Health

Summary

Mrs C's late mother (Mrs A) was admitted to the Western General Hospital as an emergency, and had an operation to release pressure in her bowel. She was told that her case would be discussed by a multi-disciplinary team (MDT) in a few days, and that they would advise on her future treatment. Before this could happen, Mrs A fell and broke her hip and was transferred to the Royal Infirmary of Edinburgh for an operation, where two days later she suffered a heart attack and died. Mrs C complained that the board did not keep her fully informed about her mother's condition and what was happening. She said she had understood that her mother's case was to be discussed at the MDT meeting at the Western and this had not happened, which caused both her and her mother upset and confusion. Mrs C was also unhappy because she said that her mother's risk of falling was not properly assessed and prevented by the Western General and that the board took too long to answer her complaints.

We took independent advice from two of our advisers, one a consultant surgeon and the other a nurse. We also considered all the relevant information, including all the complaints correspondence and Mrs A's clinical records, after which we did not uphold three of Mrs C's complaints. Our surgeon adviser said that, after Mrs A's fall, the priority was, correctly, to address her broken hip and make sure that she was recovering from it well before moving on to discuss her future treatment. We noted that although it was not unreasonable that discussions did not take place because of what happened, the board had said that in future the MDT would not cancel discussions without telling the patient and their families why. The records also showed that Mrs A had been assessed as not being at risk from falling, and although she did fall, this could not have been anticipated. Although Mrs C said that the board took too long to address her complaints, we found that they did respond within acceptable time limits. We upheld the complaint about communication, however, as it was clear that the board had not kept Mrs C as well informed as she should have been, particularly about her mother's fall.

Recommendations

We recommended that the board:

• apologise for their failure in this matter; and
• remind staff of the importance of keeping relatives and their families informed, in a timely manner, when an accident/injury occurs.

Summary

Mrs C has complex health and mobility issues and has seen a number of hospital consultants over several years. After she saw a consultant orthopaedic surgeon she said she was not given enough information about her diagnosis, and the consultation was rushed. The surgeon arranged a scan, but Mrs C was unable to go through with it and a different scan was carried out instead. Mrs C said that when she raised concerns about the proposed treatment the surgeon did not then discuss alternatives, and she was unhappy with the way the surgeon described events on the day of the scan when writing to her GP about it. Mrs C then attended another consultant's clinic, but he was not there to see her. Mrs C complained to the board about both consultants. The board responded in writing and met with her, but she came to us as she was not happy with the way they handled her complaints. She said that she did not receive an amended agreed copy of the minutes of the meeting, although she provided detailed comments and followed this up with several phone calls and emails. She was also unhappy about the board's response to her complaint about the surgeon, and said that they had not explained how the missed appointment with the second consultant had come about.

We found that the board did not tell Mrs C what had happened about the updated minutes of the meeting, and that, while they responded to her complaint about the surgeon's communication and attitude during consultations, they had not properly addressed the issue of the use of inappropriate language when writing to her GP. We were satisfied that they provided a reasonable explanation and response about the missed appointment with the second consultant.

Recommendations

We recommended that the board:

• clarify in writing to Mrs C the status of the amendments in relation to the meeting note;
• bring the failures in their complaints handling identified in our investigation to the attention of relevant staff; and
• apologise to Mrs C for the failures our investigation identified.

Summary

Mr C complained about the board's treatment of his wife (Mrs C) when she was admitted to the Royal Infirmary of Edinburgh. Mrs C, who had a history of severe renal (kidney) failure, had hip replacement surgery and was kept in for five days. During that time she experienced constipation and although she asked staff for laxatives, these were not provided before she was discharged home. Mrs C continued to suffer from constipation there. She developed a sore, swollen stomach and began vomiting black liquid. Concerned about her condition, Mr C phoned NHS 24 and requested a home visit from an out-of-hours GP. The GP examined Mrs C and prescribed two enemas and laxatives. He advised Mr C to monitor her overnight and to call Mrs C's own GP in the morning if she did not improve. As she did not improve, Mr C called the GP, who examined her and immediately referred her to hospital, where she was diagnosed with a perforated bowel and had emergency surgery. Mr C complained that this could have been avoided had his wife been given laxatives in the hospital and had the out-of-hours GP recognised the seriousness of her condition.

