Health

Summary

Mr C complained to us about the care and treatment provided to his mother (Mrs A) at Dumfries and Galloway Royal Infirmary before her death. Mrs A's GP had referred her to hospital. At that time, she had end stage kidney failure, but did not want dialysis (a form of treatment that replicates many of the kidney's functions) for this. Mrs A died four days later and the cause of death was recorded as pneumonia. It was also recorded at that time that Mrs A had deteriorated despite antibiotics and that her kidney function had worsened. Mr C had subsequently complained to the board about the care provided to Mrs A.

We took independent advice on Mr C's complaint from a medical adviser who is a consultant geriatrician. We found that although it would have been better to carry out an x-ray on Mrs A on the night she was admitted rather than waiting until the following morning, this delay did not alter her treatment. It would, however, have given the clinicians and Mrs A's family more information about her condition. We also found that Mrs A had been able to make her own decisions and had expressed strong wishes that she did not wish to be subjected to cardiopulmonary resuscitation in the event of a cardiac arrest. Although the form confirming that she should not be resuscitated had not been countersigned by a senior doctor as required, the senior doctors had recorded their agreement with the decision in the notes.

It is difficult balance between very active care to keep patients alive and then switching to palliative care once it is clear they are dying. We found that, overall, the care provided to Mrs A before her death had been reasonable. We did not uphold Mr C's complaint.

Summary

Mrs C complained about the care and treatment she received from the board at University Hospital Crosshouse following her inner labial reduction surgery (reduction of the two flaps of skin on either side of the vaginal opening). Her concerns included that the board failed to provide her with a reasonable standard of care when she reported problems after the procedure and that the entire area of tissue from the inner labia had been removed during subsequent corrective surgery without reasonable discussion or explanation.

We obtained independent medical advice on the case from a consultant gynaecologist. They said that at the first sign of post-operative problems, Mrs C should have been seen as a matter of priority and the surgeon who carried out the operation should not have refused to see her. The adviser said that the surgeon suggesting that Mrs C's GP contact the plastic surgery service was not appropriate and caused further delay in Mrs C's treatment. We therefore upheld this part of the complaint. However, we noted that the adviser said that they did not feel that the outcome would have been materially different if the subsequent corrective surgery had taken place sooner. We also noted that the board had taken appropriate remedial action as a result of Mrs C's complaint.

In terms of the corrective surgery, the adviser said that almost the entire area of the inner labia was removed without consent or proper explanation. We therefore upheld this part of Mrs C's complaint. Although we noted that the board had taken reasonable remedial action in relation to their consent process, we made two recommendations.

Recommendations

We recommended that the board:

• feed back our decision on Mrs C's complaint to the staff involved; and
• provide Mrs C with a written apology for the failings identified.

Summary

Miss C's baby was not lying properly, but was in the breech position (legs downward). After unsuccessful attempts to turn the baby, she was booked in for a caesarean section (an operation to deliver a baby which involves cutting the front of the abdomen and womb). However, several days before the planned caesarean, Miss C began experiencing labour pains and called Ayrshire Maternity Unit. She was asked to come in and was reviewed, then sent back home. Two days later she called again and was asked to come in. Miss C was then admitted and monitored on the ward. She was reviewed by a doctor on several occasions, but told she was not in active labour and a caesarean was planned for the following morning. However, Miss C continued to experience symptoms and a consultant reviewed her and found she was in active labour. Miss C was sent immediately to the labour suite, where her baby was born a few minutes later. Miss C complained about the advice she was given on the phone and the management of the birth, in particular that staff did not recognise that she was in labour and arrange an emergency caesarean.

Staff from the board met with Miss C to discuss her complaint. They explained that when she was examined by the first doctor her cervix was closed, which meant that she was not in active labour. They also explained that, because Miss C's baby was under 39 weeks, the doctor wanted to prescribe steroids and allow time for these to work before conducting a caesarean (to decrease the risk of breathing problems for the baby).

After taking independent obstetric and midwifery advice, we did not uphold Miss C's complaint. We found that Miss C experienced rapid labour, which could not have been predicted by staff, and the care and treatment was reasonable in light of the circumstances known to staff at the time.

Summary

Mr C was admitted to University Hospital Crosshouse with a suspected infection following shoulder surgery a few days earlier. He complained that he received poor care in relation to the infection that developed in his wound, which required treatment under three separate general anaesthetics. Mr C was dissatisfied with the nursing care in terms of the lack of access to a bathroom and a shower, as well as the way in which his medicines were administered. He also complained about the board's delay in responding to his complaint.

