Health

Summary

Miss C complained that her late mother (Mrs A), was inappropriately discharged from hospital while still suffering from a urine infection. Mrs A had diabetes and lung disease. She was admitted to hospital suffering from a number of symptoms, including confusion and fever. Mrs A was diagnosed with a urine infection and was treated with intravenous (IV) antibiotics. Mrs A was discharged after five days, but two days later was admitted to another hospital, where she died soon after admission. The cause of death was urine infection leading to kidney failure. Miss C was concerned that during Mrs A’s stay her fluid balances had not been sufficiently monitored and that she had been discharged too soon.

Our investigation, which included taking independent advice from two of our medical advisers, a doctor and a nurse, found that the care and treatment provided to Mrs A was reasonable. It was reasonable to treat Mrs A with IV antibiotics and the blood and urine tests done during her stay showed that her condition improved. The specific bacteria causing the infection was not identified until after she was discharged. This was thought to be due to the fact that Mrs A was already being treated with antibiotics before admission, which can slow down the rate at which specific bacteria can be identified in the laboratory. In the light of the improving laboratory results, it was reasonable to discharge Mrs A with oral antibiotics to continue her recovery at home. In the event, the specific bacteria proved to be a serious and potentially fatal one which was resistant to the antibiotics prescribed. However, overall we considered Mrs A’s treatment, and the discharge were reasonable.

On the matter of the fluid balance charts, both advisers commented that these charts are notoriously unreliable as so many factors influence fluid balance. However, both also noted that the charts completed in Mrs A's case were of a reasonable and acceptable standard.

Summary

Mr C complained that there was a delay in the board carrying out bariatric (weight-loss) surgery to help control his weight. In August 2009, Mr C's GP referred him to the board's weight management service - a service that was in place between December 2008 and July 2012. The referral paperwork was lost so Mr C's GP sent a further referral in February 2010. The board told Mr C that he would receive a psychological assessment within a couple of months, but the appointment did not take place until a year later. The board did not tell Mr C or his GP that there were no psychological assessment clinics running during this period. In October 2011, the psychologist confirmed that Mr C met the criteria to be further assessed for bariatric surgery and that he would be referred to another board's obesity service, which was the procedure in place at this time. In November 2011, the GP referred Mr C through the appropriate channel but the board failed to advise the GP or Mr C that no referrals to the other board were being accepted, due to the demand on the service. In July 2012 a new national weight management criteria was implemented and in October 2012, Mr C was advised that he was no longer eligible to be referred for surgery because he did not meet new age criteria.

Our investigation found that, had Mr C's referral paperwork in 2009 not been lost, and had there not been a significantly long delay of a year in his psychological assessment going ahead, he would have been assessed under the criteria in place before July 2012. In addition, Mr C appeared to have been misled about the boards weight management service. We concluded that the board should have followed through on their agreement to further assess Mr C's suitability for bariatric surgery.

Recommendations

We recommended that the board:

• consider prioritising Mr C's assessment for surgery under section 3 of the national obesity treatment best practice guide (July 2012); and
• apologise to Mr C for the delay in his psychological pre-assessment being carried out and for the lack of information given to him about his referral to the other board.

Summary

Mrs C's daughter (Miss A) was pregnant, and was admitted to hospital for her baby to be induced. However, her baby was born by emergency caesarian section (an emergency operation) the next day, and Miss A was discharged home a few days after that. On the day she was discharged, she had been reviewed and an ileus (a condition where the bowel stops contracting and relaxing to move the bowel contents) was suspected. However, Miss A was reviewed again later in the day, noted to be well and was discharged. She had to be readmitted to hospital the next day, with vomiting and a suspected bowel blockage. She needed surgery to release a suture which had been around part of her bowel, and the bowel was then re-sectioned (part of it removed).

Mrs C complained on Miss A's behalf that her daughter had not received a reasonable standard of medical care, and that she was released from hospital too early. She alleged that insufficient care had been taken when Miss A's caesarian section was carried out and that her bowel had been perforated because of this. However, the board said that Miss A's emergency section had been carried out in a routine manner and that she had suffered an unusual complication. Overall, they said that her care had been appropriate.