We upheld the complaint about Mrs C's hospital treatment, as we found that that staff clearly failed to provide her with laxatives during her admission, despite her requests. We accepted independent medical advice that patients with renal failure are particularly sensitive to medications and their side effects, noting that Mrs C was on pain medication containing codeine, which is known to cause constipation. Staff should have been aware of the increased risk of constipation and should have closely monitored her for this. Although tools were available to prompt them to ask patients about their bowel movements, staff did not use these and Mrs C was discharged without a proper assessment of her bowel activity. We did not, however, uphold the complaint about the out-of-hour GP's examination of Mrs C, as we found that medical records showed that her symptoms at the time did not suggest a perforated bowel. As such, the treatment provided and the advice offered was entirely reasonable under the circumstances.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for failing to implement the safeguards that they had in place to identify and manage constipation during Mrs C's admission; and
• conduct a review to assess whether their post-operative care pathway and patient information are sufficiently rigorous, particularly for patients with renal failure.

Summary

Ms C's late father (Mr A) had a complex medical history including heart disease. He had a chest x-ray, which showed a mass on the lung but was wrongly reported as normal. After further tests and body imaging Mr A was diagnosed with advanced lung cancer. Ms C said Mr A was told that his tumour was inoperable, and it was decided to treat him with chemotherapy and radiotherapy. Mr A developed kidney disease after the first cycle of chemotherapy, which was stopped, and he was then treated with radiotherapy. However, he became more unwell and was diagnosed with radiation pneumonitis (lung damage arising from radiotherapy). A scan the next month showed lung changes that were reported as relating to emphysema (lung disease that causes shortness of breath). Shortly afterwards, however, an underlying lung condition was detected. Mr A continued to deteriorate and he was admitted to the Western General Hospital where, despite treatment, he died.

Ms C complained that the hospital did not detect her father's underlying lung condition quickly enough. She said that, had it been spotted earlier, Mr A could have had surgery instead of radiotherapy, which she believed would have led to a more positive outcome. She was concerned about a consultant's communication with her family about her father's treatment options, and said that the board failed to treat his heart condition. She was also unhappy with the way they handled her complaint.

We took independent advice from two of our medical advisers, who specialise in oncology (treatment of patients who have cancer) and radiology (the analysis of images of the body). They said that it was reasonable that Mr A's underlying lung condition was not detected earlier and, while knowing about it might have made radiotherapy a more risky option, surgery was also a high risk option with no guarantee of a cure. The oncologist said that the management of Mr A's conditions was appropriate based on information available at the time of treatment (including for his heart condition). We appreciated that, for the family, learning about Mr A's underlying lung condition was extremely distressing and clearly caused them a great deal of uncertainty about the potential outcome. However, our adviser said that it was very unlikely that Mr A's life expectancy would have been different had treatment changed. Our radiology adviser criticised the radiologist's interpretation of the x-ray, although they also said that the failure to identify the mass would not have affected the outcome. Although a number of aspects of Mr A's care and treatment were reasonable, we upheld the complaint as there was an unreasonable delay in identifying the mass, which was a significant failure and led to a delay in diagnosis.

We did not uphold Ms C's complaint that the consultant did not discuss surgery or heart treatment. The advice we accepted was that communication was reasonable and there was evidence that treatments were fully discussed. This was on the basis of the information available to board staff at the time and, as already noted, it was reasonable that they did not pick up Mr A's underlying lung condition earlier. Our oncology adviser also said that there was evidence that the consultant had explained the issues and obtained Mr A's consent for treatment.

On the complaints handling, we were satisfied that the board fully addressed the complaint and that the time they took to respond was reasonable as there were delays in obtaining consent from the family. However, it was clear after further contact from Ms C that she wanted clarification and a further response to the issues raised, and the board should have taken earlier steps to provide this.

