot buster rtPA, the ABCD2 score, carotid Doppler and admission to an acute stroke unit to the staff involved;
• identify and address training needs for staff in A&E and the MAU on guideline 108 of the Scottish Intercollegiate Guidelines Network;
• provide Mrs C and her family with a written apology for the failings identified in the first recommendation;
• feed back the failings identified in Mrs A's nursing care to the staff involved;
• complete their review of the use of the GCS score, taking into consideration the medical adviser's views, and provide us with evidence of the outcome of the review; and
• provide Mrs C and her family with a written apology for the failings identified.

Summary

Mr C complained about the board following the death of his partner (Mrs A). Mrs A had attended A&E at Galloway Community Hospital with abdominal pain. She was recorded to have a high temperature and fast heart rate. The doctor who examined Mrs A diagnosed her as having a urine infection, and he discharged her with antibiotics. The next day, Mrs A was accompanying a friend to a hospital in another board area when she collapsed. She developed signs of sepsis (blood poisoning), originating in the gall bladder, and despite resuscitation and intensive care, she passed away.

In their response to Mr C's complaint, the board accepted that the early signs of sepsis had been missed at Mrs A's initial attendance at A&E and apologised for this. However, Mr C brought his complaint to us as he wanted further assurances that appropriate steps had been taken to avoid similar mistakes in the future.

We took independent advice from a medical adviser, who considered Mrs A's initial diagnosis when she attended A&E to be unreasonable based on her symptoms at the time. We also found Mrs A's elevated heart rate and temperature to be of sufficient concern that further investigation should have been warranted and admission to hospital considered. As such, we upheld the complaint.

In response to our enquiries, the board provided extensive details of procedural changes and training that had taken place in Galloway Community Hospital to aid in the diagnosis and treatment of sepsis, so we did not consider that any recommendations of this kind were necessary. We did, however, make a recommendation regarding the doctor who assessed Mrs A, and we asked the board to apologise to Mr C.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified; and
• confirm that the doctor who assessed Mrs A has discussed the treatment they provided to Mrs A at their annual appraisal.

Summary

Mr C complained about the care and treatment of his late mother (Mrs A) at Borders General Hospital. He raised concerns that staff unreasonably put in place a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order without discussing this with him, despite him holding welfare power of attorney. We took independent advice from a consultant physician. They found no evidence of the decision having been discussed initially with Mr C. We were critical of the board for failing to properly involve Mr C in discussions and we upheld this part of the complaint.

Mr C also complained about the actions of staff in relation to his mother's feeding. In particular, he questioned the process surrounding the insertion of a PEG (percutaneous endoscopic gastronomy) feeding tube. The advice we received indicated that Mrs A's nutritional intake was appropriately monitored throughout her stay. We were satisfied that Mr C was appropriately consulted and involved in decisions in this regard, including the decision to insert a PEG tube. We did not uphold this part of Mr C's complaint. In addition, Mr C complained about the general nursing care provided to his mother. We took independent advice from a senior nurse who reviewed the records and advised that the overall nursing care provided to Mrs A was of a good standard. We did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained about the adequacy of the board's response to his complaint. We found their response generally to have been of a reasonable standard. However, in addressing Mr C's concerns surrounding the DNACPR decision, they provided some information that was not supported by the medical records. Furthermore, while the board acknowledged and apologised for a failure to prescribe some of Mrs A's usual medication, they did not identify a subsequent gap in the prescribing chart. We upheld this aspect of Mr C's complaint. We made some recommendations in relation to both the complaints handling and prescribing failures identified.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to properly involve him in discussions about Mrs A's DNACPR status;
• remind their medical staff of the importance of involving patients and their carers in discussions about end of life care and of documenting such discussions;
• review their process for checking and prescribing relevant medication following admission and inform us of the steps they have taken to avoid a repeat of the failings this investigation has highlighted;
• apologise to Mr C for the inadequate response to his complaint; and
• remind complaints handling staff of the importance of investigating and responding to complaints comprehensively and accurately, ensuring that the information provided is supported by available evidence and that any discrepancies are reflected in their correspondence with complainants.

Summary

Mrs C suffers from fibromyalgia (a long term condition that causes pain all over the body). Over the course of several years, she received a number of treatments including acupuncture and attended the pain management clinic at Crosshouse Hospital. Unfortunately, none of the treatments resulted in good control of Mrs C's pain and, in early 2014, a decision was made to discontinue her acupuncture course and to discharge her. It was suggested that she attend a pain management programme but Mrs C disagreed and complained to the board.

We took independent advice from a consultant in anaesthesia and pain specialist and we found that Mrs C had received all the standard pain management approaches for fibromyalgia but that her treatment had not been successful. We learned that this was not uncommon. Mrs C had also had a second opinion but it was agreed that there was little that could be done for her that would likely make a significant lasting difference and that it would be futile to continue.

While it was evident that Mrs C suffers considerable pain and it was hugely disappointing that medication or other intervention would not help her, there was no evidence to suggest that this was the consequence of any action or inaction on the part of the board. For this reason, we did not uphold the complaint.