Health

Summary

Mr C's father (Mr A) had a complex medical history and was admitted to Aberdeen Royal Infirmary with a suspected heart attack, which was believed to have been caused by an infection in his leg. Surgery to amputate his leg below the knee was delayed to minimise post-operative risks, but carried out two months later. A few weeks after surgery, Mr A's health began to deteriorate, but there was a delay in admitting him to the intensive care unit and he died of a cardiac arrest. Mr C complained that staff failed to provide a reasonable standard of medical and nursing care and treatment, and that there was a failure to admit Mr A to the intensive care unit within a reasonable time. Mr C also complained about the length of time it took the board to respond fully to his complaint.

We took independent advice from a nursing adviser and an adviser who is a specialist in end-of-life care. We found that the medical and nursing treatment provided was reasonable and that there was relatively prompt recognition of Mr A's problems. However, we also found that the delay in admitting Mr A to the intensive care unit was unacceptable. We found that, while it may not have altered the outcome for Mr A, an earlier admittance would have improved his chances of survival. Also, while the board's investigation of the complaint was thorough and comprehensive, the delay in responding was unreasonable, as it caused further distress to Mr C and his family at a difficult time.

Recommendations

We recommended that the board:

• ensure the action plan is implemented in full;
• review their processes to ensure that investigations into complex complaints are completed within a reasonable time and that complainants are regularly updated and told of their right to contact us; and
• apologise for the failures in complaints handling this investigation identified.

Summary

Mr C complained that the prison health centre's handling of his pain medication was unreasonable. He had been prescribed a medicated patch for nerve pain for a trial period of one month. Mr C said that the doctor did not review his treatment throughout the trial period or when the prescription ended. Because of that, he said he was left in pain.

The information available confirmed that Mr C did not raise any concerns with healthcare staff about pain whilst receiving the treatment or after the treatment ended. We took independent advice from one of our GP advisers who noted that Mr C's mental health at the time the medication was being trialled was unstable and he did have episodes of self harm which involved him creating more damage to his wound. Because of that, our adviser considered that a routine review of Mr C's treatment for pain was not feasible at that time, and management of his acute and unpredictable mental health was the priority. In addition, our adviser noted that it was not practicable or common practice for doctors to contact patients routinely to enquire whether their prescribed medication was sufficient. Therefore, we did not uphold Mr C's complaint.

Mr C also complained that the board failed to respond appropriately to his complaint but we did not agree.

Summary

Mrs C, who is an advocacy worker, complained to the board on behalf of her client (Mrs B). Mrs B's mother (Mrs A) had been admitted to Forth Valley Royal Hospital with swallowing difficulties, and there was a problem when a nurse was performing an endoscopy (a procedure where a tube-like instrument is put into the body to look inside). A consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) was called to continue the procedure and Mrs A's oesophagus was perforated, which meant the procedure had to be cancelled. Mrs A was transferred to the intensive care unit (ICU) and Mrs B complained that Mrs A suffered problems with her catheter, blockages of her NJ tube (nasojejunal tube - a small tube that is passed through the nose and into the small intestine), inappropriate management of her chest drain, and poor communication from staff.

The board maintained that the perforation of the oesophagus was a rare but recognised complication of an endoscopy procedure and that Mrs A was transferred to ICU for close monitoring. They said Mrs A had received appropriate care and treatment, and that it was appropriate for the catheter to have been fitted. They said the blockages in the NJ tube were addressed in a timely manner, and explained that staff dealt appropriately with problems of fluid build-up by managing chest drains correctly.

After taking independent advice from a gastroenterologist adviser and a nursing adviser, we did not uphold the complaint about the care and treatment which Mrs A received. We found that Mrs A had suffered a recognised complication of an endoscopy procedure which was not caused by failings by the staff involved. We were also satisfied that the staff provided Mrs A with appropriate care and treatment in relation to the problems with her catheter, NJ tube and chest drain management. However, we did find that, although communication from the staff to the family was generally good, there was a four-day period after Mrs A's transfer to ICU when senior staff did not provide her family with an update.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings in communication from ICU staff;
• take steps to ensure the relevant staff are made aware of the importance of communication with relatives, in line with General Medical Council guidance; and
• remind staff who compile draft complaint response letters to ensure that all relevant issues are included.

Summary

Mrs C complained to us on behalf of her husband (Mr C), following surgery he had at Victoria Hospital. Mr C was given morphine for post-operative pain, administered through a Patient Controlled Analgesia device (PCA - a special syringe allowing pain relief on demand). Over the subsequent 18 hours Mr C administered his own morphine, within limited doses, via the PCA. Nursing staff contacted the Hospital at Night team when they were concerned about the amount of morphine he had received, but he was not seen by a doctor until ward rounds the next morning. Concern over his pain relief led to a referral to the pain team. Mr C was seen by a pain nurse, who stopped his PCA and prescribed alternative, morphine based pain relief. Three hours after his PCA was stopped Mr C started to show clear signs of opiate toxicity (overdose). A doctor was called and he was given medication to reverse the overdose.