Recommendations

We recommended that the board:

• raise the failures identified with relevant staff; and
• apologise to Ms C for the failures identified.

Summary

Ms C complained that after her GP referred her to orthopaedics (the specialty for conditions of the musculoskeletal system) at Wishaw General Hospital, she was inappropriately allocated to podiatry (specialising in disorders of the foot, ankle and lower limb). She had previously attended private podiatry appointments with no improvement to her condition, and thought she should have been referred to an orthopaedic surgeon. She thought that this would have resulted in quicker treatment and would have meant that she did not need to obtain a private referral to an orthopaedic surgeon. She also said that the board should have told her that she was being allocated to a podiatrist, to allow her to decide whether to request further private referrals and avoid delays in treatment.

We considered the information she provided and that from the board. We found that Ms C's GP gave her a routine referral to orthopaedics and was initially triaged (deciding where patients should be treated, based on their condition) by an extended scope practitioner (ESP) podiatrist in the orthopaedic team. This person can give an onward referral to podiatry or other specialisms, and can also request specialist investigations, such as radiology and scans. Triage could include a further review by other ESPs and surgical staff. We noted that the review by the ESP podiatrist was in line with the board's protocols. Although the board had not told Ms C or her GP that she would be triaged this way, this did not disadvantage her as this is what happens to all routine orthopaedic referrals. The board explained, and we accepted, that it would be impractical to tell all patients and GPs who would carry out the triage. As the board had clearly followed their protocols, we did not uphold Ms C's complaints.

Summary

Mr C's son (Master A) suffered multiple mini-seizures and nausea and vomiting after his epilepsy medication was increased. Mr C and his GP tried to contact Master A's neurology consultant at Hairmyres Hospital for advice but he was on leave, and there was then confusion over where Master A should be referred. Mr C complained that there was inadequate cover during the consultant's absence and that staff did not provide timely advice.

Our investigation found that during the consultant's leave general advice was available from the covering neurology service. If emergency treatment was needed, Master A could have gone to the A&E department of the local hospital, where staff would have sought neurology advice if required. Master A did not, however, need emergency treatment. We also found that board staff gave appropriate advice to the GP to reduce the medication, pending a scheduled review appointment with the neurology consultant.

Summary

Mrs C complained that when she had a colonoscopy (examination of the bowel, using a camera on a flexible tube) at Monklands Hospital some years ago, it was not carried out properly. She explained that she was in severe pain throughout the procedure, but the doctor disregarded her requests to stop. She had, more recently, experienced problems with her bowel, which she thought were a result of the procedure.

Mrs C said that there was a nurse present during the procedure, whom she felt would be able to recall what happened. We asked the board to obtain a statement from the nurse, but neither he nor the doctor who carried it out could recall specific details. We also took independent advice on this complaint from one of our medical advisers, who is a hospital consultant. He said it was understandable that staff could not recall the specific procedure, given the time that had passed since the procedure. He said, however, that the records showed no evidence of Mrs C having asked for the procedure to be stopped, and she did not appear to have raised any concerns immediately afterwards, when her pain was noted to have settled.

As we found no evidence that the procedure was not properly carried out and the adviser thought it unlikely that Mrs C's more recent bowel problems were connected to the earlier procedure, we did not uphold the complaint.

Summary

Mrs C had a caesarean section (an operation to deliver a baby, which involves cutting the front of the abdomen and womb) in Wishaw General Hospital when her baby was born. The wound subsequently became infected, and Mrs C complained about the way it had been closed. She said that her health visitor told her that the hospital had used double the amount of staples that should have been used, and that they were put in too tightly. After taking independent advice from one of our medical advisers, we found that the procedure was carried out by someone with appropriate skills and experience. The number of staples used was within the range of acceptable practice and the advice we were given is that it is not within the surgeon's control to apply the staples more or less tightly. However, they can become tighter if, as in Mrs C's case, the wound becomes infected. We found that the way the wound was closed was reasonable.

Mrs C also complained that the wound was not reasonably treated during her time in hospital. Although it had become infected, this is a common complication of caesarean section and we found that appropriate measures had been taken to reduce the risk of infection. The wound care provided was reasonable and appropriate and was in line with the hospital's guidance.

