Health

Summary

Mrs C complained about the care given to her late husband (Mr C) while he was in hospital. She said that he was moved three times but only on the last occasion was it suitable for his condition. She alleged that he was not comfortable or properly looked after and that his clinical care was poor. In particular, she said that he endured terrible pain when his chest drains were being replaced. Overall, Mrs C believed that the lack of proper care hastened Mr C's death. She further complained that she was not kept informed by staff about his condition.

In investigating this complaint, we obtained independent advice from medical and nursing advisers. We also took into account all the information provided by Mrs C and by the board (including the relevant correspondence and clinical records). The board had said that the clinical care and treatment given to Mr C were appropriate. However, our medical adviser said that Mr C should have been referred earlier to a thoracic surgeon and should not have undergone four attempts to insert chest drains, particularly without appropriate sedation. There were also failings in Mr C's nursing care, in that his dignity and privacy were not always protected. We, therefore, upheld Mrs C's complaints about her husband's care and treatment, although we did not uphold the complaint that she was not kept informed, as the evidence showed that good attempts were made to let her know what was happening.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for the shortcomings in the clinical care given to her husband;
• train doctors, as insertion care appears to be less than adequate, to ensure that drains are properly inserted and secured properly;
• review their protocol for Intercostal Chest Drain to ensure that it is sufficiently comprehensive and includes how to deal with recurrent pneumothoraces;
• make a formal apology to Mrs C for failings in the nursing care given to her husband; and
• provide the Ombudsman with evidence confirming that systems are in place (and regularly monitored) to address the failures identified.

Summary

Mrs C complained about the care and treatment the board provided to her son (Master C) after he was admitted to hospital with a perforated appendix. His appendix was removed but he later had to be re-admitted to hospital because of infections, and twice had further unplanned abdominal surgery to release fluid. It was almost a month before he recovered. Mrs C complained that the board failed to diagnose and correct her son's problem; failed to identify a leakage from the stump of the appendix which she felt suggested that the initial surgery had failed; denied her request for the attendance of a surgeon; and failed to provide appropriate nursing care for her son when his condition deteriorated. She also complained that the board did not respond to her complaint appropriately, by failing to answer her question about her son being transferred to a major paediatric surgical centre for treatment.

We took independent advice on this case from one of our medical advisers, who is a paediatric surgeon, and a nursing adviser. Our medical adviser said that the protracted course of events was more likely to be related to the advanced stage of the appendicitis when Master C reached hospital, rather than the care he received there. He explained that the leak was unlikely to have been caused by the initial surgery, but more likely to be associated with the severity of the underlying diagnosis. He was of the view that the board did not unreasonably deny Mrs C's request for a surgeon, that the timing of surgical review was reasonable and the review itself appeared to have been appropriate. Our nursing adviser indicated that staff took appropriate action in response to Mrs C's concerns about her son's deteriorating health and that they requested review as appropriate. We accepted the views of both our advisers.

Although we deemed the board's care and treatment of Master C to be reasonable we did, however, draw their attention to our medical adviser's view that that, given Master C's unplanned further operations, it would be reasonable for the board to discuss his case at a departmental meeting. On the matter of the response to Mrs C's complaint, we considered that the board did answer the question about why they decided to transfer Master C to another hospital and explained why they were unable to continue to treat him where he was.

Summary

Mrs C complained about an examination she was given by a doctor before undergoing an emergency caesarean section (c-section - an operation to deliver a baby). She felt the examination was unnecessary, that she was not given information on what it entailed and that the doctor had not obtained her consent for it. Mrs C was also unhappy with the length of time it took the board to reply to her complaint and said that some of the information in their letter was inconsistent with previous information she had been given.

The hospital had identified two days before the c-section was carried out that Mrs C's baby was in the breech position (ie in a bottom down position instead of the more common head down position). We established that on the day of the c-section, it was necessary for the doctor to examine Mrs C to confirm whether her waters had broken and that she was in labour. After taking independent advice from one of our medial advisers, we found that the examination was carried out in accordance with both the board's local policy and guidance issued by the Royal College of Obstetricians and Gynaecologists. Without further independent evidence, we could not say for certain what the doctor discussed with Mrs C about the examination, as her recollection of events differed to those of the doctor. Our medical adviser said that it is good practice for oral consent to be documented, and that the General Medical Council recently issued guidance that a patient's consent to an intimate examination should be obtained and recorded. We noted that this guidance was not in place at the time of Mrs C's examination, however, so although we made a recommendation we did not uphold that complaint.

