Health

Summary

Mrs C complained to us about the care and treatment of her late mother (Mrs A) while she was in the care of St Michael's Hospital. She raised concerns about her mother's oral health care, and her enteral tube feeding (she was fed by a percutaneous endoscopic gastrostomy (PEG) tube into her stomach, also known as 'enteral tube feeding').

We took independent advice from one of our advisers, who is an experienced nurse. We found that Mrs A was an in-patient for 13 months. A care plan was put in place when she was admitted, which identified her oral health care needs, and we found that this was followed. However, it was not reviewed and updated on a monthly basis, and did not take into account Mrs A's increased risk of mouth problems due to the enteral tube feeding. Mrs A was also given a mouth wash on an ongoing basis, as she had a painful mouth due to gum disease. Our adviser pointed out that the guidelines for the use of the mouthwash indicate that it should only be used for seven days, after which its use should be reviewed. This did not happen.

In relation to Mrs A's enteral tube feeding, Mrs C raised concerns that the care and management of her mother's tube was insufficient, and that on occasion she was fed while lying flat. This then led to her aspirating (breathing in foreign material) her food, and contracting aspirational pneumonia (inflammation of the lungs and airways from breathing in foreign material). Mrs A died of aspirational pneumonia. Our investigation found that Mrs A's enteral tube feeding was in line with her care plan. However, the documentation of this care was on an 'exceptional' basis, in that staff only recorded events that were outside the normal care provision. The evidence indicated that Mrs A had not been laid flat to feed, and that when she was found flat, appropriate action was taken to remedy the situation. We found that the board's actions in relation to Mrs A's tube feeding were reasonable, but that their care in relation to her oral health was inappropriate.

Recommendations

We recommended that the board:

• ensure that staff are aware of the need for monthly reviews of oral care plans and the level of detail that should be recorded; and
• provide a written apology for the failure to provide appropriate oral health care for Mrs A.

Summary

Mrs C complained about the care and treatment that the Royal Infirmary of Edinburgh provided to her late mother (Mrs A) who passed away 12 days after being admitted there after having had a stroke. Mrs C was also concerned about poor staff communication about Mrs A's deteriorating condition, and the way in which the board dealt with her complaint.

After taking independent advice on Mrs C's complaints from one of our medical advisers, we did not uphold her complaint about her mother's care and treatment. The adviser said that although Mrs A’s condition was complex, the care and treatment she received was in line with national guidance recommended by the Scottish Intercollegiate Guidelines Network on the management of stroke patients. We found evidence that accident and emergency (A&E) staff assessed Mrs A and arranged a brain scan in a timely manner. Furthermore, A&E staff sought prompt advice from specialist staff. Although aspirin could have been given to Mrs A sooner, it was administered within the 48 hour guideline recommended by NHS Quality Improvement Scotland, and the adviser thought it unlikely that Mrs A's outcome would have been any different even had it been given sooner. We also concluded that Mrs A was promptly assessed by both physiotherapy staff and speech and language therapy staff after she was transferred to the stroke ward. In addition, frequent medical reviews were carried out and appropriate monitoring and treatment of her heart rate to help keep it under control.

We did, however, uphold Mrs C's other complaints about communication and complaints handling. When the board met with Mrs C to discuss her complaint, they apologised for the lack of information about Mrs A's deteriorating condition on the day of her admission to A&E and accepted that there were significant communication problems when Mrs A was transferred to the combined assessment unit and then to the stroke ward. They said that they were taking steps to address this.

The board accepted that there were mistakes in their written response to Mrs C's complaint. They apologised for these, issued an amended version of the correspondence, and reimbursed Mrs C for the money she had to pay to receive their letter, which had insufficient postage on it. We also found that, although Mrs C told the board that they had written to her at the wrong address, there was a delay of three months before she received a further letter from them responding to her complaint as they had used the incorrect address again. We also established that: they had not responded within the 20 working day target set out in the Scottish Government's complaints procedure guidance; contrary to that guidance, the board's internal complaints policy permitted them to suspend the 20 working day response target when the person complaining accepted the offer of a meeting, and they had not kept Mrs C updated about when their response would be issued.

Recommendations

We recommended that the board:

• provide evidence to support the action they have taken to improve communication between staff and relatives regarding patients who have suffered a stroke;
• feed back to relevant staff the importance of ensuring timely and accurate responses to complaints, and of providing updates when the 20 working day timescale cannot be met, in accordance with the Scottish Government's complaints guidance; and
• review their internal complaints policy to ensure that it is in line with the Scottish Government's complaints guidance.

Summary

Mr C, who is a prisoner, complained that the board failed to arrange for him to see the prison psychiatrist following a suicide attempt. Mr C had been treated in hospital and said that the psychiatrist there told him that he would be seen by the prison psychiatrist when he returned to prison. After taking independent advice from one of our medical advisers, our investigation found that there was no evidence that Mr C was told this, and that the hospital discharge summary said no psychiatric action was required at that time. In addition, Mr C was reviewed by the clinical manager in mental health when he returned to the prison, and this review was then discussed with the prison psychiatrist. In view of this, we found that that it was reasonable that Mr C was not seen by a psychiatrist on his return to prison.

