Health

Summary

Miss C's mother (Mrs A) was admitted to hospital for surgery. Her recovery took a long time and she developed pleural effusions (fluid that gathers around the outside of the lung). After about four months she was transferred to another hospital. At this time she was still very unwell, being tube-fed and having a urinary catheter (a thin tube used to drain and collect urine from the bladder). Tests showed abnormalities in her abdomen. At the end of that month, Mrs A was transferred to a third hospital but returned to the second hospital several days later when tests indicated a chest infection. She was diagnosed as having contracted clostridium difficile (a common healthcare-associated infection). A line to provide better access to her veins for intravenous fluids and antibiotics was inserted but became dislodged. Her condition continued to worsen and she died a few days after being transferred.

Miss C complained that during her mother's time in the second hospital the board did not reasonably attempt to address her chest condition, and failed to help with eating or to consider her dietary requirements. She also complained that the board inappropriately transferred Mrs A to the third hospital, given her chest condition, and that they failed to take reasonable steps to ensure that the access line did not become dislodged. Finally, Miss C complained about the board's complaints handling.

We took independent advice from a medical adviser and a nursing adviser. The medical adviser said that before Mrs A's transfer to the third hospital there were shortcomings in diagnosing and managing the inflammation that Mrs A had and that the decision to transfer her was, therefore, questionable. The nursing adviser said that the nursing care in relation to nutrition was reasonable. However, given our concerns about the shortcomings in medical care we upheld the complaint. We were satisfied that in their complaint response the board provided a reasonable explanation for the cause of Mrs A's pleural effusions. However, we upheld the complaint about this because although they acknowledged that Mrs A's care could have been better managed, they failed to provide any further details. We also noted that they did not respond to her second letter of complaint for 14 weeks.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised with the relevant clinicians during their next appraisal;
• review their complaints handling process in light of our findings; and
• apologise to Miss C for the failures identified.

Summary

Miss C's sister (Miss A) fell at home and was admitted to a hospital. Although she injured her back in the fall, her health had already been deteriorating for around two months. Miss A had a history of alcoholism and was underweight, and her GP had been treating her for urinary and lower respiratory tract infections. While in hospital, Miss A became lethargic and developed symptoms of liver disease. Although she initially responded well to treatment, her condition deteriorated and she was transferred to the care of liver specialists at a second hospital in a different board area. By that time Miss A was also suffering from pneumonia and increasing confusion, and she died two weeks after falling.

Miss C complained about the quality of nursing care at the second hospital, and the level of communication with family members. Specifically, she complained that she was not told that she could visit her sister outwith the standard visiting times, and that she was not contacted during the night when her sister's condition deteriorated. Miss C visited Miss A the following morning and found that she had died. She was unattended, with unconsumed medication on and around her bed.

We found the level of nursing care to be below an acceptable standard. Miss C should have been given clearer information about visiting times and should have been contacted when her sister's condition deteriorated. We accepted advice that, although Miss A's condition was closely monitored, staff should have identified that her deterioration was indicative of a terminal decline. Their failure to do so meant that Miss C was not able to be with her sister when she died. We also found that staff failed to provide adequate supervision of Miss A's medication intake.

Recommendations

We recommended that the board:

• apologise to Miss C for failing to make her aware of their flexible visiting arrangements and for failing to contact her when her sister's condition deteriorated;
• review their visiting policy to ensure that relatives are provided with information about visiting arrangements for patients who are critically ill;
• apologise to Miss C for failing to act on the changes to Miss A's vital signs during the night before she died;
• consider whether their nursing staff would benefit from refresher training on end of life care; and
• remind nursing staff of their responsibilities in line with section 2.10 of the Nursing and Midwifery Council Standards for Medicines Management.

In March 2014, the NHS board involved in this case told us that they had identified further evidence which meant we were able to investigate further. We issued a public report of our findings on 18 February 2015, under reference 201401376. The decision below is not, therefore, the final decision on this complaint and is retained here for archive purposes.

Summary

Mrs C, who is an advocacy worker, complained on behalf of the partner of Mr A that the board failed to provide Mr A with an appropriate level of treatment. Mr A was admitted to a hospital's acute medical assessment unit with chest pain. He was transferred to the care of cardiologists (specialists dealing with disorders of the heart) who noted that he had severely high blood pressure. He was treated as having acute coronary syndrome (a medical term used when doctors believe that the patient has a serious problem with the narrowing of one or more of the coronary arteries) because of an elevated serum troponin (this is present in the bloodstream when there has been damage to the heart).