We took independent advice from medical and nursing advisers on the care and treatment Mr C received. We were critical of a lack of evidence showing that Mr C's wound had been examined by three different doctors who had reviewed him on the day of admission to hospital. We made a recommendation to address this failing. However, we considered the assessments and treatment carried out thereafter were reasonable. In terms of the nursing care, we found that there was good reason (because of infection control and the facilities in the high dependency unit) for Mr C not having specific access to a bathroom and shower.

We did not uphold Mr C's complaints about his medical and nursing care, although we did identify shortcomings in the prescribing of his medication and made two recommendations to the board about this. There was also an unreasonable delay of four months in the board responding to his complaint and we made a further recommendation to address the matter.

Recommendations

We recommended that the board:

• review their medicines reconciliation process to ensure that medication is prescribed and checked in a systematic manner;
• draw to the attention of the medical staff involved in Mr C's care the failure to review his heart rhythm to check whether he required to continue with the existing treatment or have any additional medication prescribed;
• review their handling of Mr C's complaint in order to identify ways in which they can ensure regular updates are given and keep any delays to a minimum; and
• share the adviser's comments with the three doctors involved in Mr C's care.

Summary

Ms C raised concerns that the there was a failure to reasonably inform her of her treatment options prior to having a laparotomy (a surgical procedure that involves an incision being made into the abdominal wall) at Western Isles Hospital. Two ultrasound scans of Ms C's pelvis, carried out six weeks apart, showed she had a cyst on her right ovary. Ms C said she initially understood that she was to have a laparoscopy (a surgical procedure to access the abdomen and pelvis) to treat the cyst and only learned at a pre-operative appointment that she was to have a laparotomy. The board accepted that more explanatory detail could have been provided to Ms C.

We took independent advice from a medical adviser who said that the entries in Ms C's medical records indicated that she was always to have a laparotomy, and as she thought she was having a laparoscopy, she evidently had not been given enough information to make an informed choice about her treatment options. Also, it was unclear if the risks of surgery had been explained to Ms C. Therefore, we upheld this part of the complaint.

Ms C also complained she had not been provided with reasonable care and treatment. When Ms C had the laparotomy, no cyst was found on her right ovary and she questioned this. The adviser agreed with the board that the most likely explanation was the cyst had ruptured before surgery. The adviser also said that overall, the care and treatment Ms C received was reasonable. We agreed with this and did not uphold this part of the complaint.

Ms C further complained that she was not provided with reasonable post-operative care. She said that following the laparotomy she suffered continuing abdominal pain and tenderness. The advice we received was that the symptoms Ms C was experiencing post-operatively were not unusual and would be expected. There was also no evidence she had a post-operative infection. While we did not identify any failings in Ms C's clinical care we considered there were failings in communication with Ms C and for this reason we upheld this part of the complaint.

Recommendations

We recommended that the board:

• apologise to Ms C for the failure to ensure that she understood the surgical procedure she was to undergo;
• provide evidence that clinicians have been advised to confirm with patients that they understand the procedure they are to undergo and that this information and any comments made by the patient will be recorded in the patient's case records;
• ensure that where the risks of surgery are explained to a patient, this information is clearly recorded in the patient's medical records;
• provide an update on the review and development of their obstetric and gynaecological protocols;
• consider investing in appropriate training to improve the communication skills of their medical staff; and
• feed back the outcome of this investigation to the relevant clinicians.

Summary

Mrs C's husband was an adult with incapacity and she was his power of attorney. He was diagnosed with an abscess on his right kidney and had to be transferred by air ambulance to a hospital in another board area. Mrs C accompanied her husband in the air ambulance and arranged to stay in accommodation near to the hospital. She sought to claim back the accommodation expenses from the board but her claim was refused. Mrs C complained that the board acted unreasonably by failing to refund her accommodation expenses.

Following our investigation, we established that the board had followed their patient travel policy when reaching a decision on her claim. Section 10.2 of the policy was clear that travelling in the air ambulance did not make an individual an escort for the purpose of the policy and that they would be responsible for their own accommodation and return expenses. Therefore, we did not uphold Mrs C's complaint.

Summary

Mrs C learned that she had a gene mutation which increased the risk of breast and ovarian cancer. She decided to have surgery to remove both breasts to reduce the risk of developing breast cancer, and reconstruction surgery. Her surgery was cancelled on the morning she was due to be admitted. The board said that the cancellation was due to their failure to ensure the correct implants were available for the surgery to progress, and apologised. When she complained to us, Mrs C was concerned that she has not been given an alternative date for surgery.

