Health

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.

Summary

Ms C's late sister was extremely ill and was admitted to hospital. Ms C, who had travelled from abroad to be with her, wanted to stay with her sister on the receiving ward but was asked to leave as it was outwith ward visiting times. Ms C complained that the nurse who had asked her to leave failed to treat her with appropriate compassion. Ms C's sister died three days after being admitted.

After taking independent advice from our nursing adviser, we upheld the complaint. Our adviser said that the notes showed that Ms C's sister's condition was deteriorating and indicated that she was nearing the end of her life. She said that it did not appear that this was taken into account, and pointed out that staff should be able to assess when it is appropriate to be flexible with policies such as visiting. Our adviser also criticised the language in the medical notes for being rigid, not compassionate and not in keeping with the Nursing and Midwifery Council Code and Patient Rights Act.

Recommendations

We recommended that the board:

• discuss this incident with the relevant staff members and senior managers involved as a learning exercise;
• review their policy in light of this complaint and examine the ethos of relative/patient involvement in the admissions unit; and
• apologise to Ms C and her late sister's family for the distress caused.

Summary

Mr C complained that there was an unreasonable delay in the board providing care and treatment for his back pain. He told us that the board had lost a referral from his GP for orthopaedic (conditions involving the musculoskeletal system) assessment. We found that the board, in responding to Mr C's complaint, explained what went wrong, apologised for what happened, and explained that they had fixed the problem with the referral system. Given the loss of Mr C's referral and the consequent delay, however, we upheld the complaint although we did not need to make any recommendations in view of the action the board had already taken.

Mr C said that, because of the delay and his personal circumstances, he had been left with no choice but to seek private treatment, and he wanted the board to pay for this. From Mr C's description, we did not doubt that he and his family had found the situation difficult and distressing. However, because Mr C sought private treatment rather than pursuing treatment with the board, we did not know if there would have been any further significant delay in the board providing the treatment. We could not, therefore, say whether Mr C had no option but to obtain private treatment when he did. In such circumstances, we could not recommend that the board consider reimbursing Mr C for this.

Summary

Mr C complained about the board's treatment of his daughter (Miss A). When Miss A was two, she drank some of the contents of a bottle of Calpol (paracetamol-based medicine) and was taken to the emergency department at the Victoria Infirmary. National guidance for paracetamol poisoning requires staff to calculate the amount of paracetamol ingested (taken) per kilogram of the person's body weight (calculated as mg/kg). If the patient is thought to have taken more than 75mg/kg of paracetamol, blood tests should be taken four hours after ingestion to check for paracetamol levels. If more than 150mg/kg has been taken, the patient should be treated immediately with n-acetylcysteine (a drug used to treat paracetamol poisoning) without waiting for blood test results. Based on the available evidence, staff estimated that Miss A had likely taken less than 75mg/kg of paracetamol, and she was discharged home with advice to return if she started to vomit. Later that evening, Miss A vomited and was taken back to the hospital. Staff re-estimated how much paracetamol she might have ingested. Believing she might have had more than 100mg/kg, they arranged for her to be transferred to the Royal Hospital for Sick Children. There, staff assumed the worst case scenario and immediately started treatment with n-acetylcysteine. Blood tests taken later showed that she had ingested a non-toxic amount of paracetamol.

Miss A had a severe anaphylactic (allergic) reaction to the n-acetylcysteine. This was treated successfully, but she was kept in hospital, and later had a seizure. This affected her eyesight. Miss A was diagnosed with cortical blindness (blindness caused by damage to the brain). Mr C complained that the board's staff did not do enough to establish the extent of his daughter's paracetamol poisoning when she first went to the Victoria Infirmary. He felt that, had a blood test been carried out then, his daughter would not have required treatment with n-acetylcysteine, would not have had an allergic reaction and would not have developed cortical blindness.

We found that the national guidance recommended that patients should only be discharged when there is absolute certainty that they have not ingested more than 75mg/kg of paracetamol. After taking independent medical advice on Miss A's case, we did not consider that it was possible for staff to be absolutely certain and as such, blood tests should have been carried out to confirm how much paracetamol she had ingested. This would have shown that she had ingested a non-toxic amount; n-acetylcysteine treatment would not have been required and her anaphylactic reaction would have been avoided. We also found that the n-acetylcysteine had been administered incorrectly, with the first dose being administered over a period of 15 minutes. The national guidance had changed some months earlier and it should have been administered over one hour, specifically to reduce the likelihood of allergic reaction. We were critical of the board's processes for sharing medication guidance updates with clinical staff.

We accepted advice, however, that Miss A's anaphylactic reaction was not the most likely cause of her subsequent seizure and cortical blindness. Whilst this could not be ruled out entirely, we accepted that a virus that Miss A had been suffering from was the more likely cause.

We also investigated a further complaint from Mr C about delays to the board's handling of his formal complaint, and were satisfied that they handled it in line with their complaints procedure.

