Health

Summary

Ms C complained that a hospital failed to provide her late mother (Mrs A) with appropriate nursing care and treatment towards the end of her life. Ms C told us that several issues arose that caused her concern. These included the lack of support Mrs A received in order to help her to eat; visiting times; the method by which paracetamol was administered; the treatment of a skin rash; the lack of information given to Ms C about Mrs A's diazepam medication; communication with the charge nurse; financial harm; funeral parlour arrangements; the documentation of private conversations and a missing page of Mrs A's clinical records.

We took independent advice from one of our medical advisers, and took account of this alongside all the documentation provided by Ms C and the board. Our investigation found no evidence of failures in the overall nursing care or standard of record-keeping so we did not uphold any aspect of Ms C's complaint.

However, we were critical of the comments made by and the general tone of the written records of one of the nursing staff, and of the inflexible attitude towards Ms C and family members about visiting times and assisting at mealtimes, and so made recommendations to reflect this.

Recommendations

We recommended that the board:

• ensure that staff are familiar with all aspects of person centred care;
• ensure that staff are reminded that relatives and carers should be included in decision making and where appropriate involved in care planning;
• ensure staff are reminded that rules for visiting and meal times are for the benefit and care and treatment of patients, but should be flexible to allow individual care for patients and their families;
• ensure that consideration is given to the individual personal circumstances of those who wish to be with terminally ill relatives/patients;
• ensure effective and sympathetic communication is made with those who wish to be with terminally ill relatives/patients; and
• ensure that wherever possible leaflet information about undertakers is available on the ward to assist relatives at times of bereavement.

Summary

Mrs C's dentist extracted her bottom left molar. Eleven days later, the dentist extracted Mrs C's upper right molar and prescribed antibiotics because of pain at the site of the previous extraction. Several days after that, Mrs C was treated by another dentist for infected sockets. They gave her an antiseptic mouthwash and a dressing to promote healing. Mrs C was also given advice about giving up smoking and pain relief. Mrs C said that shards of tooth came out of her gum at the extraction sites. A radiograph was taken and showed no retained roots. She returned to the dental practice a month later and another dressing was put in place. At the end of the following month, Mrs C returned to the practice saying that another back tooth was causing discomfort and that she felt unwell. She was prescribed antibiotics and had further extractions a couple of months later. She was then referred to the dental hospital. Mrs C complained that the extraction sites have not healed, she has loose teeth and she takes antidepressants due to the poor cosmetic appearance of her teeth. Mrs C also complained that there were delays by the practice in responding to her complaint.

We found that the clinical care and treatment provided was reasonable, but that there were failings in relation to record-keeping, about which we made a number of recommendations. In relation to complaints handling, the practice delayed in sending a written response, but did take other action. They arranged a meeting between Mrs C and a dental practitioner to discuss her complaint and referred Mrs C to hospital. We were satisfied that, on the whole, the practice dealt with Mrs C's complaint in line with the NHS complaints procedure as they took action to respond to and resolve it within a reasonable time.

Recommendations

We recommended that the practice:

• ensure that a copy of a signed treatment plan for scheduled appointments is retained in patient records;
• ensure that dentists record information about medication provided;
• ensure that dentists record it when they provide a post extraction information sheet to patients following extractions;
• ensure that dentists report on all radiographic findings in patients' records; and
• ensure that there is written evidence of a British periodontal (gum) examination in patients' records for all scheduled appointments.

Summary

Mr C's mother (Ms A) was admitted to hospital with chest pain. A CT scan (a special scan using a computer to produce an image of the body) was carried out, and suggested an underlying tumour. The board decided that a biopsy (a sample of tissue) was required to diagnose Ms A's condition. The sample was taken at hospital two weeks later. The results confirmed that Ms A had high grade lymphoma (a type of cancer). A chemotherapy regime (a treatment where medicine is used to kill cancerous cells) was planned, but Ms A started to deteriorate and died four weeks after admission to hospital. Mr C was concerned about the time taken to diagnose Ms A's condition and that she had not been adequately hydrated when she was under the care of the board.