We sought independent advice from nursing, anaesthetic and general medical advisers. The nursing adviser was satisfied that nursing staff had appropriately monitored Mr C's condition. The anaesthetic adviser noted that Mr C had shown signs of mild opiate toxicity before his overdose, and that a review by an anaesthetist should have been requested either at those times or when he was seen by the pain nurse. The general medical adviser agreed with this assessment.

The signs of opiate toxicity which Mr C displayed in the hours after his surgery were short-lived, and his observations on charts remained reasonable. While nursing staff monitored him appropriately, and it was reasonable to refer him to the pain team, we decided he should have been reviewed by an anaesthetist to identify whether alternative medication was more appropriate. We found that this could have eliminated the risk of an overdose. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• discuss this case in an appropriate multi-disciplinary setting, to identify alterations to current procedures to assist staff in identifying when they should seek an anaesthetic review; and
• apologise to Mr and Mrs C for the failings identified and the distress caused as a result.

Summary

Mrs C's late husband (Mr C) was receiving treatment for prostate cancer. His condition deteriorated and Mrs C complained that GPs at the practice failed to take into account concerns that the medication to treat the cancer was the cause of the problems and that Mr C had a history of severe allergic reactions. Mrs C said that the GPs did not listen to her concerns and that Mr C rapidly deteriorated and died following a heart attack caused by an allergic reaction to the medication. She said that she and her husband were not warned about the possible side effects of the medication, and that staff failed to take reasonable action to resolve matters.

We took independent advice from one of our medical advisers. We found that the care and treatment provided to Mr C was reasonable, and that the practice took Mr C's symptoms into account and acted appropriately in addressing his concerns about his medication. We also found that Mr C had suffered an acute heart attack and there was no indication to suggest that this was imminent. As such, his condition could not have been anticipated.

Summary

Mr C complained about his treatment when he was admitted to Dumfries and Galloway Royal Infirmary for bowel surgery. He had been diagnosed with bowel cancer and underwent surgery to remove the right side of his colon. He became unwell following surgery, experiencing severe pain, and a scan three days later revealed a leak in the join in his bowel. He was taken back to theatre the same day for corrective surgery. He complained about the delay in diagnosing the complication arising from the initial surgery. He also raised concerns that the potential for this complication had not been explained to him in advance and that his wife was not informed of the severity of his condition prior to the corrective surgery.

We took independent clinical advice from a consultant colorectal surgeon who advised us that the risk of a leak was recorded on the consent form that Mr C had signed, thus suggesting that it had been discussed with him. It was our adviser's view, however, that the possibility of a leak should have been considered more closely and a scan arranged a day earlier. We, therefore, concluded that there was an avoidable delay in identifying the leak and carrying out the corrective surgery. Our adviser told us that earlier surgery would not have altered the clinical outcome, however, we noted that it would have minimised the distress caused to Mr C and his wife. We upheld the complaint. The board had already accepted that they should have given more information to Mr C's wife regarding his condition. They had apologised for this and discussed it with senior staff. However, they had not accepted that there was a delay in identifying the leak and we recommended that our findings in this regard be fed back to medical staff.

Recommendations

We recommended that the board:

• arrange for the learning from this decision to be discussed by medical staff at a relevant departmental meeting; and
• apologise to Mr C for failing to identify his post-surgical complication earlier.

Summary

Miss C, an advocacy worker, complained on behalf of Mr and Mrs A about the care and treatment their late daughter (Miss A) received during an admission to Dumfries and Galloway Royal Infirmary. Miss A, who was severely disabled, was admitted with breathing and swallowing difficulties, but she became increasingly unwell and died two weeks later. Mr and Mrs A complained about various aspects of her medical and nursing care. They also complained that staff failed to reasonably communicate with them, and they raised concerns about the way in which the board handled their complaint.

We took independent advice from a nursing adviser and one of our medical advisers, who is a consultant physician. We were advised that a reasonable standard of medical care was provided to Miss A and that her death could not have been prevented. We, therefore, did not uphold this aspect of the complaint. However, we noted that one of the recorded causes of death was not appropriate, which the board had already acknowledged, and we asked them to bring this to the attention of the relevant member of staff. We considered that most of the nursing care provided to Miss A was also of a reasonable standard, but we identified a failure in respect of her bowel management. Miss A required her bowels to be manually evacuated and this task unreasonably continued to fall to Mr and Mrs A during her admission. The board's manual evacuation, or digital removal of faeces (DRF), policy was not fit for purpose and staff failed to seek specialist advice to allow them to carry out this task. We upheld this aspect of the complaint.

We also found deficiencies in the recorded level of communication between staff and Mr and Mrs A. In particular, we noted that medical staff did not have a sensitive discussion with them regarding the fact that Miss A was approaching the end of her life. This lack of discussion regarding the severity of the situation left them to attribute the deterioration of her health to a lack of appropriate care and thus added to their distress. We upheld this aspect of the complaint. We also upheld the complaint regarding the way in which the board handled Mr and Mrs A's complaint to them. They unreasonably delayed in responding and, having met with Mr and Mrs A, they failed to follow this up with a full response showing that all the issues raised had been fully investigated.