To investigate the complaint, we took independent advice from one of our medical advisers. Our adviser confirmed that Miss A's bowel injury was a rare but recognised complication of a caesarian section, particularly one that was not planned and was carried out in the later stages of labour, and that the records showed that all reasonable care had been taken during the operation. She also said that there had been no reason not to discharge Miss A, although some of the record-keeping could have been better.

Recommendations

We recommended that the board:

• remind all staff of the importance of timing and dating all entries in the record. Also that staff are reminded that when a complication is suspected, the subsequent records are explicit about the progress of the symptoms giving cause for concern.

Summary

Ms A was removed from the practice's treatment list. She believed this was inappropriate, and complained to the practice. She remained dissatisfied when she received their response and her partner (Mr C) complained to us on her behalf.

When we investigated, we found that the practice had not met the requirements of the relevant regulations for the removal of a patient from a treatment list. We upheld Mr C's complaint that Ms A's removal from the practice list had been inappropriate, and made recommendations to address this.

Recommendations

We recommended that the practice:

• apologise directly to Ms A that she was inappropriately removed from their treatment list; and
• review their procedures on the removal of patients from their treatment list to ensure that they comply with the relevant regulations, guidelines and guidance.

Summary

Mrs C complained that the care and treatment provided to her sister (Ms A) was unreasonable. Ms A had a history of chronic obstructive pulmonary disease (a long-term lung condition), osteoporosis (thinning of the bones) and heart problems. A GP from the medical practice visited and, after examining her, prescribed antibiotics and steroids (drugs commonly used to fight infections) in tablet form. Ms A had trouble taking these as she was normally unable to swallow tablets and usually had medication in liquid or powder form. Her condition did not improve.

A second GP visited the next day and again examined Ms A but was unable to take her temperature as his thermometer was broken. The GP prescribed a different antibiotic, again in tablet form. Neither GP considered that Ms A's condition warranted emergency admission to hospital and the second GP said that Ms A had specifically told him that she did not want to go to hospital. Ms A's condition continued to deteriorate and Mrs C called NHS 24 (a national advice helpline) later that evening. Ms A was taken by ambulance to hospital where she was found to be suffering from sepsis (serious infection) and hypothermia (where the body temperature falls below the normal range). She was admitted, but died shortly afterwards.

We did not uphold any of Mrs C's complaints. Our investigation, which included taking independent advice from a medical adviser, concluded that the examinations and management plan for Ms A had been reasonable. In particular, the adviser said that in light of Ms A's reluctance to go to hospital it was appropriate to take her views into consideration and to manage her condition at home. The family disputed that Ms A did not want to go to hospital, but the records showed that the ambulance paramedics had recorded her reluctance to go there. The practice acknowledged that Ms A had medication in liquid form, but there was nothing specific in her notes to highlight that she had difficulty in swallowing tablets. In any event, the second GP did not have access to the notes on his visit as he had been passed the call while out of the practice doing other home visits. There was also no clear evidence that Ms A or the family specifically told either GP that Ms A could not swallow tablets.

Summary

Mrs A was an 87-year-old nursing home resident. She had Alzheimer's disease and a history of breast cancer and heart disease.

Mrs A was admitted to hospital after being found in the early hours of the morning on her bedroom floor after a fall. She was found to have fractured her hip. She had surgery in hospital the next day, and was discharged back to the nursing home two days later. Mrs A fell again in hospital on the morning of her discharge, but was medically assessed as uninjured.

Mrs A's daughter (Mrs C) believed that, despite providing one-to-one nursing to the best of their ability, staff at the nursing home struggled to manage her mother's care after her discharge because of her medical condition, impaired mobility and deteriorating cognitive function (the ability to think, concentrate, formulate ideas, reason and remember).

Mrs A fell again, from a chair, six days after being discharged from hospital. She had fractured her arm and was readmitted to hospital. Several days later, she was transferred to another hospital for palliative care (care to prevent or relieve suffering) and died shortly after.

Mrs C said that hospital staff failed to assess her mother's cognitive impairment and individualise her care and treatment, particularly in relation to falls prevention.

