Health

Summary

Mr C complained about the care and treatment that district nurses provided to his late mother (Mrs A) before her death. He said that they had not taken reasonable steps to assess and monitor Mrs A's pain when changes were made to her medication. He also said that they unreasonably put Mrs A on the Liverpool Care Pathway (a framework used by healthcare professionals in the last hours or days of life when a death is expected).

We took independent advice on Mr C's complaints from a nursing adviser and a medical adviser. After doing so, we did not uphold the complaints. Our advisers said that the district nurses had assessed Mrs A's pain appropriately and in line with guidance. We found that Mrs A's level of pain had been assessed at every visit, the family had information on what to do if they had concerns about her, and that it had been reasonable that the nurses had not used a pain assessment tool. The decision to put Mrs A on the Liverpool Care Pathway was predominantly made by a GP and a palliative care nurse, although it did involve discussion with family members and the district nurses. We found that, on balance, the decision to start the Liverpool Care Pathway had been reasonable and we did not identify any failings by the district nurses in relation to this decision. We found that it had been completed and implemented appropriately and that communication with Mrs A's family had been reasonable.

Summary

Ms C complained about the care, treatment and diagnosis she received from the board. She raised concerns about the board's consultation with a family member, their refusal to provide her with a second opinion and a doctor at the board divulging information about her at multi-agency meetings without her consent.

During the early stages of our investigation of the complaint, Mrs C advised us that her GP had arranged for the board to provide her with a second opinion. As this was the outcome Mrs C had been seeking, we closed her complaint.

Summary

Ms C, who is an advice worker, complained on behalf of her client, Ms B. Ms B's late fiancé (Mr A) had died a few days after being admitted to Glasgow Royal Infirmary with severe jaundice. Ms B had told Ms C that the board provided inadequate nursing care, and that hospital staff failed to communicate adequately with Mr A's family, including about the severity of his condition, which she said caused Mr A and his family unnecessary distress and suffering. Ms C also complained about the board's complaints handling.

During our investigation, we reviewed Mr A's clinical records and took independent advice on his care from our nursing adviser. We found that at the heart of the complaint was Ms B's view that nursing staff acted insensitively towards Mr A. In cases where people are unhappy with the attitude of staff, it is often difficult to find evidence to support the complaint. This is not to say that we do not believe the accounts given; rather we find there are differing recollections, and often no independent evidence of behaviour or attitude. In Mr A's case, we could not reach a finding on whether nursing staff were insensitive.

Based on the evidence in the clinical records, we did not uphold the complaints about nursing care and communication. The records showed that Mr A was attended to regularly, and our adviser did not have any concerns about nursing care, noting that the board had since taken steps to support a person-centred care approach. The adviser also said the records showed that staff had tried to communicate the seriousness of Mr A's condition. The board had, however, acknowledged that some aspects of communication should have been better and had put improvement measures in place. In terms of how the complaints were handled, however, we upheld Ms C's complaint, as we found gaps in the records, and unreasonable delays in resolving the complaints.

Recommendations

We recommended that the board:

• reflect on staff's practice of introducing phone calls by saying 'do not worry', to determine whether they think it is appropriate as routine wording in all cases; and report back to the Ombudsman;
• ensure that, wherever possible, complaints (whether informal or not) are progressed in the absence of staff on sick leave;
• remind staff of the need to make records of informal complaints, in line with guidance; and
• ensure staff record when they tell complainants about the formal complaints process.

Summary

Mrs C complained on behalf of her family about the care and treatment given to her late aunt (Mrs A) by a medical practice. She told us that there was a delay in providing a diagnosis and appropriate treatment, which affected Mrs A's prognosis and led to her consequent suffering.

We took independent advice on this complaint from one of our medical advisers, and took all the relevant documentation, including all the complaints correspondence and Mrs A's medical notes, into account. Our investigation found that the care and treatment that the practice gave Mrs A was not reasonable. After the results of a magnetic resonance imaging scan (a scan used to diagnose health conditions that affect organs, tissue and bone) raised concerns, the practice had referred Mrs A to hospital for further investigation. However, they had marked this referral as 'routine'. Our adviser said that, in the circumstances, they should have marked it as 'urgent' and the referral letter should have contained more detail, particularly about the scan's abnormal results. We also found that Mrs A's clinical notes were insufficiently detailed and it was unclear whether GPs had physically examined her.

The practice had carried out a significant event analysis (SEA) into what had happened, but our adviser pointed out that it did not reflect on what had gone wrong. There was also no recognition on the part of the practice that the abnormal findings of the scan should have been considered.

Recommendations

We recommended that the practice:

• provide a formal apology for the shortcomings identified;
• complete a reflective SEA to address the inadequacy of the previous report;
• ensure that the GPs concerned undertake audits of the quality of information contained in referrals and advise the Ombudsman of the findings; and
• ensure that the GPs concerned audit the quality and completeness of their clinical notes and advise the Ombudsman of the findings.