Whilst we found that the board regularly updated Mrs C on the progress of her complaint, we found that there was a significant delay of three months in providing a full response and we upheld that element of her complaint. We concluded, however, that the response was not contradictory, but provided more detailed information than a previous letter to Mrs C about her complaints.

Recommendations

We recommended that the board:

• ensure that verbal consent for intimate examinations on the labour ward is recorded in a patient's medical records; and
• ensure that complaints are responded to in a timely manner, by carrying out a review of how Mrs C's complaint was handled to identify potential improvements.

Summary

Mr C complained about the care and treatment of his late mother (Mrs A) in the final year of her life. Mrs A suffered from shortness of breath, which became an increasing concern over the final months of her life. Her medical practice made a provisional diagnosis of chronic obstructive pulmonary disease (COPD) sixteen months before her death. She was seen by GPs at the practice several times after this diagnosis, in relation to this and other health complaints. She was also admitted to hospital twice in the last year of her life. During the first admission she was diagnosed with left ventricular failure (a form of heart failure). She was then referred to a cardiology consultant, who diagnosed her with congestive cardiac failure (when heart failure leads to shortness of breath). Four months later, during Mrs A's second admission to hospital, she was diagnosed with idiopathic pulmonary fibrosis (a rare condition when normal lung tissue is gradually replaced with stiff, immobile tissue). Following this diagnosis, Mrs A was treated with oxygen at home. She had consultations with GPs at the practice in relation to a throat infection in the three weeks before her death, but this was treated with antibiotics, and no major concerns were raised.

Mrs A died at home of a heart attack, and Mr C complained that GPs at the practice did not do enough to diagnose his mother's respiratory problems early, and that one of the GPs indicated on the death certificate that he was the doctor 'in attendance' at Mrs A's death.

We sought independent medical advice on this case. Our adviser found that the practice had taken appropriate action to diagnose a cause for Mrs A's shortness of breath. They had followed up appropriately with a referral to cardiology, and had taken appropriate steps to follow up after her hospital admissions. The adviser noted that there was nothing in Mrs A's final consultations with GPs to suggest that she was at increased risk of a heart attack. The adviser also considered that it was appropriate for the GP concerned to indicate on the death certificate that he was in attendance of her health at the time of her death, given the number of times he had seen her over the previous year, including issues relating to her heart condition. On the basis of this advice we did not uphold either of Mr C's complaints.

Summary

Mr C complained that when, during hospital treatment for glaucoma (an eye condition affecting vision), he asked to be treated by another clinician, his request was blocked by the consultant who was treating him. Mr C also said that the consultant who was treating him had misled him.

In investigating this complaint, we took independent advice from one of our medical advisers. Our adviser considered the key aspects of this case, including the documentation supplied by Mr C and the board. Our adviser said that there was no evidence that Mr C was incorrectly advised about the availability in the hospital of a suitably experienced clinician that could take over his glaucoma care at the time it was requested. We also found no evidence that Mr C's request had been dealt with incorrectly nor that decisions made about his request had been unreasonably delayed.

Summary

Ms C complained about the standard of nursing care that her late mother (Mrs A) received after she was admitted as an emergency to hospital with shortness of breath, unexplained weight loss and dehydration. Mrs A was diagnosed with cancer of the oesophagus (gullet) and died four days later after a cardiac arrest. Ms C complained about 16 incidents in the hospital and about aspects of her mother's care.

