Health

Summary

Mrs C, who is an advice worker, complained on behalf of Mr and Mrs B about the care and treatment of their late son (Mr A). Mr A had an aggressive form of leukaemia (cancer of the white blood cells), and received a transplant of stem cells (cells made in the bone marrow, which can produce other cells). However, after the transplant it became apparent that the donor had developed an immunity to a virus called cytomegalovirus (CMV, a member of the herpes virus family) after he was accepted as a donor. This was evident in a blood test that the board received shortly before the transplant, but the change was not identified until after the transplant. Mr and Mrs B were concerned that this should have been identified, and that they were left not knowing what would have happened if it had been identified and acted on earlier.

Mr A became unwell after the transplant, and showed signs of very low levels of CMV in his blood, which was treated with medication. However, he had problems with his lungs, and his condition deteriorated further. Mr and Mrs B expressed concerns that this was worsened by the presence of CMV. His condition continued to deteriorate, despite a reduction in his level of CMV, and six weeks after his transplant, he died.

The board accepted that an error was made in not identifying the change in the donor's CMV status. However, there was no policy or procedure in place at the time to ensure this unusual event was identified. They also said that although this was discussed with the family at the time, the focus on his treatment meant that the discussions about CMV were not as detailed as they could have been.

As part of our investigation, we took independent advice from a specialist medical adviser, who said that the care and treatment given to Mr A was reasonable. She said that this was a most unusual problem. We noted that as there was no procedure in place at the time for checking for changes in blood tests, there was no failure of procedure, and also that as this was such a rare occurrence it was not surprising that this was not catered for. Our adviser also said that there was an urgent need for Mr A to have a transplant, and that the donor was still the most appropriate match, despite the change in his CMV status, as the risks associated with CMV were much less than those of not having a transplant at all. She said that Mr A's CMV level was reducing before his death, and that she was of the view his death was due to complications resulting from his transplant, and not the CMV. She noted that there was a lack of information in the records of discussions with the family in relation to their son's CMV status and the change in donor's status.

We did not uphold Mrs C's complaints, as we found that the board had followed their procedures in so far as they covered such a situation. We noted that they had now introduced procedures to ensure checks are made in future. We did consider whether Mr A in fact gave informed consent to the procedure as he did not know about the donor's status, but accepted our adviser’s view that it was very difficult to provide fully informed consent given all the variables involved. We also acknowledged that the reason that Mr A was not told about the change in status was because the team did not know about it, not because they did not tell him. Based on the advice we received, it appears that Mr A died of other complications, and the change in the donor's CMV donor status did not appear to have caused his death.

Recommendations

We recommended that the board:

• review the consent form and consider including reference to CMV risks and update the list of immunosuppressants used in the procedure; and
• remind staff of the need to ensure that appropriate records are kept of all discussions in relation to the giving of test results, particularly those where consent is required, and of subsequent meetings with family members.

Summary

Mr C was admitted to hospital for a hip replacement. Shortly after his operation, he said that he was in severe pain. Mr C said that he reported this to a nurse who told him that she could not divert from the anaesthetist's pain management plan until she discussed this with him when he was available later that day. The anaesthetist reviewed Mr C several hours later and prescribed a fast-acting morphine tablet. He also prescribed other pain relief, including a slow acting morphine tablet. However, Mr C complained that over the next few days, nursing staff refused a number of requests for pain relief. When his pain levels subsided several days later he decided to make no further requests for this. Mr C also complained that nursing staff failed to accurately record his reported levels of pain and the drugs administered.

We sought independent advice from our nursing adviser. The adviser said that the board's account of the drugs administered after surgery was evidenced by the medical records, although she recognised that pain was subjective and that it can be difficult in some instances to eliminate all pain. The board had also acknowledged this in their replies. We noted that the level of pain Mr C said he experienced was not reflected in the medical records. Having considered the matter carefully, we were unable to reconcile the different accounts of the level of pain experienced, and we did not uphold his complaint. We found that appropriate pain relief was administered in accordance with board policy and the level of pain recorded in Mr C's notes at the time. In addition, we noted our adviser's comments that a balance had to be struck between relieving pain and ensuring a patient was not over-sedated.

Summary

Mr C complained about the quality of his care after he had a kidney removed. He said that he was not provided with adequate pain relief, his call buzzer was not working during his stay so he could not call for assistance, and he was inappropriately discharged, despite displaying symptoms of an infection. Mr C was readmitted with a wound infection six days after being discharged. He also complained that there was a delay in transferring him to an appropriate specialist unit and that he received poor care, resulting in an infected vein. Mr C did not believe that the board had taken adequate steps to prevent these problems happening again.

