Health

Summary

Mr C complained about the care and treatment of his late mother (Mrs A) when she was admitted to hospital. Mrs A suffered from cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember) and had difficulty settling. Although Mr C's sister offered to come in to help her go to sleep, staff refused the offer. Mr C said that, when he visited on the evening of her admission, he found his mother 'trapped' in a chair behind a desk at the nursing station. She was cold, with no blanket, socks or slippers. Mr C said that throughout her stay in hospital his mother received only basic care and, although she was diagnosed as having gastric cancer at the end of her stay, she was discharged the next day without a care plan in place and with only a box of paracetamol.

Mr C said that the board did not deal with his family reasonably on the day his mother was admitted to hospital, nor did they make reasonable arrangements for Mrs A's discharge. Mr C was also unhappy with the way in which the board responded to his subsequent complaint.

Our investigation took all the relevant information into account, including the complaints correspondence and Mrs A's clinical notes. We also obtained independent nursing advice. The adviser said that while it was not clear why Mrs A was in the chair on the evening of her admission, she had been there too long. The adviser also said that the offer of assistance should perhaps have been accepted, and that communication with Mr C and his family that day was poor. Because of this, on balance we upheld the complaints about communication and Mrs A's overall care and treatment, although we found that her medical care was reasonable. We found that a discharge plan was available for Mrs A, but there was no evidence that it had been communicated adequately to her family or her GP and so, although we did not uphold this complaint, we made a recommendation. Our investigation found that the board had reasonably dealt with Mr C's complaint.

Recommendations

We recommended that the board:

• formally remind staff on the ward of the professionalism required of them;
• remind appropriate staff of the necessity of completing patients' records properly and fully; and
• advise the Ombudsman of the action since taken to prevent such a situation recurring, and if no action has been taken, advise what is proposed.

Summary

Mr C complained about issues arising when his late wife (Mrs C) was admitted to hospital. He said that at first it was believed that Mrs C was suffering from pneumonia and had suffered a slight heart attack. This was confirmed by a heart scan. However, during her stay in hospital, Mrs C began to show symptoms of confusion. A psychiatric opinion was obtained which confirmed that she was suffering from fluctuating delirium (confusion). Despite Mr C's concerns about his wife's mental health, he said he was told that she was not detainable in hospital and was subsequently discharged. Mr C said that at this time she was in a very confused state.

A few days later, Mrs C was readmitted to hospital as an emergency. Mr C said he was advised that his wife had not suffered another heart attack and that no procedures would be carried out. He was told that he could go home, which he did. However, after short time, Mrs C died without her family beside her.

Mr C complained that his wife was discharged from hospital despite being in a very confused state. He also alleged that the board failed to explain the seriousness of Mrs C's condition to him and said that she had not suffered a heart attack.

As part of our investigation we obtained independent clinical opinions from two of our medical advisers, who are consultants in geriatric medicine and forensic psychiatry. Having considered her medical records, they confirmed that Mrs C's state of mental health was not such that the board could detain her, and concluded that she was not unreasonably discharged from hospital. We did not uphold this complaint. However, we found that the notes taken at the time of Mrs C's final admission were insufficiently clear to confirm what Mr C was told about her condition. It was clear, though, that his wife had in fact suffered a very serious heart attack from which she was unlikely to recover. It was, therefore, arguable whether Mr C was given appropriate information from which he could make an informed decision about whether to leave the hospital. We upheld Mr C's complaint about the information provided.

Recommendations

We recommended that the board:

• make a formal apology for the circumstances on the night of Mrs C's death; and
• remind staff in Accident and Emergency and the Coronary Care Unit of their obligation to properly record the information given to families about the condition of their relatives who have suffered a heart attack.

Summary

Mr C, who is a MSP, complained on behalf of Mrs A's family. Mrs A, who was 94, was admitted to hospital with shortness of breath, and chest and back pain. Her family were told that she would be examined for a possible chest infection or a clot on her lung. Mrs A was found to have a chest infection and pneumonia. The family were reassured that she would be discharged home within a few days. During her admission, however, Mrs A had a fall and a number of seizures. She also developed confusion. Her breathing difficulties persisted and she died nine days after admission.

Mr C raised a number of concerns about the treatment and nursing care provided during Mrs A's admission. He also complained about the level of communication with the family.

We took independent advice from two of our advisers, one a specialist in the care of older people, and the other an experienced nurse. Our investigation found that, although Mrs A was initially assessed as being at a low risk of falling, she was not reassessed in line with the board's policy after she fell, and so we upheld the complaint about this. That said, we were satisfied with the level and type of investigations that the board carried out to assess whether she had incurred any injuries or whether her condition had changed. We did not uphold the other complaints, as generally we found the nursing care to be adequate, although we highlighted some issues that could have made Mrs A's stay in hospital more comfortable. Mrs A's family had found the communication from staff to be poor and the information contradictory on some occasions. Based on the clinical records, however, we were satisfied that the family were given full details of the nature and severity of Mrs A's condition. We recognised that there may have been additional conversations not documented in the notes, but felt that, overall, the communication was sufficiently frequent and detailed.

Recommendations

We recommended that the board:

• remind staff of the post-fall protocol outlined in the in-patient falls resource pack and the need to properly record all action taken; and
• provide the Ombudsman with evidence of the additional training provided to nursing staff.

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.