Health

Summary

Mrs C complained about the aftercare provided to her father (Mr A) at the Royal Infirmary of Edinburgh following hip replacement surgery. She said a student nurse had removed some stitches while cleaning his wound and, on discharge from hospital, Mr A was not fitted with compression stockings. Mr A's leg then began to swell. As there was a possibility he would suffer a blood clot, he had to reattend hospital. Mrs C was unhappy the board had maintained that the stockings were fitted on discharge.

The board apologised that the stitches were removed in error. They said that the prompt action of arranging a medical review resolved the mistake. They also said that the records showed evidence that the stockings were fitted on discharge.

We took independent advice from a nursing adviser. The adviser said that the action taken after the accidental removal of the stitches was appropriate. However, the medical records contained confusing and contradictory information about whether the compression stockings were fitted on discharge. Stockings had been fitted immediately following surgery but, as Mr A's heels were becoming marked, their use had to be reassessed before he was discharged. However, there was no evidence that they were reassessed. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the failure to keep clear and accurate hospital records; and
• remind the staff involved of the importance of keeping clear and accurate hospital records.

Summary

Miss C complained about the care and treatment her baby son received from the GPs at the practice. Miss C said she attended the practice a dozen times over a three-month period as her son was continually crying and was in great distress. Miss C raised a number of issues about her son’s care. She said that the GPs at the practice unreasonably failed to listen to her concerns about her son’s health. She said that they failed to ask relevant questions which might have helped get to the bottom of her son’s problems sooner. She also said that they did not recognise when they were out of their depth and needed to refer her son to more specialist medical staff. Miss C said that eventually a referral was made to the Royal Hospital for Sick Children, where severe reflux and colic was diagnosed as the cause of her son’s symptoms.

We obtained independent medical advice on the complaint from a GP adviser. The adviser said that the GPs at the practice listened to Miss C’s concerns and tried reasonable medication options. The adviser said that, when there was no evidence of consistent improvement, they arranged specialist referral to a dietician and a paediatrician (a doctor dealing with the medical care of infants, children and young people). The adviser said that the practice’s response was reasonable, referral occurred early on in the consultation history and there was no evidence of delay in referral.

The adviser found no evidence that the GPs failed to ask relevant questions which might have helped diagnose Miss C’s son’s medical problems sooner, or that the GPs treated him beyond their competencies. The adviser also indicated that the GPs acted in accordance with relevant national guidelines and Lothian NHS board’s policy.

Summary

Ms C complained about the care and treatment she received when she attended St John's Hospital in 2000. In particular, Ms C maintained that she should not have been discharged following her consultation with a consultant cardiologist, due to a family history of sudden death from hypertrophic cardiomyopathy (HCM - a disease where the heart muscle thickens abnormally).

During our investigation, we took independent advice from a consultant cardiologist. We found that while it was not clear in 2000 whether or not Ms C had HCM, the results of tests carried out at that time were not quite normal. It was possible that the results could have been due to the early signs of HCM. The advice we received and accepted was that while no further investigation or treatment was appropriate at that time, Ms C should have been offered a two-year review. We found that Ms C should possibly have been given more information about her condition at that time. If Ms C had been followed up, it was possible that a definitive diagnosis of HCM might have been made sooner.

However, the advice we also received was that the lack of follow-up made no difference to Ms C's treatment. Ms C had an implantable cardioverter defibrillator (ICD - a device implanted in the body that can reestablish a normal heart rhythm) fitted in 2014. However, the advice we received was Ms C did not fulfil criteria for primary prevention ICD implantation either in 2000 or in 2014. The adviser noted that the decision to implant an ICD is always difficult and may be based on additional factors such as anxiety. However, we were concerned about the lack of communication between the clinical genetics team and cardiologists about whether an ICD had been recommended in 2014.

Recommendations

We recommended that the board:

• apologise that follow-up investigation was not arranged in 2000;
• make relevant staff aware of the adviser's comments about the need for follow-up investigation in cases such as this, and provide details of the action taken as a result;
• make relevant staff aware of the adviser's comments about the adequacy of information given to a patient about their condition, and determine if there are any lessons to be learned from this case; and
• review the standard of communication between the clinical genetics team and cardiologists, and provide details of the action taken.

Summary

Mr C complained to us about his care and treatment during an assessment for psychological therapy. He was seen by a junior clinical psychologist at St John's Hospital to identify what form of treatment he might be suitable for. However, the psychologist was concerned about some of the issues he raised, and referred Mr C for a psychiatric review. Mr C was seen by a junior psychiatrist later that day, and had a home visit the following day from two psychiatric nurses. He was also seen the next day by a consultant psychiatrist. The consultant was satisfied that, while Mr C had disturbing thoughts, he did not have any plans to act on them, and was fully in control of his behaviour. The consultant therefore discharged him from psychiatric services, but noted his referral for psychological treatment. Mr C said that this succession of different assessments by various professionals had been distressing, and had not been necessary.