After taking independent advice from two of our medical advisers - on nursing care and the clinical decisions made - we found that the board had failed to provide adequate pain relief during Mr C's first admission to hospital and that the standard of care of intravenous cannulas (needles used to give drugs and fluids to a patient) was unreasonable. We also upheld his complaint that the buzzer was not repaired during his stay. We found, however, that although with hindsight he most likely had an infection when discharged, the actions of staff at the time were in line with acceptable clinical practice, that his second admission was handled appropriately and that the delay in his transfer was beyond the board's control.

Recommendations

We recommended that the board:

• apologise in writing for their failures; and
• carry out a serious critical incident review into the failure to provide adequate pain relief.

Summary

Mrs C said that a family member (Mr A) had been admitted to a community hospital for palliative care (care to prevent or relieve suffering only). She complained to us that a nurse had been very reluctant to ask the out-of-hours doctor to visit, despite Mr A's pain, and that when he did visit, the nurse did not give Mr A the medicines the doctor prescribed.

Our investigation revealed that there had been no clinical reason for the out-of-hours doctor to be contacted and that the medicines he prescribed were strong pain relievers, to be given as and when needed. (Mr A had already been prescribed middle-strength pain relievers and was taking these.) It was clear from the clinical records that there was no reason for Mr A to have the strong ones at the time and that when, a few days later, he was in particular pain, they were given. We took independent advice on the case from our nursing adviser, who said that it is established good practice for medical staff in such a situation to prescribe drugs on a 'just in case' basis, so that nursing staff can assess their patient and administer medicines when required. In conclusion, we considered that the nurse's actions had been reasonable.

Summary

Mrs C, who is an advice worker, complained on behalf of Miss B that the care and treatment provided to her late mother (Mrs A) was unreasonable. Mrs A had been admitted to hospital as an emergency with severe stomach pains and vomiting. She told doctors that she had been having irregular vaginal bleeding for the previous six months. Two days later, she had a major haemorrhage (escape of blood) after which she was scanned and was found to have a pelvic mass. Her care was passed to the gynaecological team and a biopsy (tissue sample) was taken from the inside of her womb before she was discharged from hospital. This showed that Mrs A had developed a high grade and aggressive form of cancer. She was referred to the nearest gynaecological cancer specialist centre and a provisional plan was made to admit her there for an operation. However, Mrs A deteriorated very quickly. She was admitted to hospital again and died there before she could receive the planned treatment.

As part of our investigation we took independent advice from one of our medical advisers. We found that Mrs A had a particularly aggressive form of cancer and there were no undue delays in treating her. The first planned treatment was less than one month after it was first suspected that she had cancer. The investigations carried out and the actions taken were entirely reasonable and appropriate.

Mrs C also complained about the hospital's communication with family members. We found that in general, the team's communication with Mrs A and her family was appropriate and in line with her wishes. The consultant had kept Mrs A informed of the progress of the investigations and treatment. When Mrs A was initially discharged from hospital, the diagnosis of cancer had not been confirmed. In addition, before she was readmitted, staff were proceeding with a plan for Mrs A to be treated, and her condition was, therefore, not terminal at that point. However, when Mrs A was readmitted to hospital, it was identified that her condition was in fact terminal. Miss B complained that before she knew this, a doctor asked her whether Mrs A should be resuscitated. Although we upheld this aspect of the complaint, we did not make any recommendations, as the consultant had apologised to Miss B and the board had discussed the matter with the junior doctor involved.

Summary

Mrs C was due to have gynaecological surgery in hospital. When she arrived before the operation, she was seen by her consultant, who discussed changing the planned procedure to a more extensive operation. Mrs C was not given extra time to consider the implications of this, but consented to it. She complained that she did not receive adequate care after the surgery and that symptoms of complications arising from it were overlooked. Mrs C said that as a result of these complications, she lost the function in her left kidney. She also complained that there was an unreasonable delay before the board provided a response to her complaint.

After taking independent advice from two of our medical advisers, we did not uphold the complaint about Mrs C's care, as we found that the board had done all that could be reasonably expected in arranging care after surgery. The advisers said that the medical records showed that there had been no obvious symptoms of the complications, and staff had acted appropriately in discharging her. While considering that complaint, however, we noted that Mrs C was not given enough time to reflect on the changes to her surgery, which had serious implications for her ability to start a family, and we made a recommendation about this. We upheld the complaint about complaints handling, although the board had already acknowledged that their complaints handling procedure was inadequate and had taken steps to rectify this, including restructuring the complaints team and reviewing the procedure itself. Although we found that the delay in responding was unreasonable, we considered that the board had already taken enough action to prevent this happening again.

Recommendations

We recommended that the board:

• apologise in writing for the delay in providing a full response to the complaint; and
• review their procedures to ensure that for complex gynaecology patients, sufficient time is allowed for discussion of the full potential complications and implications with the patient, during the consent process, should the planned operation change.

Summary

Miss C, who is a prisoner, complained that there was an unreasonable delay in her receiving dental treatment. She also complained because the prison doctor refused to review her pain medication.