Mr C also complained that the board failed to provide him with appropriate treatment for blood loss after he self-harmed when he returned to prison. We found that the immediate follow-up care provided to him was reasonable in many aspects. The records also showed that Mr C had refused medical treatment on at least one occasion. However, he had lost a significant amount of blood. We found that the failure to clearly state that his haemoglobin (a protein found in the red blood cells that is responsible for carrying oxygen around the body) should be monitored and to specify the timing or frequency of the monitoring in his care plan was unreasonable. Mr C's haemoglobin was not checked until two weeks later, at which time he was immediately transferred to hospital for treatment. Staff also failed to record his vital signs (signs of life including the heartbeat, breathing rate, temperature, and blood pressure) and his nutrition and fluid intake. We upheld this aspect of Mr C's complaint.

Finally, Mr C complained about the board's handling of his complaint. We upheld this complaint too, as the board had failed to respond to all the points Mr C had raised. We also found it inappropriate that in their response to his complaint the board criticised Mr C's behaviours, while noting that these were discussions that clinicians and others would clearly be entitled to have with him in another context.

Recommendations

We recommended that the board:

• issue a reminder to the staff involved in Mr C's care that care plans should clearly document the interventions planned and when/how frequently they are to be implemented;
• issue a reminder to the staff involved in Mr C's care that they should chart a patient's vital signs and nutrition/fluid when this is indicated; and
• make the staff involved in the handling of Mr C's complaint aware of our findings.

Summary

Mr C, who is a prisoner, had a stomach ulcer for which he had emergency hospital treatment in January 2012. Helicobacter pylori (a stomach infection) is the most common cause of ulcers and the hospital arranged for him to be tested for infection in March 2012. The results were negative, but Mr C was not made aware of this. He complained that the prison health centre team had not done anything about his ongoing stomach pain and that he had not received his test results or a hospital appointment despite having being referred there in June and October 2012.

We took independent advice on this complaint from one of our medical advisers. We upheld Mr C's complaint, as although we found that the health centre team had prescribed appropriate medication for his symptoms in line with national guidance, we concluded that they had unreasonably delayed in following up his test results with the hospital. We also found that there was a failure in sending a further referral to the hospital requesting that Mr C be re-tested when the hospital apparently told staff that they had no record of a test being done in March 2012. We were unable to clearly establish why Mr C was not told the results of the test carried out in March 2012, nor why it took so long for him to be re-tested.

Recommendations

We recommended that the board:

• ensure the prison has procedures in place to follow-up test results in a timely manner and, where appropriate, arrange prompt re-testing if necessary; and
• apologise to Mr C for failing to follow-up his March test results in a timely manner along with prompt re-testing.

Summary

Mrs C complained that when she was admitted to the Western General Hospital she was mistaken for another patient. She had obtained a copy of her medical records and told us that they contained references to procedures and conditions that could not have applied to her. Although the board met with her on several occasions and apologised for failings in her care, as well as providing her with an action plan of the steps taken to improve their performance, Mrs C did not believe that they had accepted or investigated her concerns that she was mistaken for another patient and about inaccuracies in her medical records.

We took independent advice on this complaint from our nursing adviser. She said that although there were clearly failings in Mrs C's care, she did not consider that the board could carry out any more meaningful actions in respect of Mrs C's complaint. The failings identified had arisen due to errors by individual members of staff, rather than through a systemic failure. The board had apologised, and taken the appropriate action to address these failings by providing training for staff members. Mrs C had met with senior board staff and her concerns had been listened to and responded to. Although we upheld Mrs C's complaint, as our investigation found that she was not provided with a reasonable level of care during her treatment, we made no recommendations as we found that the board then acted appropriately in response to her complaint.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Ms A) about the care and treatment she received at two hospitals, the Royal Infirmary of Edinburgh (RIE) and Roodlands Hospital. Ms A had had keyhole surgery (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin), but felt that because of her ethnicity and the fact that she had existing scar tissue from a previous operation, she should instead have had open surgery. She was also unhappy about the level of post-operative aftercare she received and said that she was discharged inappropriately from the RIE hospital when she was suffering from low blood pressure. She complained about the level of care she received when she attended Roodlands Hospital's unscheduled care service complaining of pain and discharge from her wound.

To investigate the complaint, we considered all the relevant documentation, including the complaints correspondence and Ms A's medical records. We also obtained independent advice from three of our advisers (two doctors and a nursing adviser). Our investigation found that the decision to perform keyhole rather than open surgery was reasonable and we did not uphold that complaint. We found, however, that the board failed to provide a reasonable level of post-operative aftercare and that the nursing decision to discharge Ms A had been unreasonable. Our advisers said that Ms A's vital signs should have been recorded more frequently and acted upon, her high pain score should have been acted on and that a surgical review should have been requested before deciding to discharge Ms A. They said that actions indicated by the Scottish Early Warning System score (SEWS - a scoring system used as an early warning of deterioration) did not appear to have taken place.

We also found the board failed to provide a reasonable level of care when Ms A attended the unscheduled care service. The advice we received was that there was no evidence that the member of staff who saw her there had taken a separate history of what had happened, or that the examination carried out was of a reasonable standard in terms of assessing post-operative complications.