Mrs C held welfare power of attorney for her mother and believed that staff failed to communicate with her as they should have, about Mrs A's discharge. As a result of this, Mrs C said that Mrs A was improperly discharged and the board failed to ensure that adequate arrangements for later support were in place. Mrs C also said that they failed to implement an effective falls care plan for her mother, and failed to fully take into account her high falls risk on discharge. As a result, Mrs C believed that Mrs A's fall from the chair, which caused her severe suffering and proved fatal, was avoidable. Finally, Mrs C believed that the board misrepresented the findings of a visit by the Healthcare Inspectorate, a regulatory body. In responding to her complaint, the board said that it was found that ‘a high standard of care was being delivered to elderly patients with cognitive impairment’.

After taking independent advice from a medical adviser, who specialises in mental health issues, we upheld all of Mrs C's complaints. We found that the board's communication with Mrs A's family was unreasonable both in relation to the Adults with Incapacity (Scotland) Act 2000 and to discharge. We considered that a lack of meaningful consultation with Mrs C and the nursing home led to a significant personal injustice to Mrs A, as her discharge was ineffectively planned and coordinated and failed to ensure that her needs were met. We were also extremely concerned about the overall failures in communication, given the importance of meeting the needs of patients with dementia in every aspect of care, treatment and clinical management.

We found that the board failed to comply with their falls prevention policy in a number of important respects. This was unacceptable. The risks of falling cannot be completely eliminated, but can be minimised by careful assessment and clinical management. Some measures were implemented for Mrs A, but additional measures should have been taken to further reduce the risks, given the potentially significant and severe consequences of a fall injury to an elderly person with dementia.

We found that there were a number of significant failures by the board in addressing Mrs A's mental health care needs. We were particularly concerned that Mrs A’s cognitive function was not formally tested during her stay in hospital. Finally, we drew to the board’s attention our finding that the Healthcare Inspectorate report had in fact highlighted the need for improvements in the areas of assessment and care-planning.

Recommendations

We recommended that the board:

• audit staff awareness of the board's policy on falls prevention and the knowledge and skills of staff relevant to its effective implementation, and take action to address any knowledge and skill gaps identified by the audit;
• review the fractured neck of femur care pathway to ensure it meets the needs of patients with dementia, in particular around assessment of cognitive functioning, pain assessment and communication under the Adults with Incapacity Act; and
• inform the Ombudsman of progress in implementing the action plan arising from the Healthcare Inspectorate report and how related clinical practice will be monitored and assessed.

Summary

Ms C's daughter (Miss A) was diagnosed with throat cancer and was admitted to hospital for chemotherapy and radiotherapy. She was found to have chest and urinary infections, so her chemotherapy and radiotherapy were postponed until these were treated. When her condition improved, Miss A received chemotherapy. After a second course of chemotherapy, she became neutropenic (the blood cells that fight infection had reduced) and was taken to another hospital, where she died.

Ms C complained that her daughter's condition was not properly monitored. In particular, she noted that blood tests were not taken daily, as had happened with another family member with cancer. Ms C felt that, had Miss A's blood results been closely monitored, she could have been treated and her prognosis might have been better. Ms C also complained about staff communication with the family. She was told after Miss A's death that the tumour was one of the largest the consultant had seen. She said that had she known this earlier, she might have decided to keep Miss A at home during her final days.

We took independent advice from one of our medical advisers, who confirmed that blood tests are not carried out daily following chemotherapy. This is because it will already be known that the treatment makes the patient neutropenic. Neutropenia is only an issue if the patient develops sepsis (a severe blood or tissue infection), and this is not diagnosed through blood tests, but from the patient's physical symptoms. If there is evidence of sepsis, then blood tests would be carried out. We found that Miss A’s treatment and monitoring was in line with the board's protocol for treating patients with head and neck cancers.

The evidence also suggested that communication with the family was good, although we were unable to establish whether specific information was provided about the size of the tumour. It was, however, clear from the records that both Miss A and her sister were told the tumour was extensive; and that Miss A continued with hospital treatment in full knowledge of this.

Summary

Mrs C complained that when she was admitted to hospital with a broken ankle, staff administered an unreasonable level of morphine, resulting in a severe reaction. She also complained that when she raised her concerns about this with the board, they failed to provide her with a sufficiently detailed response, and failed to respond within a reasonable timescale.

We investigated Mrs C's concerns, and sought independent advice from one of our medical advisers. Our adviser noted that Mrs C was given a fairly high dose of morphine, both orally and by injection, and suffered a subsequent reaction (opiate toxicity). However, we did not uphold this complaint as the adviser said that the levels prescribed were not unreasonable, given Mrs C's condition and the fact that she was about to undergo a plaster replacement on her ankle which would have resulted in an increase in pain.