The board told us that Miss C saw the dentist for treatment but she was missed for a follow-up appointment. They told us that this probably happened because the way the waiting list system operated had changed. Miss C saw the dentist again a little over five months after her initial appointment. We agreed this delay was unreasonable and we upheld Miss C's complaint. In addition, Miss C said in her complaint to the board that her pain medication was not helping. The board told her that the doctor had said it was not appropriate to review her medication before she had been seen by physiotherapy, and had advised that if she responded poorly to physiotherapy then her medication would be reviewed. We took independent advice on this from one of our medical advisers, who said that it was not acceptable for the prison doctor to refuse to review Miss C's pain medication only after she had been to physiotherapy, as she had indicated she was in pain and her medication was not helping. In light of that, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise for the delay in Miss C receiving further dental treatment; and
• take immediate steps to review Miss C's current pain medication and discuss the matter with her.

Summary

Ms C complained to the board about a possible breach of confidentiality caused by automated messages which had been left on the family's landline phone. Ms C heard no more until the board sent her a formal response to her complaint some six months later. The response explained that the automated service had been suspended until new procedures could be installed to prevent possible breaches of confidentiality.

Our investigation found that the board had treated Ms C's complaint as a return complaint rather than a new one, and that the delayed response was compounded by a period of high numbers of staff absences. We upheld the complaint but made no recommendations as the board had recently formally apologised to Ms C and provided detailed explanation of the action taken to prevent a repeat occurrence.

Summary

Mr C was admitted to a hospital accident and emergency (A&E) department after falling down stairs. On arrival his neck was immobilised in a collar, and it was noted that he had movement in his arms and legs with sensation in all his limbs. However, it was also noted that there were problems with his cooperation during this examination. A scan showed no acute fracture or bleeding and Mr C's neck collar was removed. The next morning, Mr C was found to have lost the power in his legs and he was transferred urgently to another hospital for treatment. His wife (Mrs C) complained that, given his accident, Mr C should have been kept immobile and given a full spinal scan. She also believed that proper tests were not carried out to determine the extent of his injuries and that he should have been transferred immediately to a specialist unit.

To investigate the complaint, we carefully considered all the relevant information, including all the complaints correspondence and Mr C's medical records. We also obtained independent advice from a consultant in emergency medicine and took this into account. Our investigation found that although Mr C was immediately immobilised on his admission to A&E, his neck collar was removed despite recorded difficulties in completing an assessment. Relevant advanced trauma life support (ATLS) guidelines suggested that Mr C should have remained in the collar until he was determined to be neurologically normal and could have been properly assessed. We upheld the complaint that Mr C should have been kept immobile, but did not uphold the others as our investigation found that all appropriate tests were carried out to establish the extent of his injuries and that the proper protocol was followed in transferring him to another hospital, rather than to a specialist unit.

Recommendations

We recommended that the board:

• apologise to Mr C for removing the hard collar before he was confirmed to be neurologically normal; and
• take appropriate steps to satisfy themselves that, with regard to evaluation, ATLS guidelines are fully complied with.

Summary

Ms C complained that the board had failed to take action to prevent her father (Mr A) from falling while he was in hospital. The hospital had completed a nursing assessment when Mr A was admitted. It was recorded that he was able to walk independently with a stick, but that he needed bed rails. Mr A got up to go to the toilet during the night. The nightshift staff in the hospital found him standing next to the toilet, holding onto the handrail. The next day, staff found that Mr A's mobility had deteriorated. He told them that he had fallen in the toilet during the night. Staff arranged an x-ray and it was found that Mr A had fractured his pelvis.

After taking independent advice from one of our medical advisers, we found that it was appropriate to promote Mr A's independence and that it was reasonable that he was able to go to the toilet alone. Although it was decided that Mr A needed bed rails, the board's guideline for falls management stated that bed rails would not prevent a patient leaving their bed and falling elsewhere, and should not be used for this purpose. Ms C said that her father had told her that the bed rails were not up when he went to the toilet. However, the member of staff who had assisted Mr A when she found him in the toilet recorded that the bed rails were up when she took him back to the bed. Although we recognised that the fall had a significant impact on both Mr A and Ms C, we found that there was no evidence to suggest that it could have been prevented.

Ms C also complained about the board's handling of her complaint. We found that they had delayed in responding, although they had apologised to Ms C for this. They had also failed to provide a full and detailed response to the complaint. We found that they should have tried to address the points Ms C made about whether or not the bed rails were up when Mr A got out of bed. In addition, the response had incorrectly referred to her late mother instead of her father. In view of all of this, we upheld this aspect of her complaint.

Recommendations

We recommended that the board:

• issue a written apology to Ms C for incorrectly referring to her mother instead of her father in their response to her complaint and for failing to provide a full and detailed response to the complaint.