Health

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.

Summary

Mrs C complained about the care of her daughter (Miss A) who committed suicide while she was an in-patient at Hairmyres Hospital. Mrs C raised concerns that staff did not appropriately supervise Miss A in view of her condition, and that the family were not told about a suicide attempt the day before Miss A’s death.

When we reviewed Mrs C’s complaint we found that the Crown Office and Procurator Fiscal Service was currently investigating the circumstances of Miss A’s death. Additionally, the Child Protection Committee was also conducting a significant case review in consultation with the Mental Welfare Commission. In view of these on-going investigations by other independent organisations, we decided not to investigate Mrs C’s complaints further at this stage. We invited Mrs C to contact us again if any issues raised in her complaint were not investigated as part of these processes.

Summary

Ms C was concerned about the care and treatment given to her late mother (Mrs A) at Wishaw Hospital. She felt that Mrs A's symptoms were initially not properly investigated and, had they been, her chances of survival may have been improved. She complained that, other than chemotherapy, Mrs A received little treatment. Ms C also said that the information provided to Mrs A was confusing.

The complaint was investigated and we took independent advice from a consultant general surgeon. We found that Mrs A had a type of stomach cancer that was very difficult to diagnose and was very aggressive. Because of this, there was only a very small chance of any treatment curing the cancer. Although Mrs A was given appropriate tests, the results were not regarded with enough suspicion and, despite not providing an explanation for Mrs A's symptoms, no further investigations were made. Mrs A was not diagnosed until a year later when the only treatment she could be offered was palliative chemotherapy. Mrs A died the following year. In light of our findings, this aspect of Ms C's complaint was upheld.

Mrs A initially responded well to treatment, which may have led her to question her diagnosis and the information she had been given. However, our investigation showed that discussions with Mrs A explaining her diagnosis and treatment had taken place. For this reason, we did not uphold this part of the complaint.

Recommendations

We recommended that the board:

• make a full, formal apology for their failure to diagnose Mrs A sooner; and
• bring the terms of this decision to the attention of the staff involved, including the endoscopist and the junior surgical doctor concerned, for them to reflect upon and discuss at their next formal appraisals.

Summary

Mr C complained about the treatment his father (Mr A) received from the board. Mr A had had a history of Parkinson’s disease, dementia and type 1 diabetes. However, Mr A controlled his diabetes well and lived independently before having a fall. He was admitted to Hairmyres Hospital with hip pain and reduced mobility. X-rays showed no sign of a fracture, but Mr A was kept in hospital due to his poor mobility. His pain and mobility worsened, and a second x-ray was taken around four weeks later. This showed a displaced fracture in his hip. Mr C complained that his father’s diabetes was poorly managed during his admission, causing increased confusion and unsafe blood sugar levels. He also complained about a delay to the second x-ray and the diagnosis of Mr A’s fracture.

We took independent advice from a nursing adviser, and found that the nursing staff failed to properly manage Mr A’s diabetes. The board had already identified failings in this respect and we were satisfied that they had learned lessons from Mr A’s experiences.

We also took independent advice regarding the diagnosis of Mr A’s hip fracture from a consultant in orthopaedic and trauma surgery and a consultant physiotherapist specialising in orthopaedics (relating to the musculoskeletal system). Whilst there was no visible sign of the fracture on the first x-rays, Mr A's pain and mobility did not improve. We concluded that, in line with national guidance, further x-rays or scans should have been ordered to rule out a fracture. There was a clear delay to this happening and, by the time of the second x-ray, the fracture had displaced. This required a more invasive operation than would have been needed had the fracture been diagnosed before it displaced. We were critical of the board for this delayed diagnosis.

Recommendations

We recommended that the board:

• conduct an audit of the relevant ward's performance in terms of effectively managing diabetic patients' insulin regimes to gauge the effectiveness of action taken in response to Mr C's complaint;
• apologise to Mr A and his family for the delay in diagnosing his fractured hip;
• share our decision with their orthopaedic staff with a view to learning from Mr A's experiences; and
• consider whether orthopaedic staff would benefit from refresher training on the national guidance on treating hip fractures in elderly patients.

Summary

Mr C was diagnosed with attention deficit hyperactivity disorder. To help with his symptoms, he was started on a drug regime which was changed twice after his condition had been reviewed. However, Mr C said that he had not found any of the treatment he had been given particularly helpful, and he had continuing problems sleeping and concentrating. He questioned whether the care and treatment he received had been appropriate. He also complained that, since his diagnosis, the board had not taken reasonable steps to keep him informed. However, in responding to his complaint, the board said that he had been treated reasonably. While they acknowledged Mr C's concerns about communication, they said that his doctor always allowed 30 minutes for consultations to allow patients to raise questions.

We took independent advice from a consultant psychiatrist. We found that Mr C's care and treatment was all reasonable and in accordance with national guidance, as he was regularly reviewed and his medication was changed after reporting that his symptoms were not being helped. He had had the support of community psychiatric nurses and occupational therapists. Although Mr C considered that he had not been kept informed, there was evidence to show that his condition and drug therapy had been discussed with him. On this basis, his complaints were not upheld.

Summary

Miss C said that she had attended the Early Pregnancy Clinic at Raigmore Hospital as she was considering having a medical termination of her pregnancy. She had experienced bleeding and was concerned that she was going to miscarry. She was unhappy that the consultant had told her to take the contraceptive pill, and that she had to return the following day for a medical termination of her pregnancy. Miss C continued to suffer from pain. She attended her GP, who told her not to take the contraceptive pill and that she would probably miscarry without medical intervention. Miss C did not return to the clinic but subsequently attended her GP. The GP arranged for a pregnancy test which proved to be negative. Miss C felt that it was inappropriate for the consultant to have ordered her to take the contraceptive pill.

We took independent advice from a nursing adviser. The adviser said that the medical record of Miss C's attendance at the clinic was detailed. It contained information regarding the plans for a medical termination of her pregnancy, and confirmed that Miss C was advised to seek medical advice if she should have additional bleeding or pain. The adviser felt that in such situations it would also be appropriate for a consultant to discuss family planning matters such as contraception. We did not uphold the complaint.

Summary

Mr C had a longstanding spinal problem and the board had been providing treatment to him for many years. When Mr C's condition deteriorated to the point that he could no longer walk 100 yards without pain, his regular consultant at Raigmore Hospital referred him to a specialist colleague. Mr C said he heard nothing and after 12 weeks he phoned the board. He was told they did not know when he would be offered an appointment. He phoned again two weeks later and was told the same thing. After 18 weeks Mr C complained. He said there had been an unreasonable delay and no communication from the hospital.

We upheld both of Mr C's complaints. We found that the time taken to give Mr C an out-patient appointment (30 weeks) was too long. We found the board had not been proactive in communicating with Mr C, which they should have been, given the known pressure the service was under at the time.

Recommendations

We recommended that the board:

• review the process for managing the orthopaedics waiting list to ensure that people receive clear and accurate information about waiting times.