We took independent advice from a medical adviser who is a psychiatrist. The adviser was satisfied that, given the issues raised by Mr C during his initial consultation, it was reasonable for the psychologist to refer him for psychiatric review. The adviser said that the initial psychiatric consultation had covered some of the same issues as the psychologist had, but in greater detail. Overall, they considered that this consultation was reasonable. They noted the need for some assessments to be carried out over a number of days to assess fluctuations in symptoms. They considered the visit by psychiatric nurses to have been reasonable. They were satisfied that the consultation with the consultant psychiatrist had been reasonable, and had appropriately considered the stability of Mr C’s mental health.

We noted the distress that this assessment process had caused Mr C. However, given the assurances of the adviser, we were satisfied that this process was reasonable, and did not uphold the complaint.

Summary

Mr C, who is an advice worker, complained on behalf of Mr A about the care and treatment he received at the Royal Infirmary of Edinburgh's A&E department, when he injured his shoulder. In particular, Mr A maintained that the hospital failed to carry out a proper assessment of his injury, and that they delayed in offering follow-up appointments.

During our investigation, we took independent advice from a consultant in orthopaedic and trauma surgery. We found that the treatment given to Mr A was reasonable and appropriate. The advice we received was that there was no evidence the hospital had failed to carry out a reasonable medical assessment of Mr A's injury. We found that the injury was diagnosed by A&E in a reasonable manner and he was appropriately referred for further specialist assessment and management. We also found no evidence that there was any delay in the follow-up appointments for his injury.

Summary

Mr C complained about the care and treatment his late wife (Mrs C) received from St John's Hospital and the Royal Infirmary of Edinburgh. Mrs C attended the emergency department at St John's Hospital where she had tests carried out that suggested that she may be suffering from a viral illness and/or a urinary infection. She was discharged home with antibiotics but remained unwell. She visited her GP four days later who arranged for her to be seen by the medical assessment unit at St John's Hospital. There were delays in Mrs C being seen by a doctor and she was found to have had a small heart attack. Further tests revealed that she had significant coronary artery disease (blockages of the arteries) and so she was transferred to the cardiology team at the Royal Infirmary of Edinburgh. It was further identified that she had an overactive thyroid. Surgery to address the blocked arteries was carried out a few days later. However, within 24 hours Mrs C's condition continued to deteriorate and further investigations were difficult to perform given her poor state of health. Mrs C was transferred to another hospital but died shortly afterwards.

We took independent advice on this case from three medical advisers who are specialists in emergency medicine, endocrinology (hormone-related diseases) and cardiology. On Mrs C's first visit to the emergency department of St John's Hospital, a junior doctor failed to refer her to a more senior doctor before discharging her. We therefore found that the care provided was unreasonable. We were also critical that, on Mrs C's second visit to St John's Hospital, there was a delay in her being admitted and seen by a doctor. The board accepted and apologised for this. We considered that the treatment given thereafter at St John's Hospital was reasonable. We concluded that the care provided by the Royal Infirmary of Edinburgh was appropriate and in accordance with national guidelines. However, we found that communication with Mr and Mrs C about Mrs C's condition was unreasonable by both hospitals.

Recommendations

We recommended that the board:

• ensure the junior doctor reflects on the failings identified at their next appraisal;
• ensure St John's Hospital reviews its policy for patients who should be reviewed by a more senior doctor before discharge from the emergency department, taking account of high-risk presenting symptoms;
• review its pathway for patients referred from their GP to the medical assessment unit at St John's Hospital to ensure that patients who should be seen urgently do not experience an excessive wait;
• share with relevant staff involved in Mrs C's care at the Royal Infirmary of Edinburgh the importance of explaining to patients and their family relevant matters related to their condition, and document that this has been done; and
• apologise to Mr C for the failings identified in relation to Mrs C's initial visit to the emergency department and for the communication failures identified.

Summary

Mrs C was in the Royal Infirmary of Edinburgh for emergency surgery. After she was discharged, she experienced pain, swelling and numbness in her forearm and hand. She felt this was the result of the insertion of a cannula (a thin tube to administer medication, drain fluid or insert a surgical instrument) in her wrist.

We took independent advice from a nursing adviser and a medical adviser, who is a hospital consultant. We found there was poor record-keeping in relation to the care of Mrs C’s cannulas, and that not all of the cannula care was in line with expected good practice. We upheld Mrs C’s complaint.

Recommendations

We recommended that the board:

• provide us with the most recent audit of cannula care to show that it has improved;
• remind staff of the importance of expected good practice in cannula care, in line with relevant local and national standards and guidance; and
• remind staff of the importance of record-keeping as noted in the relevant guidance.

Summary

Mrs C complained to the board about the nursing care and treatment provided to her late grandfather (Mr A) during admissions to the Royal Infirmary of Edinburgh (RIE), Astley Ainslie Hospital (AAH) and Midlothian Community Hospital (MCH). Mr A had a fall at home and broke his hip. He was admitted to the RIE and underwent surgery. During his time as an in-patient at the RIE, Mr A developed pressure ulcers on his lower back and heel. Mr A was later transferred to AAH for rehabilitation, then moved to MCH to wait for a place in a nursing home. His condition deteriorated at MCH and it was decided that he would remain in hospital. Mr A died in MCH. Mrs C complained about Mr A's pressure ulcer care, hydration and nutrition, access to call buzzers, nursing care of his contracted leg, and communication with her family, particularly regarding the collection of Mr A's death certificate.