As part of our investigation, we sought independent advice from a medical adviser. He considered that the board needed to obtain a biopsy to diagnose Ms A's condition. He further explained that the biopsy would have been difficult to obtain because of its location and the risks involved. The adviser considered it reasonable that medical staff were fully appraised of the situation and had to consider the best way of obtaining a biopsy. We accepted the adviser's view, and did not uphold this complaint.

Mr C also complained that Ms A had not been adequately hydrated. Ms A's medical notes indicated that instructions had been given to administer intravenous (IV - administered into a vein) fluid to rehydrate Ms A. This therapy was started two days after the instructions to do so had been given. We were critical of this and upheld this complaint.

Recommendations

We recommended that the board:

• bring this issue to the attention of staff involved and all other relevant staff and ensure that where IV fluid is considered to be required for a patient it is recorded and commenced without delay; and
• issue a written apology to Mr C for failing to ensure that Ms A was adequately hydrated.

Summary

Mr C complained on behalf of his father (Mr A) about the care and treatment he received when he was admitted to hospital three times over a period of about eleven days. Mr A had a history of high blood pressure and arthritis, as well as a history of heavy drinking, for which he was being treated by his GP with Antabuse (a drug that causes an unpleasant reaction when taken with alcohol). Mr A was taken to hospital after suffering a seizure. He was complaining of shaking in his right arm and leg, speech disturbance and confusion, and had a three-day history of headache. He was admitted overnight for observation and investigation and was discharged the next day. Mr A's wife (Mrs A) and daughter went to collect him and felt that the attitude of the staff on the ward changed towards him when Mrs A mentioned that he was taking Antabuse. Despite Mrs A and her daughter telling staff that they thought Mr A was still confused and unwell, he was discharged.

Mr A was re-admitted to hospital later that night suffering from confusion and hallucinations. He was again kept in overnight and discharged the next day. Mrs A was told that his condition had been brought on by his previous lifestyle. The family said that Mr A remained confused and disorientated over the next week. He then suffered four or five fits at home and was taken by ambulance to the hospital, where he was again admitted. Mrs A phoned the hospital the next morning to ask if she could bring in some personal items for her husband at lunchtime, and was told that she could do so. However, when she phoned again at 11:45 she was told that Mr A had been discharged some ten or 15 minutes previously.

Mrs A and a friend went to the hospital and also reported to the police that Mr A was missing. He was later found sitting at the main entrance to the hospital dressed only in a vest, cardigan, jogging bottoms and slippers. He had a supply of medication with him that he had been given on discharge from the ward. He had no money with which to phone home or pay for a taxi. His family say he was generally confused and did not know what the supply of medicines he had were or when he had last had his regular medication. It was only after Mr C made a verbal complaint to the hospital that someone phoned and spoke to Mr A's daughter and explained the medication. The caller did not phone Mr C or respond to his verbal complaint as he had been expecting them to do. Mr C, therefore, made a written complaint but was dissatisfied with the response he received.

We upheld Mr C's complaints. Our investigation, which included taking independent advice from two of our medical advisers, found that while in general the investigations of Mr A's condition were reasonable, there were some deficiencies in the care and treatment provided. In particular, the discharge planning and documentation were inadequate. There were also insufficient arrangements made for Mr A to be followed up in the community after his discharge from hospital.

Recommendations

We recommended that the board:

• apologise to Mr A and his family for the failings identified;
• consider the introduction of structured pathways for patients presenting with complications of alcohol consumption to standardise appropriate treatment, discharge and follow-up; and
• ensure that all relevant staff are aware of and properly trained to apply the board's admissions and discharge planning guidelines.

