Health

Summary

Miss C complained that the medical and nursing care and treatment provided to her late mother (Mrs A) was inadequate. She also complained about inadequate communication between staff and her late mother and the family. Mrs A was admitted to hospital suffering from a blood clot in the intestine which then caused problems with her bowel. She had surgery several times while in hospital and was transferred to the intensive care unit (ICU), where she died some three weeks after being admitted.

In relation to the medical treatment, Miss C complained that when Mrs A was taken into hospital with sudden abdominal pain, there were delays in obtaining a diagnosis; in undertaking investigations; and in addressing her level of pain. Miss C also complained that it was unreasonable to have transferred Mrs A from the Accident and Emergency department to the Surgical Observation Unit before transferring her to an in-patient ward. During our investigation we took independent advice from one of our medical advisers, an experienced surgeon, who was of the view that Mrs A's medical care and treatment had been reasonable. The blood clot had caused tissue in Mrs A's intestine and bowel to die, and the adviser said that diagnosis of this condition is largely one of elimination of possible causes and that there had been no unreasonable delays in investigating and treating Mrs A's condition. The adviser said that the condition can be very painful but that strong painkillers can mask physical symptoms and so it was not unreasonable that it took some time to get Mrs A's pain under control. We did not, therefore, uphold Miss C's complaints about her late mother's medical treatment.

In relation to the nursing care and treatment, we also took independent advice from our nursing adviser, who had concerns over some of the issues Miss C had raised. In particular she was concerned about monitoring and observations, record-keeping, pain scoring, and communication by nursing staff. There were also problems with the communication of a decision to reverse a Do Not Attempt Resuscitation decision (DNAR - a decision taken that means a doctor is not required to resuscitate the patient if their heart stops) from medical staff. While the medical adviser was satisfied that both the original DNAR decision and the reversal decision were appropriately taken, only the original decision was discussed with the family. While such decisions are clinical ones and do not require approval or consent from the patient or family, it is good practice to discuss these issues where possible. Overall, we upheld Miss C's complaints about nursing care and communication.

Recommendations

We recommended that the board:

• apologise to Miss C and her family for the failings identified during this investigation;
• provide evidence that the standards of record-keeping meet the required professional standards across the wards/units involved in this complaint and, where necessary, provide training to meet these standards;
• ensure that there are robust systems for handover between the clinical departments identified when patients are transferred;
• ensure that the knowledge and skills of the nurses involved in this complaint when performing clinical observations, including pain assessments, meet the relevant local guidance;
• ensure that staff on the ICU ensure that alternative support strategies are in place for families/carers when visiting arrangements are reviewed; and
• remind all staff involved in this complaint of the importance of good communication between staff and patients and their families/carers.

Summary

Miss C's partner (Mr A) was admitted to Wishaw General Hospital with increasing shortness of breath, coughing and wheezing. Medical staff diagnosed that his chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed) had got worse and that a toe on which he had recently had surgery might be infected. The next day, Mr A's condition deteriorated abruptly. He had central chest pain and was very wheezy. As there was no intensive care bed available in the hospital, he was transferred to the intensive care unit of another hospital, where he died two days later.

Miss C complained that the board provided Mr A with inadequate care and treatment. We took independent advice on her complaint from one of our medical advisers. The adviser noted that when Mr A was admitted, it was recorded that he had previously been admitted to the high dependency unit in the hospital with breathlessness. Miss C considered Mr A should also have been admitted to the high dependency unit on this occasion. However, our adviser said that it was reasonable not to admit him there, as his condition had been stable at that time. Staff took Mr A's existing health problems into account and the care and treatment provided to him was reasonable and appropriate. A doctor acted correctly in reducing the amount of oxygen delivered when there were signs of a deterioration in Mr A's respiratory function. It was also appropriate for a consultant anaesthetist to intubate and ventilate (pass a tube into the airway and place on a mechanical ventilator to assist with breathing) Mr A in response to his vomiting and low oxygen saturation levels.

Miss C also complained that staff had failed to communicate with Mr A's family adequately. She said that they had not contacted her to let her know that Mr A's condition had deteriorated. However, we found that his deterioration coincided with Miss C's arrival at the hospital to visit him and there had not been time for staff to contact her before this. We did not consider that there were any major failings in the initial period of communication with the family. However, communication with them was not satisfactory when Mr A was stabilised and awaiting transfer to the other hospital's intensive care unit. We also found that the board had delayed in responding to Miss C's complaint. Although we upheld these complaints, we made no recommendations as we were satisfied that the board had apologised and had confirmed that lessons had been learned.

Summary

Mrs C complained about orthodontic treatment (dentistry dealing with the prevention and correction of irregular teeth) provided to her son (Mr A). Mrs C was of the view that the treatment left Mr A with an underbite (a condition in which the lower teeth and jaw protrude in front of the upper teeth) and no continuity between his top and bottom teeth.

We took advice from our orthodontic adviser. He advised that the treatment provided had focused solely on Mr A's upper jaw. This was reasonable as the rate of growth in the lower jaw was unpredictable. The orthodontist who treated Mr A was entitled to take a view on whether treatment to Mr A's lower jaw was appropriate. Our investigation found that the care and treatment provided to Mr A was reasonable and that the growth of his lower jaw could not have been affected by orthodontic treatment, making it impossible for the development of his underbite to be prevented.

Summary

Mr C complained that his wife (Mrs C) sustained injuries while she was a patient in Wishaw General Hospital. Mrs C suffered from dementia and normally lived at home. She was in hospital for some seven months, during which she fell several times, sustaining minor injuries, and was involved in a series of incidents with other patients or visitors to the ward. Towards the end of her stay in hospital, Mr C was helping his wife to change when he noticed bruising on her back, which he considered could only have come from punches. When he reported this to a staff nurse, it became apparent that no staff member had reported these injuries. One nurse had seen - but had not reported - them, assuming someone else would already have done so.

Our investigation found that there were failings in the assessment and monitoring of Mrs C's falls risk; vulnerable adult safeguarding; record-keeping and communication with the family. Although staff took appropriate action after Mrs C fell, there was no evidence that they told her family on these occasions, and it was entirely inappropriate that no-one reported the bruising on Mrs C's back. Mrs C was a vulnerable adult and staff should have taken appropriate action to report and record this, as reflected in the board's own guidance. It was not, however, possible during our investigation to establish how Mrs C had sustained these injuries.

Our investigation found that the board had investigated Mr C's concerns and had acknowledged the failings that our investigation confirmed. They had already taken some reasonable remedial action so we made recommendations aimed at confirming that this had been effective.

Recommendations

We recommended that the board:

• provide the Ombudsman with evidence that all aspects of the remedial action plan formulated after the internal investigation have been implemented or are progressing within reasonable timeframes; and
• provide the Ombudsman with reassurance that all staff involved with caring for vulnerable adults have the knowledge, skills and training to recognise, raise and respond appropriately to safeguarding issues.

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.