Summary

Mrs A had a brain tumour. Two years after she was diagnosed with this, and after three epileptic seizures and a possible stroke, she was admitted to hospital. Mrs A's family were unhappy with her care and treatment while she was there and discharged her home early the next month. Mrs A died just under three weeks later. Mrs A's son (Mr C) complained about her care and treatment and the level of communication with her family while she was in hospital. He also complained about the way the board dealt with his subsequent complaint.

During our investigation, we gave careful consideration to all the relevant information, including all correspondence, meeting notes, Mrs A's clinical records and the board's complaints policy. We obtained independent advice from our nursing adviser and this too was taken into account.

Our investigation found that Mrs A's fluid and food intake was poor, but that the nursing notes showed that she was offered food and drinks. Our adviser said that while staff had clearly tried to improve her intake, it was often the case that very unwell patients were reluctant to eat or drink. Mrs A also had a thrush infection in her mouth, and this must have been difficult for her. We found that Mrs A's medication and pain relief were appropriate for her condition and she had been referred to the palliative care (care to prevent or relieve suffering) team. We also found that before Mrs A was discharged, a plan was put in place to support her at home. The records showed that staff had tried to keep the family regularly updated, but it was accepted that their efforts had not perhaps met the family's expectations and could be improved. Overall, we found that Mrs A's care and treatment was acceptable. However, we upheld Mr C's complaint about complaints handling, as after he complained there was clear evidence of delay.

Recommendations

We recommended that the board:

• offer a formal apology for the delay in dealing with the complaint.

Summary

Mr C complained that his wife (Mrs C) was not provided with reasonable care and treatment after an operation to remove her womb, ovaries and fallopian tubes at Glasgow Royal Infirmary. He said that Mrs C had received an incorrect amount of morphine (pain relief) after surgery and as a result she stopped breathing and nearly died. Mr C and his son witnessed this and it had caused them both considerable upset. Mr C also said that the board unreasonably handled his complaint about this.

We took independent advice on this complaint from one of our medical advisers, who is a consultant anaesthetist. Our investigation found that Mrs C did not receive excessive morphine. Our adviser said that Mrs C exhibited a recognised but rare complication of a standard analgesic (pain relief) technique, which resulted in her breathing being impaired. We found that hospital staff and clinicians provided the correct care and treatment to Mrs C throughout her stay in hospital and so we did not uphold this complaint. However, we found that staff communication at the time of the incident could have been better, and made a recommendation to improve this.

During our examination of the complaints handling we found a period where the board delayed in contacting Mr C, which they had acknowledged. For this reason we upheld that complaint and made a recommendation.

Recommendations

We recommended that the board:

• advise the Ombudsman on the steps taken to ensure that the communication failures (after the incident, and a misleading entry on the discharge letter) do not recur;
• issue Mr C with a full and sincere apology for the failings identified; and
• advise the Ombudsman of the steps they take to ensure that the complaints handling failures identified in this complaint do not recur.

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr A), who had a number of medical conditions. She said that when he was admitted to hospital, despite his complex medical history he was denied admission to intensive care. He was instead admitted to the acute medical unit, where he died some nine days later. Mrs C said that the care and treatment her brother received was less than he deserved and meant that he was denied the chance to live. She also complained that the board did not communicate well with the family, and that the family were unaware of Mr A's 'not for resuscitation' status (a decision taken that means a doctor is not required to resuscitate the patient if their heart stops).

In investigating the complaint we carefully considered all the relevant documentation, including Mr A's medical records and the complaints correspondence, and obtained independent medical advice from one of our advisers, a consultant in acute internal medicine.

Our investigation found that when Mr A was admitted to hospital, he was comatose (unconscious) and in a very serious condition. Because he had a complex and difficult medical history, he was reviewed and doctors decided that Mr A should not go to intensive care, but to the acute medical unit. Our adviser said that this decision was based on what was best for Mr A and was in accordance with the board's policy and national clinical guidance. The adviser recognised the gravity of the decision, but said that to do otherwise would have been futile and unethical, as more invasive treatment would have meant that Mr A's final days would have been needlessly uncomfortable and painful. While this was contrary to what the family wished, good practice was to put the interests of the patient first and to make Mr A as comfortable as possible. Mr A was extremely unwell, and in the circumstances we found all his care and treatment to have been reasonable.

We found that the decision not to treat Mr A should his heart or breathing stop was documented, and that Mrs C was told about it. Although Mrs C said that she was not told what was happening to Mr A or about the decision not to resuscitate him, the records detailed a number of conversations with her and other family members.