We took independent advice on this case from one of our medical advisers. She noted 13 areas where the board had acknowledged failings on their part, apologised and said that they had taken or would take appropriate remedial action. In the remaining three areas, the adviser said that when a patient was admitted with dehydration, a five hour wait for intravenous fluids was unacceptable and she would have expected these to have been started in the emergency department. She also noted Ms C's concern about her mother's white blood cell count being low and that information from hospital staff suggested there was a delay in a blood transfusion. The adviser said the records showed that the transfusion started on the day of Mrs A's admission to hospital and was not delayed. On the final point, the adviser was critical that when Ms C was called to the hospital during the night because of her mother's deteriorating condition, no-one was asked to meet her at the hospital entrance and take her to her mother's ward.

The adviser said there was evidence of significant failings that led to a traumatic experience for Mrs A in her last hours of life and to her immediate family. We noted that the board had investigated and addressed Ms C's complaint and that statements from staff members appeared to contain important reflections about their care and treatment of her mother and suggested that they were truly sorry for their failings. As the board had already taken action in a number of areas, we made recommendations to reflect this.

Recommendations

We recommended that the board:

• provide Ms C with a written apology for failing to start her mother's intravenous fluids in the emergency department;
• feed back our adviser's views on this failing to relevant staff;
• consider what local arrangements are in place to ensure that distressed relatives arriving at night are welcomed/orientated to the ward areas;
• provide us with full documentary evidence of each of the remedial actions identified in our investigation (with the exception of the apologies); and
• provide us with an update to improvements in the ward in question in the areas set out in the quality improvement plan, and demonstrate that the issues have been addressed and that learning has taken place.

Summary

Ms C, who is an advice worker, complained on behalf of Ms A about the care and treatment that her late father (Mr A) received during the last three days of his life, and about how her complaint about this was handled.

Mr A's GP referred him to a medical admissions ward. Mr A went straight to the ward, and was asked to wait in the day room. He remained there for four hours before he was seen by a doctor, given a bed, and treatment was started. Information on his referral showed he was very unwell, indicating that he had pneumonia and kidney failure. Mr A was treated with antibiotics, and was transferred to a different ward the next day.

For the next two days Mr A’s condition remained stable and his vital signs (pulse, blood pressure, temperature and oxygen levels) were taken roughly every four hours. In the evening of the second day Mr A became increasingly unwell. This was noted by staff, who increased the frequency of checks on his condition to hourly. A doctor reviewed Mr A and identified that he needed more oxygen. He arranged for a special blood test to check oxygen levels in Mr A’s blood, and asked for a repeat of this test two hours later. There are references to the results of both these tests in the clinical notes, but only the first test was noted in detail, and the second set of results were not identified by the board in their response to Ms C’s first complaint. As a result, Ms C was mis-informed about these tests. This was because the test results were held on record electronically, and were not added to the clinical file. Despite further assistance with his breathing, Mr A died the following day.

We obtained independent advice on this complaint from one of our medical advisers. We upheld the complaint about the delay in getting a bed, as his advice indicated that Mr A should not have been kept waiting in the day room of the admissions ward for such a long time, and that this created risks for patient care. We did not uphold Ms C's complaints about vital sign checks and blood tests. Our adviser reviewed all the checks made on Mr A’s vital signs and found them to be appropriate. He also reviewed blood test results from shortly before Mr A’s death, and found that they were appropriate, but criticised the way in which the board held these records and reported them to Ms C. On complaints handling, Ms C had said that she did not get a final response until more than eight months after she first complained. While we found that further issues were raised at a meeting three months after the original complaint, we found there was still a substantial delay in providing a final response, and we upheld this complaint.

Recommendations

We recommended that the board:

• raise this case at the next meeting of its clinical directorate, specifically considering the risks involved in using day rooms as waiting rooms, and considers the introduction of mechanisms to avoid these risks;
• give careful consideration to the implementation of the early identification and treatment of sepsis (blood infection), using the 'Sepsis Six' initiative;
• remind doctors of the need to record all investigation results in the case notes immediately they are available, especially for tests such as arterial blood gases, where a formal laboratory result may not be printed;
• ensure that all electronic records are reviewed during complaints handling and are passed to the SPSO on request; and
• apologise to Mr A’s family for the failures identified in our investigation.

