Health

Summary

Mr C's son (Mr A) had been suffering from headaches and vomiting for several days. When Mr A's condition got worse, Mr C took him to the emergency department at Perth Royal Infirmary. They arrived at 01:17, and at 01:29, a triage nurse assessed Mr A and gave him paracetamol (triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are). She arranged for Mr A to see an out-of-hours GP in the department at 03:15, and, without having taken any observations (temperature, blood pressure, pulse and oxygen levels) sent him home to wait for that appointment. After arriving home, Mr A's condition deteriorated further, and he could not move his neck or lift his knees. Mr C returned with him to the hospital at around 03:00, where Mr A saw a GP and was admitted to a medical ward at 03:36 with suspected meningitis, which was confirmed by tests. He was treated with antibiotics and discharged a week later.

Mr C complained that the board failed to provide Mr A with a reasonable standard of care and treatment, in that the triage nurse failed to take any observations and recognise the seriousness of Mr A's condition. He also said that the delay of two hours between Mr A being seen by the nurse and by the GP was not reasonable in light of the serious and potentially life-threatening disease Mr A was suffering from. He complained that the board failed to respond appropriately to the complaint, including that they failed to adequately explain why the nurse did not undertake observations when she examined Mr A.

We took independent advice on this case from our nursing adviser, who said that the care and treatment Mr A received from the triage nurse fell below a reasonable standard. She did not carry out a set of observations, which meant that her decision to refer Mr A to the out-of-hours service was based on minimal information that might have resulted in his further deterioration. The adviser was also critical that Mr A was not allowed to remain in the emergency department and instead was sent home. These failings made a stressful situation more difficult for the family, given Mr A's serious condition. In relation to complaints handling, we were satisfied that the board provided as full an explanation as they could in the circumstances, but in light of the delays, inaccuracies and use of technical terms in the complaint response, we upheld the complaint.

Recommendations

We recommended that the board:

• review the triage process and provide evidence that appropriate protocols and/or guidance are in place;
• take steps to ensure nursing staff in the emergency department at the hospital carry out observations and document patients' vital signs during triage, and report back to the Ombudsman the actions taken;
• provide evidence that their processes ensure staff involved in triage have the appropriate education, training, skills, competencies and adequate supervision in place to provide a reasonable standard of care;
• consider the failings identified to ensure that future responses are appropriate; and
• apologise to Mr C for the failures identified.

Summary

Mr C, who is a prisoner, complained that the prison health centre stopped his prescribed medication without any warning or gradual reduction. Mr C had been prescribed zopiclone (a drug used to treat sleeping problems) and gabapentin (a drug for pain relief). The board told Mr C that his medication was stopped as he had failed to take it in the manner in which it had been prescribed. In addition, they said that Mr C would have been aware of the consequences of his medication being stopped if any discrepancies were found.

We found that the records showed that Mr C had tried to conceal the zopiclone rather than swallow it in front of staff. This led to him being reviewed by the mental health team, and the zopiclone prescription being discontinued. In addition, health centre staff carried out a spot check of his medication around a month later and he was found to have more gabapentin tablets than he should have had. The staff did not know, therefore, how much of the prescribed medication Mr C had been taking and he had admitted to buying non-prescribed drugs in prison.

We took independent advice on this from one of our medical advisers. The adviser said that although some patients can be affected if gabapentin is stopped abruptly, the health centre did not act unreasonably in discontinuing Mr C's medication immediately, given the difficulties in planning a gradual reduction.

Summary

Ms C had welfare power of attorney (a legal document appointing someone to act or make decisions for another person) for her late brother (Mr A) who had profound learning difficulties and significant communication difficulties. Mr A was admitted to Hairmyres Hospital but died three days later from sepsis (blood infection). Ms C had concerns about some of the clinical decisions that were made and said that staff failed to communicate with her as welfare power of attorney. If they had, Ms C said she could have provided additional and important information about her brother's normal condition and that she could have contributed to the treatment plans that were set up. The board apologised to Ms C that staff failed to act on changes in her brother's medical condition but maintained this was not due to his learning disabilities.

Our investigation found that the board have an 'Adults with Incapacity: Best Practice Guide', in line with the principles of the Adults with Incapacity Act (Scotland) Act 2000. The guide says that, along with the patient's wishes, staff should take account of the views of relevant others as far as it is reasonable and practicable to do so. We took independent advice on the board's actions from our nursing adviser. She said that the best practice guide was very good, but that staff failed to implement it in relation to Mr A's care, and the level of communication fell below the level she would have expected. Ms C was not consulted or involved in the decision-making process and, more importantly, her information about her brother's deterioration was not taken seriously. We upheld Ms C's complaint, as we found staff did not communicate adequately with her, when she was best placed to advise on her brother's medical history and usual state of health, and so failed to act in accordance with the principles of the Adults With Incapacity (Scotland) Act 2000.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings in communication; and
• remind staff of the best practice guidance and ensure it is implemented in appropriate circumstances.