Whilst we were considering Mrs C's complaint she was given a date for surgery. Following Mrs C's surgery she decided not to proceed with her complaint because the quality of care she received from the board had been so good.

Summary

Mrs C complained about an ambulance crew who attended her following a fall in her garden. After the fall, Mrs C knew she had damaged her back; she was in severe pain and could not move her legs. The crew attended without carry equipment and pulled her up into a garden chair and gave her gas and air. The crew appeared to be unsure about whether or not to take Mrs C to hospital but eventually did so (after an hour) and she was diagnosed as having fractured three vertebrae.

We took independent advice from an A&E consultant and found that, given Mrs C's reported symptoms, the location and severity of her pain, it was highly suggestive that Mrs C had suffered a lumbar (lower back) spinal fracture. As a result, she required a hospital assessment for an x-ray or CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) as required. It was not appropriate for the crew to have attempted an assessment of Mrs C on scene or to have tried to sit her on a chair, and her spine should have been immobilised. We upheld the complaint and noted that the service had already arranged for the Area Service Manager to review the case and allow the crew to reflect on their actions.

Recommendations

We recommended that Scottish Ambulance Service:

• apologise to Mrs C for the failings identified.

Summary

Mr C had a history of bowel problems. He had surgery at Balfour Hospital to rectify a twisted bowel and hernia. Mr C was concerned that his bowel was perforated during the operation, which meant it leaked and was slow to heal, affecting his ability to work. Five months later he had further surgery to repair the damage, after which the healing process was quick. Mr C complained that the board did not provide adequate reasoning for the delay in carrying out the second surgical procedure.

We took independent medical advice on this case from a consultant colorectal surgeon. Whilst we recognised the significant impact that Mr C's post-operative problems had had on his life, we found that he had experienced a recognised complication of this type of surgery. He had developed a fistula (a tube-shaped hollow between organs) possibly caused by one of his stitches opening. We were satisfied that a period of time had to be left between the two surgeries to allow the fistula to repair itself and prevent further damage. The second operation was, therefore, not delayed and we found no evidence of failings by the medical team.

Summary

Mrs C complained about the care and treatment of her late mother (Mrs A) when she was admitted to the Royal Infirmary of Edinburgh with a urinary tract infection. Mrs A was also treated for a bacterial infection (staphylococcus aureus) and Mrs C raised concerns that medical staff did not adequately investigate the cause of this infection and relied upon the administration of strong antibiotics, which she considered wiped out her mother's immune system. Mrs A was subsequently diagnosed with a further bacterial infection (clostridium difficle) and, although plans were being made for her discharge from hospital, she suffered a gastrointestinal bleed and died two weeks later. We obtained independent advice from a consultant physician, who advised that most aspects of Mrs A's medical care were reasonable, including the investigation of her infections, the decision to treat with antibiotics and the management of her symptoms. The adviser did not consider that Mrs A's death could have been avoided. However, the adviser did query the initial choice of antibiotic and was also critical of the fluid management. In light of this, we upheld this aspect of the complaint.

Mrs C also complained about the standard of nursing care, including concerns about lack of available staff to provide assistance when required, dementia awareness and continuity of care. We obtained independent nursing advice. The adviser identified significant gaps in the recorded care of Mrs A, and a lack of care planning to meet Mrs A's changing needs. The nursing adviser did not consider it clear that staff understood how Mrs A's dementia affected her or took this into account in her care. We upheld this aspect of the complaint.

Mrs C raised further concerns about the hygiene and infection control measures in place on the ward. The available medical records did not provide sufficient evidence of the specific allegations of poor hygienic practice but we noted that the board had accepted and apologised for poor hygiene standards in Mrs A's care. We also upheld this aspect of the complaint.

Mrs C complained that the record-keeping in relation to her mother's care was inadequate. We received advice that the record-keeping fell below a reasonable standard and so we upheld this aspect of the complaint. We also upheld Mrs C's complaint that communication was inadequate, on the basis of a lack of evidence to show that nursing staff communicated reasonably with the family. In some instances we considered that the board had already taken appropriate action to address the identified failings and, in others, we made some recommendations.

Recommendations

We recommended that the board:

• confirm that the use of appropriate antibiotics will be highlighted to junior doctors as part of their induction process;
• confirm that the findings of our investigation will be reflected upon by the relevant consultant(s) as part of their annual appraisal;
• remind ward staff about the importance of completing fluid intake / output charts;
• apologise to Mrs C's family for the poor record-keeping in relation to Mrs A's care; and
• demonstrate to us that record-keeping on the ward is now of a reasonable standard.