Summary

Miss C complained that she was misdiagnosed in 2010 with ulcerative colitis (where ulcers form in the large intestine and rectum (the terminal part of the large intestine). She said that when she was offered a surgical procedure in 2012 this was inappropriate as her actual diagnosis was of Crohn's Disease (where the small intestine becomes inflamed, thickened and ulcerated).

Ulcerative colitis is one of a range of conditions known as Inflammatory Bowel Disease (IBD). Miss C had undergone an emergency ileostomy (where the damaged portion of the small intestine is removed and the remainder directed to an opening created in the stomach wall. The contents of the intestine are then emptied into a collection bag which remains in place for life unless the ileostomy is reversed.) In 2012 she was offered a reversal of the ileostomy as her condition had been stable for some time. After the reversal procedure Miss C experienced an increase in her symptoms and was admitted to hospital four times in the next few months. Her diagnosis was eventually changed to Crohn's Disease and she was advised to have her ileostomy reinstated. Miss C complained that as a result of her misdiagnosis she underwent two major but unnecessary surgical procedures as she had been told that Crohn's sufferers are 'never' offered reversal surgery.

After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. We found that the original diagnosis of ulcerative colitis given to Miss C was not unreasonable. The adviser said that the conditions have similar symptoms but that Crohn's Disease classically involves the small intestine. In 2010 an internal examination had shown that Miss C had ulcers only in her large intestine.

The adviser also said that the offer of reversal surgery was reasonable, on the basis of the diagnosis of ulcerative colitis and in view of her condition being well managed at the time. The adviser also said that even had the original diagnosis been Crohn's Disease, it would still have been a reasonable decision, given Miss C's condition at the time. Some patients can experience an increase in their symptoms and a relapse of their condition following reversal and this is a risk that should be discussed with the patient before surgery is agreed. There was evidence in Miss C's clinical records that this was discussed with her at an out-patient appointment. Therefore, it was reasonable to offer the reversal and the resulting relapse could not be attributed directly to it. The adviser said that all IBD conditions are characterised by unpredictable symptoms and relapses, and made reference to the IBD Standards Working Group who issued national guidance in 2009.

Summary

Miss C's sister (Miss A) was admitted to hospital after a fall at home. Miss A had injured her back in the fall, but her GP noted in his referral letter that her health had been declining for some time. She had a history of alcoholism, a number of medical conditions and had been receiving treatment for infections. Although her condition initially improved, Miss A became lethargic and developed symptoms of liver disease. Her condition deteriorated further and she was transferred to a second hospital in a different board area for specialist treatment. Their records indicate that Miss A had pneumonia and had become increasingly confused. She died two weeks after being admitted to hospital. Miss C complained to us that staff at the first hospital did not appropriately assess and treat the cause of her sister's symptoms.

After taking independent advice from one of our medical advisers, we found that Miss A was clearly in very poor health when she was first admitted to hospital. The clinical records showed that her condition was closely monitored and that appropriate investigations were carried out. Although Miss A at first showed signs of improvement she had developed a chest infection, which resulted in her condition deteriorating. We were satisfied that the board took appropriate steps to monitor her symptoms, considered reasonable causes of those symptoms and carried out appropriate diagnostic investigations. We were also satisfied that appropriate treatments were provided and that staff involved specialists from the second hospital at an appropriate stage. We concluded that Miss A's deterioration occurred despite the investigations and treatment provided by the first hospital, rather than as the result of any failure on the part of the board.

Summary

Mr C has a long-standing lung condition. He complained that when he contacted NHS 24 as he was feeling unwell, an out-of-hours GP phoned him back and said that Mr C did not require a home visit and that he was to contact his own GP when the medical practice opened in an hour and a half's time. When Mr C attended the practice, he was prescribed medication and told to return in a week if the symptoms did not resolve. Mr C felt that the out-of-hours GP was wrong to refuse a home visit and complained about this.

As part of our investigation we obtained independent advice from a medical adviser, who is an experienced GP. She said that the out-of-hours GP took an appropriate clinical history and that their decision that Mr C should wait until the practice had opened was reasonable. Although Mr C did need to be seen by a doctor, there was no evidence that his condition was unstable or that an urgent house visit was needed before the practice opened.