Summary

Ms C, who is a solicitor, complained on behalf of her client (Mr A), who is a prisoner, that the board had refused to prescribe him suboxone (a prescription medication used to treat opiate addiction). Mr A had been prescribed methadone, but said that it was causing him constipation and sickness. He had told the board that he wanted to switch to suboxone instead. However, he was told that suboxone was not available for maintenance treatment (the prescribing of a substitute drug to prevent the use of illicit substances) at that time.

In their response to our enquiries, the board said that all patients within the addictions service are regularly assessed using both national and local guidance. They said that some patients may not be offered the drug of their choice and that Mr A was receiving the most appropriate treatment for his clinical needs.

Mr A required maintenance treatment for his opiate addiction and the board's view was that suboxone was not to be used for this. After taking independent advice from one of our medical advisers, we found that the board's decision had been reasonable and we did not uphold the complaint. The board had produced new guidance for prescribing suboxone in the prison after Ms C complained, and we found that the decision was also in line with this.

Summary

Mrs C complained about the nursing care that her late daughter (Ms A) received while in Monklands Hospital, where she had been admitted with severe stomach problems. While in hospital Ms A was transferred to a second ward, and Mrs C's complaint was about the nursing care her daughter received in that ward. Ms A suffered two falls there and Mrs C complained that nurses had referred to her daughter as a 'boarder' and that she had not been treated with dignity or respect. After the second fall, and some two and a half weeks after being admitted, Ms A was transferred to intensive care after she had a seizure. Her condition deteriorated further and she died the next day.

We took independent advice on this complaint from our nursing adviser, who considered Ms A's relevant clinical records and the complaints correspondence.

Our investigation found that, while the key areas of nursing care were reasonable, a falls assessment and care plan was not implemented after Ms A's first fall, although our adviser said that this might not have prevented the second fall. We also found that the level of communication with Mrs C and her family in the ward before Ms A was transferred to intensive care was not of an acceptable standard. We upheld the complaint, and noted the action already taken by the board in response to it. This included explaining the learning that had come from the complaint, and apologising that an SBAR report (a situation-background-assessment-recommendation report, used as a communication tool) was not completed on transfer between wards; that Mrs C had felt that the nursing staff had not provided the standard of care or communication expected; and that there had been a lack of communication.

Recommendations

We recommended that the board:

• remind nursing staff on the ward of the need to complete appropriate falls assessment and care planning in line with their falls assessment procedure; and
• ensure that staff on the ward are reminded about the importance of communication with relatives and carers.

Summary

Mr C complained on behalf of a relative (Ms B) about the care and treatment provided to her partner (Mr A) during two admissions to Wishaw General Hospital before his death. Mr A was first admitted after being taken there by ambulance late at night. He had a history of cirrhosis (long term liver damage) and gastric varices (dilated veins in the stomach), chronic obstructive pulmonary disease (a lung disease related to narrowed airways), type 2 diabetes and gout. It was identified that he had low blood pressure, dehydration and kidney impairment. He was treated with fluids, his medications were reviewed to try to improve his condition and tests were carried out on a potential abnormality in his bowel. Mr A was discharged from hospital after a week, as his blood tests had returned to normal, but was readmitted three days later, as he was short of breath. The admitting junior doctor noted that Mr A had increasing breathlessness and swelling of his hands and legs. Mr A initially started to improve, but five days after admission his condition deteriorated rapidly and he died three days later.

We took independent advice on Mr C's complaint from two of our advisers, a nurse and a medical adviser. We found that the care and treatment provided to Mr A during his first admission was reasonable and appropriate. He was also adequately assessed by a physiotherapist before he was discharged. Although staff did forget to remove heart monitor cables from his skin before he was discharged, the advice we received was that these were unlikely to have caused Mr A any harm.

We found that in general, the medical and nursing care and treatment provided to Mr A during his second admission was also reasonable. However, staff had noted that blood tests should be repeated the day after Mr A was admitted. There was no evidence that this was done over the next four days, although a later note in the records said that staff were unable to carry out a blood test because of difficulty in finding veins under Mr A's skin to withdraw blood. If this was the reason why blood tests were not carried out over the four days, this should have been documented at the time. We noted that, after examining Mr A's clinical records, our medical adviser explained that it was likely that Mr A's condition would have deteriorated and that he would have died even if the blood tests had been performed as planned. We did, however, uphold this aspect of Mr C's complaint in view of the failure to complete the planned blood tests or to document why these were not carried out.

Recommendations

We recommended that the board:

• issue a written apology to Ms B for the failure to carry out blood tests as planned or to document why this was not done; and
• ensure that the staff involved in Mr A's care and treatment are made aware of our findings on this matter.

Summary

Mr C, who is a prisoner, complained that the board refused to prescribe him suboxone (a prescription medication used to treat opiate addiction). Mr C had been prescribed methadone, but he felt that suboxone would assist in his final recovery from drug addiction and told the board that he wanted to switch to this. However, the board told him that there was no absolute right for any patient to receive a specific form of treatment simply because they requested it. They said that what was important was the prescriber's clinical judgement that a treatment choice was appropriate for the individual, and whether they were at the correct stage of their recovery to support a change of treatment.