Summary

Mr C said that when he consulted his dentist for the first time, she carried out an initial examination and told him he required six fillings. Three of these were carried out nine days later, but when Mr C returned to to have the remainder of the work done, he said that the fillings she had completed earlier were sensitive. The dentist replaced the filling in the tooth that she decided was the problem, and arranged a date for the rest of the work to be done. However, before returning, Mr C obtained a second opinion. He said he was told, after examination, that the teeth remaining to be filled did not require work. Mr C complained that dental work was carried out unreasonably when none had been required.

As part of our investigation we took independent advice from a dental adviser, who reviewed Mr C's dental records and relevant x-rays. We also looked carefully at the complaints correspondence. We upheld Mr C's complaint, as the adviser agreed that there was no evidence to suggest that Mr C required the number of fillings that had been suggested.

Recommendations

We recommended that the dentist:

• apologise to Mr C; and
• provide the Ombudsman with an undertaking that she will address the concerns raised in this complaint through her continuing professional development.

Summary

Mrs C's daughter (Miss A) has a rare disorder affecting her joints. Since 2010, Miss A has had the support of iCare (a subsidiary of the health board) a respite service for children and young people with complex needs. The care is delivered at home and, to qualify, clients need to meet six health indicators. Mrs C complained that, despite her daughter's condition being unchanged, she was told that Miss A would no longer qualify as her points score had reduced to five from six.

In investigating this complaint, we looked at all the available information, including the complaints correspondence and Miss A's relevant medical records. We also asked the board to provide more information about what had happened. The board in their comments said that they no longer provided Miss C with any health intervention and that she was continent. They added that she could move independently in her electric wheelchair. The board said that Miss C's points had reduced to reflect the change in her mobility.

Our investigation confirmed that Miss C's condition was unchanged and that it would not improve. We found that she was not continent although her incontinence was managed with the use of pads. The level of support from other agencies had been the same since 2010. We found that it was not clear what health intervention had ever been provided to Miss C. Furthermore, Miss C had had the use of an electric wheelchair for many years which she had been able to operate herself.

Although we agreed that it was for the board to set qualifying criteria in the face of competition for finite resources, the assessment of individuals under these should be transparent and ensure visible fairness to all. No guidelines had been provided to show how the staff concerned assessed Miss C's health needs. We upheld the complaint and made a recommendation to address this.

Recommendations

We recommended that the board:

• create appropriate guidelines for the assistance of staff when assessing care requirements and reassess Miss C accordingly.

Summary

Miss C complained that when she had a nerve block (an anaesthetic injected directly into the nerves before surgery to numb the area) some of the anaesthetic went into her artery and caused her heart to stop. She had to be resuscitated and was transferred to the intensive treatment unit (ITU) for observation for 24 hours. Miss C also complained that she was prematurely discharged from the ITU.

Our investigation, which included taking independent advice from two of our medical advisers, found that the care and treatment provided to Miss C had been reasonable. Our anaesthetist adviser (anaesthetic specialist) reviewed the clinical records and was satisfied that there had been no error with the administration of the injection. Nerve blocks should be administered under guidance from ultrasound scanning (a special scanning technique using sound waves to produce internal images of the body). It should also be administered at a specific speed. The anaesthetist adviser was satisfied that both of these were carried out correctly and that Miss C had suffered a known, but rare, complication of this type of anaesthesia. The adviser also said that Miss C's collapse was picked up right away and correct action was immediately taken to revive her. The adviser also considered it reasonable that Miss C was sent to the ITU to be observed for 24 hours following her collapse.

On the matter of Miss C's discharge from hospital the following day, both medical advisers considered that she had been appropriately assessed on admission to ITU and prior to discharge. Although Miss C's next of kin had initially been told that she would likely be transferred to a general ward before discharge home, the advisers both considered that it was reasonable that she was discharged directly home. Miss C had been assessed on the morning after the incident as being alert, mobile about the ward, eating and drinking and had passed urine following the removal of her catheter. On the decision to send her home in a taxi, the nursing adviser said that a routine ambulance can take up to 24 hours to arrange so it was reasonable to avoid this delay by sending Miss C home in a taxi.