Summary

Ms C's aunt (Ms A) had multiple health issues and lived in a nursing home. Ms C complained that on one occasion when Ms A became distressed, a GP who was in the nursing home at the time decided not to examine her, despite the symptoms that were reported. Ms C thought it inappropriate that the GP decided there were no grounds to examine Ms A, without having seen her.

The medical practice said that the GP was there to see a number of patients for whom consultations had been pre-arranged. He had told staff to contact the practice so that another GP could make an arranged home visit to Ms A. The practice told us that when staff told the GP of the specific circumstances, he decided that there was no requirement for a consultation at that time as there were no medical issues that needed to be addressed. Having taken independent advice from one of our medical advisers, we found that the GP had made a reasonable decision that there was no need for an immediate medical assessment. Although it was clear that Ms A had been distressed, this appeared to have been triggered by an environmental, rather than a medical, issue.

Summary

Mr C was admitted to Monklands Hospital with suspected kidney damage. He was already suffering from end stage alcoholic liver disease. Mr C was initially cared for in the Emergency Receiving Unit (ERU), where he fell twice. He was then transferred to a ward. Mr C's condition continued to deteriorate. Four days after he was admitted he was reviewed by a consultant, and staff contacted his wife (Mrs C) and asked her to come to the hospital urgently as he was considered to have a very poor prognosis. Mr C died that day.

Mrs C complained that her husband did not receive appropriate medical or nursing care when admitted to hospital, and that he was not properly assessed as a fall risk whilst in the ERU. She also said that when he was transferred from the ERU to a ward there was no proper handover and nurses had lost a crucifix he wore. This was returned to her after he died, but had been irreparably damaged. Mrs C said that medical staff were slow to assess her husband's problems and failed to provide him with the appropriate treatment, as they had not considered him for a liver transplant. She was also unhappy with the board's response to her complaint, which listed Mr C's entire medical history and emphasised the role alcohol had played in his ill health, which she felt was insensitive.

We took independent advice from a medical adviser and a nursing adviser. The medical adviser said that although the medical treatment provided to Mr C was appropriate, communication by medical staff fell below a reasonable standard. He said that they had not discussed with Mrs C the decision to designate her husband as 'Do Not Attempt to Resuscitate' (DNAR - a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). They had also not explained either his poor prognosis or the decision not to refer him for a liver transplant, contrary to General Medical Council guidance. The adviser said that the decision not to refer Mr C for a transplant was, however, in itself reasonable in the circumstances.

The nursing adviser said the standard of basic nursing care was reasonable, but the record-keeping of staff in ERU fell below an acceptable standard. They had not completed the falls assessment in a timely fashion and had not responded quickly enough to Mr C's first fall. It was not possible to be certain his second fall could have been prevented, but nursing staff had not taken the appropriate action, which was unacceptable. The adviser also said staff had not shown empathy or compassion to Mrs C while her husband was dying, and end of life care was a key part of the nursing and midwifery code.

We upheld most of Mrs C's complaints, as our investigation found that the nursing and medical care provided to Mr C fell below an acceptable standard. We did not uphold the complaint that he was not considered for a transplant.

Recommendations

We recommended that the board:

• apologise in writing for the failings identified in our investigation;
• ensure patients are provided with up to date information on their suitability for liver transplant referral;
• remind all nursing staff responsible for Mr C's care of the importance of communication with family members during end of life care;
• remind nursing staff in the ERU of the importance of ensuring records are accurate and contemporaneous;
• remind nursing staff in the ERU of the importance of the timely assessment and implementation of falls reviews;
• review their procedures for assessment and care planning for patients at risk of falls;
• review the handover process for ERU staff to ensure that it is being carried out appropriately;
• remind the medical staff responsible for Mr C's treatment that where a patient has been designated DNAR for medical reasons, the earliest opportunity should be sought to discuss this with the patient and their family; and
• remind the medical staff responsible for Mr C's treatment of the importance of discussing a patient's prognosis with them and their family at the earliest opportunity.