In their response to our enquiries, the board said that all patients within the addictions service are regularly assessed using both national and local guidance. They said that some patients may not be offered the drug of their choice, and that Mr C was receiving the most appropriate treatment for his clinical condition. They also explained that they had produced new guidance for prescribing suboxone in the prison after Mr C complained.

We did not uphold the complaint, as we found that the board had acted reasonably in deciding to maintain Mr C on methadone and that this decision had been based on a clinical assessment.

Mr C also complained that the board had not provided a written response to his 'feedback, comments or concerns' form. During our investigation the board accepted that there were failures in their communication with Mr C, and apologised for this.

Recommendations

We recommended that the board:

• formally apologise to Mr C for the handling of his complaint.

Summary

Mr C complained about an operation at Monklands Hospital, and about the medical and nursing care provided there. He believed an experimental procedure had been performed on his nose, and said that he was now embarassed by its appearance. Mr C also complained that he was not given enough information to give informed consent to the operation, and that photographs were taken without his consent. He also complained that there was a poor standard of cleanliness at the hospital.

We took advice from our medical adviser, a specialist in cosmetic and reconstructive facial surgery. He said there had been three previous operations on Mr C's nose, and that each made the next procedure more difficult, due to the scarring caused. The adviser said that the operation was a complex but standard procedure and had been carried out successfully. He noted that Mr C had been provided with the mobile phone number of the consultant surgeon who carried out his operation, which was unusual and in his view, showed a high standard of personal care and attention to Mr C.

Our investigation found there was no evidence Mr C had objected at the time to the amount of information he was given before giving his consent to the operation. We also found no evidence that the hospital had failed to meet an acceptable standard of cleanliness, or that Mr C had not been provided with an appropriate level of care and treatment. There was no evidence that photographs were taken during the operation and retained by the board.

Summary

Mrs C complained that, after her husband (Mr C) died in Raigmore Hospital, the board lost his property. Mr C was very ill and was on a high-dependency ward before he died. The board had said that although they understood this had been very distressing for Mrs C, they would not offer compensation for the loss of Mr C's watch and hearing aid.

During our investigation we looked at correspondence provided by Mrs C and the board. We also looked at the board's personal property disclaimers, and we took advice from a nursing adviser with practical experience of dealing with cases like this on hospital wards.

We found that, while the board's disclaimers clearly say that patients remain responsible for their personal property when in hospital, there are circumstances when the situation is less clear. In Mr C's case, there was uncertainty over whether some or all of his property had been lost, and the board could not provide an adequate explanation of why an inventory of his property was not taken when he died. We also found statements in the board's responses about this to be contradictory. We took the view that any items of property belonging to a deceased person, no matter the amount or nature, are their personal belongings, and should be catalogued and held until they can be passed safely to the person's next of kin. To do otherwise in such circumstances is disrespectful and, therefore, unreasonable. We upheld Mrs C's complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for unreasonably losing Mr C's property at the hospital;
• make a payment to Mrs C to cover the cost of the lost watch and hearing aid;
• clarify their procedures on dealing with patients' personal property, taking account of the issues raised in this case and their own audits of lost property; and
• use the learning from this complaint to improve communication with complainants on sensitive matters.

Summary

Mr C said that, as a result of having been left too long on a hospital trolley in an x-ray department, he developed a pressure sore which was still causing him considerable problems. He explained that he is tetraplegic (paralysis or restricted movement in all four limbs as a result of spinal damage) and that as a result, extra care should have been taken to ensure that he was not lying in the same position for a long time.

In response to his complaint the board had immediately acknowledged that the delay in returning Mr C to the ward was unacceptable and apologised for the distress and inconvenience the incident had evidently caused him. They noted that there was no information from the ward highlighting that he was tetraplegic and that the ward escort had not made staff in the department aware of Mr C's situation. The board said they were taking forward an awareness programme for all clinical staff in the imaging department to identify patients at risk of developing a pressure ulcer, but that this required the patient's pressure ulcer status to be provided by the ward.

We decided that further investigation was not required and upheld Mr C's complaint without asking the board for further information. We made recommendations to the board reflecting not only Mr C's complaint about his care, but also seeking to remedy the injustice we consider resulted from the board's failure to take steps to prevent him developing the pressure sore.

Recommendations

We recommended that the board:

• review, and revise if necessary, the process within wards for giving instruction for the extra care of patients assessed as being at risk of developing pressure sores who are being moved by trolley to other departments;
• consider whether it would be appropriate for the board to assist with the cost of home care in view of the failings identified;
• advise the Ombudsman of the outcome of their considerations on assisting with the cost of home care; and
• apologise to Mr C for the poor communication between the ward and the imaging department that led ultimately to him developing a pressure sore.