Recommendations

We recommended that the board:

• bring this decision to the attention of the member of staff who certified Miss A's death in order that they can learn from the identified discrepancy;
• review their policy for manual evacuation/DRF, taking account of any appropriate national guidance in this area;
• bring this case to the attention of relevant staff with a view to improving future communication with patients and their families/carers, particularly around end-of-life care;
• review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities, as set out in the Can I Help You? guidance; and
• apologise to Mr and Mrs A for the failings this investigation has highlighted.

Summary

Mrs C complained on behalf of her husband (Mr C). She said that after he was referred to hospital for knee problems, the board failed to provide Mr C with appropriate treatment. She said that it must have been obvious following the results of an x-ray, taken a few months later, that an arthroscopy (a minimally-invasive surgical procedure to examine, and sometimes treat, joint damage) would not solve Mr C's problems, and that he required a total knee replacement. Nevertheless, an arthroscopy was carried out. Mrs C said that her husband continued to experience unacceptable levels of pain and was told to return to his GP to be referred back to hospital. It was later decided that he required a total knee replacement. Mrs C said that it was unreasonable to require her husband to go back to the bottom of the waiting list.

We took independent advice from a consultant in orthopaedic and trauma surgery and found that, at the time of Mr C's x-ray, his knee did not require replacement. In the circumstances, it was reasonable to first undertake the alternative, conservative treatment of an arthroscopy, even though a successful outcome was not guaranteed (and this was explained to him). Some time later, after his knee was shown to have deteriorated, his GP referred him back to hospital for consideration. At that point, Mr C was recommended to have a total knee replacement and, in accordance with policy and practice, he was required to join a waiting list for his operation. In these circumstances, the complaint was not upheld.

Summary

Mrs C complained to the board about how her elderly aunt (Miss A) had been cared for in University Hospital Ayr. Mrs C complained to us that Miss A was not given a bed with rails, that hospital staff did not monitor Miss A's movements, and that they did not respond in a reasonable time to Miss A falling in her ward. Miss A died shortly after the fall. Mrs C also complained about the delay in the board investigating and responding to her complaint.

We looked at the board's file on Mrs C's complaint and at Miss A's medical records. We also took independent advice from two of our advisers, one specialising in nursing, the other in general medicine. We found that when Miss A was admitted to hospital, an assessment was made that she needed bedrails. However, on the night Miss A fell, the bedrails on one side of her bed were not in use, apparently at her request. This change was not recorded by hospital staff, and is significant because they should, when making decisions like lowering the bedrails, have borne in mind that Miss A had delirium.

We found that staff failed to follow a procedure, called the bedrails algorithm, for dealing with the lowering of bedrails, which meant that Miss A was not supervised at the time she fell. Without bedrails, an alternative should have been put in place, such as close monitoring, to compensate for the lowering of the bedrails on one side. We concluded that staff did not take sufficient account of Miss A's delirium and risk of falls in providing care to her. We upheld these aspects of Mrs C's complaint. However, we did not find evidence that staff failed to respond immediately when Miss A fell.

We found, and the board acknowledged, that there was a significant delay in responding to Mrs C's complaint. We also found that updates to Mrs C were not in line with the national NHS complaints guidance. We upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• remind relevant nursing staff of the bedrails algorithm;
• provide us with details of the actions taken to ensure there has been learning from this complaint; and
• remind all staff involved in dealing with Mrs C's complaint of the national NHS complaints guidance, and of the importance of updating complainants in reasonable time.

Summary

Mr C complained about the medical treatment and nursing care that his late wife (Mrs C) had received from the board at University Hospital Crosshouse and University Hospital Ayr. Mrs C as admitted to Crosshouse Hospital four times in seven months, as well as being seen at the accident and emergency department on another occasion. She was initially diagnosed with both chest and urinary tract infections. Later, delirium became a significant issue for Mrs C. She was transferred to University Hospital Ayr so that her urology (concerned with the urinary system) symptoms could be investigated. She was discharged when this was completed but was readmitted to Crosshouse Hospital a short time later.

In relation to the medical treatment that Mrs C received, we took independent advice from a consultant physician. We found that the majority of the care that Mrs A had received at Crosshouse Hospital was reasonable. However, the adviser noted some concerns about the way that Mrs C's delirium had been managed, as changes that had been made to her medication could potentially have affected this. The adviser also highlighted concerns about the level of discharge planning that had taken place. On balance, we found that there was enough evidence to uphold Mr C's complaint about the treatment that his wife received at Crosshouse Hospital. The advice stated that the treatment provided at Ayr Hospital was reasonable. There were some concerns about the level of discharge planning that had taken place but, on balance, we did not uphold this part of Mr C's complaint.

After taking independent advice from a nursing adviser, we did not uphold either of Mr C's complaints about the standard of nursing care provided at Crosshouse or Ayr hospitals. We found that the care Mrs C had received was reasonable.

Recommendations

We recommended that the board:

• review how patients with delirium are managed in light of the adviser's comments;
• ensure that effective discharge planning is taking place on the relevant ward at University Hospital Crosshouse;
• ensure that effective discharge planning is taking place on the relevant ward at University Hospital Ayr;
• apologise for the failings identified by this investigation.