We also reviewed the board's complaints correspondence and were satisfied that they provided a reasonable response to Mrs C's concerns. However, to the extent that there was at one stage a delay in responding to Mrs C's correspondence, we upheld this complaint, although we did not find it necessary to make any recommendation.

Summary

Mr C complained that the board unreasonably delayed in diagnosing that his late wife (Mrs C) had mesenteric ischemia (reduced blood flow to the intestines). He also complained that they delayed in operating on Mrs C following her diagnosis and that this caused her death.

We took independent advice from one of our medical advisers, who explained that mesenteric ischemia is a very difficult condition to diagnose. It is usually diagnosed by excluding other causes and this can take some time. We were satisfied that the board carried out appropriate assessment and investigations to exclude other causes to diagnose Mrs C's condition. However, we found that the diagnosis of mesenteric ischemia should have been considered sooner in view of the fact that Mrs C was known to have vascular disease.

The board decided that operating on Mrs C would be very high-risk, and referred her to another board for advice. Although we found that this was in itself reasonable, there were delays in obtaining the advice. It was then decided that Mrs C required a major surgical operation, which would carry some significant risks to her health. The surgeon who had been managing Mrs C's care was due to leave the board at that time. He referred Mrs C to another board and asked that they take over her management. Again, given the circumstances, we found that this was reasonable. However, we found that the referral should have been more urgent and the board should have pursued this when no response was received from the other board.

Mrs C's condition deteriorated further before she was seen by the other board. She underwent an emergency surgical procedure and was admitted to intensive care. A second procedure was carried out to review her bowel. It was decided that the surgical options were limited, and the surgeon could not carry out a bowel resection (partial surgical removal). Mrs C subsequently passed away.

Our adviser said that Mrs C was a high-risk candidate for surgery and it was likely that this would have been unsuccessful. It could also have led to other parts of her system being compromised, even if it had been undertaken at an earlier opportunity. It would have been inappropriate to carry out surgery without obtaining advice from the other board. Although we upheld Mr C's complaints, as we found that there had been delays by the board, both before and after Mrs C was diagnosed with mesenteric ischemia, our adviser said that the outcome was unlikely to have been different if these delays had not occurred.

Recommendations

We recommended that the board:

• make the clinical staff involved in Mrs C's treatment aware of our finding on this matter; and
• review the management of Mrs C's case and consider how they can ensure continuity of care when a patient is referred to another board for treatment.

Summary

Mr C was under the care of a specialist pain physiotherapist in the board's pain clinic service. He was also referred to, and awaiting treatment from, a specialist pain psychologist there. However, the physiotherapist left her post and later, after two periods of sickness absence, the psychologist did likewise. Mr C complained about the delay in filling these posts and the resultant gap in service provision. During our investigation, we took independent advice from one of our medical advisers, who said that the board took reasonable steps to explain the position to Mr C, to make alternative treatment options available to him, and continue to provide a service in the face of challenging circumstances. We also saw evidence that Mr C had not always fully engaged with his treatment plan, and in the circumstances we did not uphold the complaint. However, although we acknowledged the difficulties the board faced in filling these specialist positions, we considered that they could have acted more promptly in advertising the physiotherapist post.

Mr C also complained about the way in which the board handled his complaint. In particular, he was unhappy that he was told that the psychologist would be returning to work, only to later find that she had resigned. We found that the information shared with Mr C was accurate when it was provided and we did not consider that the board could reasonably have foreseen that the post would later be vacated. We saw no evidence of a deliberate attempt to mislead Mr C, as he alleged. Mr C also complained that the board failed to respond to an email he sent them and to address all the complaint points he raised. The board accepted that an administrative error had led to a response not being sent and apologised for this. We also noted that the board had agreed four points of complaint for investigation with Mr C, but did not appear to have responded to all of them so, in the circumstances, we upheld Mr C's complaint about their complaints handling.

Recommendations

We recommended that the board:

• highlight to relevant staff the importance of timely recruitment to specialist posts in order to minimise disruption to patients’ therapeutic programmes; and
• remind complaints handling staff to ensure they respond to all complaint points that have been agreed with the complainant.