Recommendations

We recommended that the board:

• apologise to Ms A for the failings identified in these complaints;
• investigate the post-operative care given to Ms A and report back to the Ombudsman with the results of this review;
• provide the Ombudsman with evidence about the education and training currently in place for nursing staff to ensure they are aware of and are following SEWS protocols; and
• ensure that as a learning requirement the nurse involved undertakes a clinical update in the history and examination of a post-operative patient and in particular abdominal examination. This should be discussed with the nurse's line management to confirm these competencies.

Summary

Mrs C complained on behalf of her son that the board had decided to discontinue their consideration of the complaints she had submitted.

During our investigation, we obtained information from the board and, based upon this, we decided it was not appropriate for us to consider the matter further.

Summary

Ms C, who is an advocacy worker, complained to us on behalf of her client (Mrs A) who was concerned about the care and treatment of her late husband (Mr A). After Mr A fell and broke his hip, he had an operation in Monklands Hospital to repair it. That night he climbed out of bed and fell to the floor. He did not complain of any pain at the time, but when he woke in the early morning he complained of pain in his other hip. He was reviewed by a doctor, and an x-ray revealed that he had broken his other hip. Mrs A was told about this at 07:30 that morning. Mr A had another operation that day to repair his second broken hip, and was monitored closely for the rest of the day. The following day, he was found to be confused and was reviewed by a junior doctor. Mrs A was concerned that her husband should have been more closely monitored, that a doctor was not called soon enough, and that she was not informed of his fall until the following morning. She was also unhappy with the level of attention given to her husband's confusion following the second operation. She has said that this was only noted and acted upon after she raised persistent concerns with staff.

We took independent advice on this complaint from one of our advisers, who is an experienced nurse. She said that an appropriate care plan was in place for Mr A, which included the appropriate use of bed rails and that he had been appropriately monitored after both operations. She also considered that after Mr A fell, it was appropriate for staff to delay phoning Mrs A until the morning, as there was no immediate indication that he had been injured in the fall. She also reviewed the evidence in relation to Mr A's confusion after his second operation, and found that the records indicated that nursing staff took appropriate action by alerting doctors to Mr A's confusion. On the basis of this advice, we did not uphold the complaint as we found no evidence of failings in the care and treatment of Mr A.

Summary

Ms C, who is an advocacy worker representing her client (Miss A), complained that the board unreasonably told Miss A in writing about a decision to refer her to cancer services rather than in a face-to-face meeting, and unreasonably failed to discuss the diagnosis and treatment options with Miss A before making this referral.

Miss A had suffered for a number of years with a condition that caused pain and discomfort in her joints. In 2011, she also reported a swelling in her groin, which she felt was increasing in size. Her doctor referred her for physiotherapy and then to orthopaedic (involving the musculoskeletal system) services, and she was seen by a consultant orthopaedic surgeon for the first time in April 2012. After several investigations, including x-rays and a scan, the diagnosis remained inconclusive. The surgeon consulted with a colleague in a specialist cancer team by phone, and followed this up with a formal written referral. The specialist team took over Miss A's management, and diagnosed a non-cancerous lump, which was treated.

During our investigation we took independent advice from a physiotherapist and an orthopaedic surgeon. We found that the investigations and referral to the specialist team were reasonable, appropriate and timely. We found that it was reasonable that the surgeon did not tell Miss A in person that he was referring her there, as to have arranged an appointment for this purpose would have delayed the final diagnosis and treatment. Similarly, we considered it reasonable that the surgeon did not give a firm diagnosis or discuss treatment options with Miss A, because at the time of the referral and before the team took over her treatment, no such diagnosis had been made.

Summary

Mr C complained about the care and treatment provided to his mother (Mrs A) when she was admitted to Cowal Community Hospital on two occasions. Mrs A had a history of persistent and worsening diarrhoea and was diagnosed with clostridium difficile (a type of bacterial infection that can affect the digestive system). She was discharged two weeks later and returned home. However, she was readmitted to the hospital after testing positive for clostridium difficile again.

Mr C complained about a number of aspects of Mrs A's care. We found that much of the treatment provided to Mrs A had been of a reasonable standard. She was able to make her own decisions and was entitled to ask to go home in her nightclothes when she was discharged and to ask staff to wait for her own clean clothes before changing her. We also found that the board's communication with Mrs A and her family had been reasonable and that the correspondence issued to her GP was in line with the required standard. Mrs A's nutritional care was also reasonable and the board had taken action in response to concerns Mr C had raised about her dietary needs and about clostridium difficile.

That said, we did identify some failings in relation to the care and treatment provided to Mrs A. We considered that the hospital should have carried out an assessment to ensure that she could get into her house safely when she was discharged. However, we noted that the board had apologised for this and had taken reasonable steps to try to prevent similar problems recurring. They had also been unable to provide evidence that transfer documentation was sent to another hospital when Mrs A was transferred there. In view of these specific failings, on balance, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• issue a reminder to the staff involved in Mrs A's care that discharge documentation should be completed, filed and stored.