Recommendations

We recommended that the board:

• apologise to Miss A and her family for their poor treatment of her suspected paracetamol poisoning; and
• review their mechanisms for communicating updated guidance to ensure that staff in all departments are aware of, and working to, the most up-to-date guidance at all times.

Summary

Ms C complained about the post-operative medical care she received after Tension Free Vaginal Tape Obturator (TVTO) surgery for urinary incontinence at the New Victoria Infirmary in May 2011. After the operation, Ms C suffered constant pain until further tests revealed a year and a half later that she had suffered bladder erosion (where the tape has eroded into the bladder). Ms C was concerned that a cystoscopy (where a camera is used to check for abnormalities) was not used when the tape was implanted, and was unhappy about the time taken to identify this injury. Ms C had a further operation at the Southern General Hospital in November 2012 to have the tape removed. She complained about the nursing treatment for her wound, which became infected a week later, and that the board's response to her complaint did not address her concerns that her wound was not checked during the first week after surgery.

There are no national guidelines recommending that a cystoscopy be performed on all patients undergoing TVTO surgery, and the manufacturer's product information says that it is at the discretion of the surgeon whether to perform a cystoscopy. After taking independent advice from one of our medical advisers, we did not consider it unreasonable that a cystoscopy was not performed. TVTO had been introduced to reduce the likelihood of bladder injury, and it was not the board's policy in 2011 to perform a cystoscopy on all patients undergoing TVTO. After numerous cases of injury with the TVTO procedure were reported over the years, however, this eventually led to the board's change of policy in 2012. Nevertheless, we were critical that when Ms C complained five months later of pain and recurrent bladder infections, a cystoscopy was not arranged as supported by guidance issued by the National Institute of Clinical Excellence.

Although we found that Ms C's wound was checked and redressed twice in the week after her surgery at the Southern General Hospital, there was evidence to suggest that there were three consecutive days when it was not checked, before she told nursing staff that it was painful and leaking. Healthcare Improvement Scotland makes clear that wound charts should be started for all patients with a wound, and we noted that in Ms C's case this chart was not started until after her wound became infected. We concluded that the nursing care fell below the reasonable standard that would be expected in this surgical ward. In addition, the board did not respond to Ms C's complaint about her wound not being checked during the week after surgery and instead concentrated on the redressing that took place after the infection was identified. We upheld Ms C's complaints.

Recommendations

We recommended that the board:

• ensure that complaint responses fully address the concerns raised, in line with the Scottish Government's complaints handling guidance;
• ensure that appropriate staff take into account the relevant guidelines on performing a cystoscopy in patients with pain and recurrent bladder infections following pelvic surgery;
• draw to the attention of relevant nursing staff on the surgical ward at the Southern General Hospital the importance of having in place wound charts in line with Healthcare Improvement Scotland guidance and ensure daily dressing and/or wound inspections are conducted; and
• apologise to Ms C for the failings identified.

Summary

Mr C complained about his care and treatment after a road traffic accident. He complained that the physiotherapy service had not diagnosed his injuries correctly and were overly focused on possible legal action that he was pursuing. Mr C believed that this meant they did not believe his description of his injuries, or the amount of pain he was in. He also felt this influenced the pain clinic he was referred to, where he said staff were also dismissive of symptoms that he maintained were caused by spinal injury. Mr C later paid for a private scan of his spine, which revealed some damage to a spinal disc, which he believed proved the pain he was experiencing had a physical source.

Mr C also said that the board did not investigate his complaint properly. His first letter of complaint was lost, even though it was signed for on delivery. He said that they did not then investigate his complaints about the physiotherapy treatment, concentrating instead on his treatment at the pain clinic.

We took independent advice on Mr C's complaint from two of our medical advisers. The advice we received was that Mr C had received a comprehensive assessment, and that treatment for whiplash associated disorder had initially improved his symptoms. He returned to the physiotherapy service when his symptoms became worse. As he did not then respond to treatment, he was referred appropriately to the pain management clinic. We found no evidence that Mr C's symptoms were treated differently or inappropriately due to a focus on legal action. The private scan showed changes that were normal for a man of Mr C's age and they were not in keeping with the symptoms Mr C described. The treatment Mr C received was appropriate, and in keeping with guidelines and best practice on treating whiplash injuries. Both advisers said that the evidence showed that Mr C's care and treatment was reasonable.

Our investigation found that the board acknowledged that Mr C's initial complaint letter was misplaced, but also that it did not contain enough information to support an investigation. When they became aware that Mr C wanted to complain, they repeatedly tried to establish what he was complaining about, but Mr C did not provide information to the board until we told him he should do so. The information he then provided was limited, and the board were unable to investigate the complaint about the physiotherapy service. They did investigate his complaint about the pain clinic. We did not uphold Mr C's complaints.