Summary

Ms C complained that there was a lack of appropriate care and treatment for her late mother (Mrs A) after she fell while in hospital. Mrs A had been admitted to hospital five days previously because she had fractured her wrist and pelvis. Ms C said that the board's decision not to x-ray her mother and to proceed with her planned discharge on the day she fell was unreasonable. Ms C also raised concerns that staff refused her mother's request to use a zimmer frame immediately before she fell, and that she did not receive adequate pain relief. In response to the complaint, the board advised that it had been appropriate to discharge Mrs A, on the basis of the clinical assessment that had been carried out.

After taking independent advice from one of our medical advisers, we did not uphold Ms C's complaint. Our investigation found that there was evidence to show that during her stay Mrs A had progressed from being able to use a zimmer frame around the ward to using one elbow crutch with the assistance of a member of staff. We considered that appropriate examinations had been carried out by three different doctors, who all agreed that Mrs A could be discharged. In addition, Mrs A's mobility was assessed twice after her fall and although it was noted that she had pain, she was able to weight bear and walk several metres. There was also no evidence of serious injury to suggest that an x-ray should be carried out. However, we took the view that Mrs A's family could have been better involved in the decision to discharge her. We also identified that, whilst Mrs A was given appropriate pain relief, there was insufficient evidence to show that her pain levels had been adequately monitored between the time she was admitted to hospital and her subsequent discharge.

Recommendations

We recommended that the board:

• ensure that relevant staff on the ward clearly monitor and assess a patient's pain using the recognised measurement chart.

Summary

Ms C complained about the care and treatment that her late father (Mr A) received in hospital before his death. She said that staff failed to recognise and manage her father's pain and to act on her concerns about this. During our investigation, we took independent advice from one of our medical advisers. We found that there was no evidence in Mr A's medical records to suggest that he was in pain, and there was evidence that staff had recognised and acted on Mr A's agitation.

Ms C also said that Mr A was left sitting in a chair that he could not get out of unaided. Although our investigation found that the times that Mr A was in the chair were not recorded, our adviser said that it was reasonable for staff to get him out of bed, as moving and being in an upright position would have helped to prevent complications such as chest infections and venous thrombosis (a blood clot forming in a vein).

Finally, Ms C complained that a junior doctor did not pass on or discuss her concerns with senior colleagues and that she had difficulty in being able to speak to senior doctors. We did not find any evidence that this was the case. However, we did find that staff did not make it sufficiently clear that Mr A was dying before he was discharged from the hospital. We also upheld Ms A's complaint that staff delayed in responding when Mr A's family and carer used the assistance buzzer.

Recommendations

We recommended that the board:

• consider whether they should provide training to staff on giving difficult messages / bad news to patients and families; and
• provide confirmation that the nurse call system is now set at a volume that nursing staff can clearly hear.

Summary

Ms C complained to us that, at a medical appointment, a GP unreasonably requested her granddaughter (Miss A) to make a further appointment to discuss her low mood. This was the third issue that Miss A raised during the consultation, and Ms C felt that her granddaughter had little choice but to comply with the GP's request. Ms C felt that this had left her granddaughter in a vulnerable position.

As part of our investigation, we took independent advice from one of our medical advisers. The adviser noted that low mood was a potential symptom of depression. However, the adviser also noted that a doctor would, ordinarily, assess the patient while the patient was making such a statement (for example, by observing eye contact). The adviser also noted that there was a delay of around a month before the subsequent appointment was made, at which point Miss A declined the offer of assistance from a mental health worker.

Even taking account of the doctor/patient dynamic and acknowledging that it took courage for Ms C's granddaughter to raise the issue with her GP, the adviser noted that the GP had followed accepted practice. In addition, the delay in Miss A making the subsequent appointment (in addition to the offer of a mental health worker being refused) indicated that the GP's request was reasonable.