After taking independent advice from a nursing adviser, we upheld Mrs C's complaint. The adviser considered that Mr A's pressure ulcers could potentially have been prevented from developing if an appropriate care plan and other interventions had been used at the RIE. The adviser said that there was a reactive rather than proactive approach to pressure area care at the RIE. The adviser noted that risk assessments and care plans (Adapted Waterlow Pressure Area Risk Assessment and SSKIN (Surface, Skin inspection, Keep Moving, Incontinence, and Nutrition) bundle) were not completed at appropriate times during Mr A's care. Although the adviser considered that on Mr A's admission to AAH, appropriate assessments of his pressure areas were carried out, his subsequent care in this area was not reasonable. The adviser said that the SSKIN bundle care plan was not used until Mr A had been in AAH for several weeks, and interventions to prevent pressure had not been implemented at appropriate times.

We noted that the board had apologised to Mrs C about communication with her family regarding two visits by Mr A to other hospital sites during his admission at the AAH. We received advice that it is good practice to keep family informed unless the patient says otherwise. We also noted that the board had apologised to Mrs C for any distress caused about the death certificate. The adviser explained that nursing staff would have no control over when this was available. We considered that other areas of Mr A's care were reasonable.

Recommendations

We recommended that the board:

• issue Mrs C with a written apology for the failings in pressure care identified by this investigation;
• ensure that all relevant staff are aware of the requirements in completing the Adapted Waterlow Pressure Area Risk Assessment and SSKIN bundle;
• highlight to all relevant staff the adviser’s comments on the use of proactive preventative strategies for pressure care;
• take steps to remind relevant staff of the need to keep call buzzers within the reach of patients; and
• ensure that all relevant staff are made aware of the adviser’s comments on keeping family and carers informed of patients’ visits to other sites.

Summary

Mr C complained about the care and treatment his late wife (Mrs C) received during an admission to the Western General Hospital. Mrs C had advanced lung cancer and her admission was arranged when it was identified that her condition was deteriorating despite treatment. She was discharged home after two weeks with a palliative care package but died in another hospital five days later. Mr C complained about the standard of nursing and physiotherapy care provided to Mrs C during her two-week admission. He also complained about the standard of communication between staff and him and his wife.

We took independent advice from a nursing adviser. The adviser identified various deficiencies in the standard of record-keeping. For instance, pain charts and records of care rounds were not fully completed. However, we were advised that, overall, there were no serious flaws or omissions in the nursing care provided. We did not, therefore, uphold this complaint but we made a recommendation regarding record-keeping. We were also advised that the level of input from physiotherapists was reasonable and we did not uphold this complaint.

We upheld the complaint about communication. The board had already acknowledged that their communication with Mr and Mrs C could have been much better. In particular, they accepted that there was a lack of continuity and consistency amongst medical staff. They also apologised for the lack of suitable private rooms in the hospital for having confidential discussions with patients and their families. We did not consider that the remedial action planned by the board would address all of the identified communication failings, and we asked them to develop a more robust action plan to tackle the issues with medical continuity and consistency.

Recommendations

We recommended that the board:

• reflect on the failings identified, alongside relevant Nursing and Midwifery Council guidance, and inform us of the steps they will take to improve record-keeping;
• develop a robust action plan to address the acknowledged failings surrounding continuity and consistency amongst staff in the medical oncology (cancer) team; and
• apologise to Mr C for the failings identified.

Summary

Mrs C complained about the care and treatment she had received at the Royal Infirmary of Edinburgh after the birth of her son. We took independent advice from a midwifery adviser. We found that, in general, the care and treatment provided to Mrs C had been reasonable. However, on the night of her son's birth, Mrs C had been left in bed with a buzzer that was not working. Given that she was sedated and had had a spinal anaesthetic, we considered that this was unreasonable and upheld the complaint. The board had already apologised to Mrs C for this and had reminded staff to check that buzzers are working when patients are admitted, and so we did not make any recommendations.

Mrs C also complained about the care and treatment provided to her baby. We found it was unreasonable that he had been left unclothed all night, although this did not cause the subsequent deterioration in his condition. We also found it had been unreasonable that staff had taken the baby away during the night without documenting Mrs C's consent to this. Although we upheld this aspect of her complaint, we were satisfied with the action that the board had taken in response to Mrs C's complaint and did not make any recommendations.

Mrs C's baby had then been admitted to the neonatal unit (specialising in the care of newborn babies). Mrs C complained that they had carried out procedures on her son without her consent. We took independent advice on the treatment the baby received there from a medical adviser who is a consultant neonatologist. We found that staff in the unit should have taken steps to obtain verbal consent from Mrs C before carrying out a lumbar puncture (where tests are carried out by inserting a needle into the lower part of the spine). We also upheld this aspect of her complaint, although we noted that the board had already apologised to Mrs C for this.

Recommendations

We recommended that the board:

• provide evidence that staff in the neonatal unit have been informed of our decision that they should have obtained verbal consent before carrying out the lumbar puncture.