Summary

Mrs C complained that the care and treatment provided to her husband (Mr C) were inappropriate. She also complained that it was unreasonable for staff to communicate directly with her husband, who is profoundly deaf and cannot speak, when he had asked staff to communicate through Mrs C.

Mr C had heart problems for which he was taking warfarin (a blood-thinning medication). When he developed blood in his urine, he was initially treated as an out-patient but was then scheduled for surgery as an in-patient at Gartnavel Royal Hospital. Following surgery Mr C was catheterised (a tube was inserted into the bladder to drain urine). It took some time for the blood in Mr C's urine to resolve and he had to receive blood transfusions and antibiotics (drugs to fight bacterial infections) when he developed an infection. Mrs C complained that something must have gone wrong with the operation and said that she suspected that there had been a problem with the instruments used. She also complained that, unusually, Mr C suffered pain from the catheter used after his operation.

Our investigation, which included taking independent medical and nursing advice from two of our advisers, found no evidence that anything had gone wrong with either the instruments or the actual operation. Our medical adviser said that the records of the operation were very clear and documented a straightforward and uneventful procedure. There was no evidence of a problem with the instruments. The medical adviser said that when Mr C went into hospital his warfarin medication was changed to heparin (an anti-coagulant) which was reasonable. Patients taking long-term warfarin or heparin are prone to increased bleeding and that this was the reason for Mr C's extended blood-loss, which was treated appropriately. Both advisers were of the view that the type of catheter used, although larger than the type that Mr C was used to, was appropriate for his condition at the time. This was a 'three-way' catheter that allowed nursing staff to irrigate Mr C's bladder with sterile water which the advisers considered was appropriate.

On communication with Mr C, both advisers were of the view that it was reasonable for staff to use hand-written notes to communicate directly with him, and noted that he engaged in this without objection. Healthcare staff have to tread a fine line between respecting the wishes of the patient and their family and doing what is necessary to provide care safely and with the informed consent of the patient. Mrs C could not be with her husband at all times and it was important that staff were able to communicate with him to provide care. The nursing adviser also commented that, even when Mrs C was present, there would be times when staff would have to ensure they had Mr C's consent before providing care.

Summary

Mr C complained about the care and treatment that a medical practice provided to his late mother (Mrs A) before her death. He said that GPs had not taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. He also said that they had unreasonably put Mrs A on the Liverpool Care Pathway (a framework used by healthcare professionals in the last hours or days of life when a death is expected).

We obtained independent advice on this complaint from our GP adviser. We found that in general, the practice had taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. However, we upheld this complaint as they should have ensured that arrangements were in place to review Mrs A and that this was noted in the medical records, after her medication was increased on one occasion and it was identified that she had a chest infection. At the very least, they should have phoned to find out if the medication was effective or was causing problems. There was no evidence that they did so.

Our investigation also found that the practice had considered admitting Mrs A to hospital or to a hospice when her condition deteriorated. They discussed this with the family and with the nursing staff caring for Mrs A. They decided that she should not be admitted and that they would start the Liverpool Care Pathway. We did not uphold this complaint as, although we considered that the GP should have recorded more detail about the decision we found that, based on the information available at the time, the decisions not to admit Mrs A to hospital and to start the Liverpool Care Pathway were, on balance, reasonable. That said, we found that the practice's responses to Mr C about the matter had not been satisfactory and that they had failed to respond in detail and we made a recommendation to address this.

Recommendations

We recommended that the practice:

• make the staff involved in Mrs A's care and treatment aware of our findings;
• issue a written apology to Mr C for the failure to satisfactorily respond to his complaints;
• take steps to ensure that in the future complaints are investigated and responded to appropriately; and
• remind the GPs of the need to maintain clear and thorough medical notes.

Summary

Mrs C complained that nursing staff failed to provide support to her daughter (Ms A) after she was discharged from hospital. She said that they had failed to act appropriately in relation to two visits made to the local housing office to try to secure accommodation for Ms A. Mrs C also complained about the handling of her complaints.

To investigate the complaint, we took all relevant documentation into account, including Ms A's clinical notes and the complaints correspondence. We also obtained independent advice from two of our medical advisers.

The investigation showed that there were differing accounts of what happened after the first visit to the housing office, which we could not reconcile. Based on the available evidence and our advisers' comments, we found that Ms A's discharge was planned and that the support provided by the nursing staff was reasonable. We were, however, concerned about a lack of detail in the nursing notes, and made a recommendation about this. We also found that, while the board had provided a reasonable response to the issues Mrs C raised, they failed to respond within the timescale set out in the NHS complaints procedure.

Recommendations

We recommended that the board:

• ensure that, when nursing staff on the ward record clinical events, they do so in sufficient detail that it is clear to colleagues precisely what occurred, what risks there were (if any), and how matters were dealt with and by whom; and
• apologise to Mrs C for the delay in responding to her complaint.