An echocardiogram (an instrument for diagnosing heart abnormalities that uses reflected ultrasonic waves to show the structures and functioning of the heart) was carried out at Mr A's bedside on the day of his admission. Two days later, he was sent for a further echocardiogram. This showed the presence of a tear in the ascending aorta (a portion of the large artery that carries blood from the left ventricle of the heart to branch arteries). A CT scan (a procedure that uses x-rays to define normal and abnormal structures in the body) was performed the same morning confirming the diagnosis of aortic dissection. Arrangements were made for Mr A to undergo surgery that day, but he died in the anaesthetic room before the operation could begin.

We took independent advice from one of our medical advisers, who said that aortic dissection is a rare condition and it is not unusual for the diagnosis of it to be missed. This is because unless a CT scan or, as in Mr A's case an echocardiogram, is performed there may be no specific pointers away from the presumed diagnosis of acute coronary syndrome. For most patients, it is relatively unlikely that a chest CT scan would be performed on a routine or even random basis. Although the fact that Mr A was at risk of aortic dissection was not picked up from the first echocardiogram, there was no recording of this and it was possible in any case that the tear developed after this had taken place.

Mr A had to wait for his operation because it was the holiday period and there was only one surgeon on call, who was in the middle of an operation. We found that it was not unreasonable that the cardiac surgeon completed the operation he was performing, before operating on Mr A. It was also likely that Mr A would have died before an operation could have been performed if he had transferred to another cardiac surgical centre. Mr A was in the acute phase and needed a very high-risk operation. In addition, we considered that Mr A had received the correct medication to lower his blood pressure and relieve his chest pain.

We found that overall, the actions of the doctors were reasonable and appropriate and we did not consider that there were any unnecessary delays.

Summary

Mrs C complained about the care and treatment that her late father (Mr A) who was 93 years old, received from his medical practice. In January 2012, Mr A went to his GP with backache. He said that he was told he was wearing too many clothes and to return to see the nurse for blood and urine tests. Mrs C contacted the practice and arranged for a nurse to call at the house, but she only took blood tests. Mr A continued to deteriorate and his GP said he would refer him to hospital as he had swallowing difficulties. Mr A went to the hospital on a number of occasions and was seen in various departments. A scan in June 2012 confirmed lesions in Mr A's pancreas, and that this was likely to be pancreatic cancer. A multi-disciplinary team met in the hospital, and decided that Mr A would not be offered surgery in view of his age, other medical conditions (including diabetes) and because it was unlikely to be successful. Palliative care was to be offered instead. The hospital wrote to the practice with the results of the scan 17 days later. Mr A's condition continued to deteriorate and Mrs C requested a home visit from the GP, who was delayed in getting there. When he arrived and assessed Mr A, the GP requested an ambulance to admit Mr A to hospital. Mr A died six days later.

Mrs C complained that the practice did not treat her father's backache, and did not treat or refer him to hospital for problems with his diabetes. In his last few weeks, Mr A stopped eating, lost a tremendous amount of weight and was bedridden. She said that the practice also failed to offer additional homecare. Mrs C said that the GP should have visited and admitted Mr A to hospital earlier. She believed that the practice displayed a lack of care and attention towards Mr A and failed in their duty of care to him.

As part of our investigation we took independent advice from one of our medical advisers. The advice, which we have accepted, was that the practice provided a reasonable standard of care to Mr A (including diabetic care) and that the family were offered additional homecare on a number of occasions, but Mr A's wife declined this. It was also clear that communication was reasonable and that the practice tried to provide Mrs C and her family with information, but that this was hampered by delays by the hospital. We were satisfied that the standard of medical care provided to Mr A by the practice was reasonable.

Summary

Mrs C received hospital treatment for a cerebrospinal fluid (CSF - the fluid that surrounds the brain and spinal cord) leak in 2009. As other procedures had been unsuccessful, a shunt (a device inserted to transport excess fluid elsewhere) was inserted, but Mrs C believed this to have been too short, and that this contributed to her subsequent stroke.

She complained that the treatment she received to try to repair the CSF leak was unreasonable, that it took too long to identify that she had suffered a stroke, and that the board unreasonably failed to tell her in advance that there was a risk that the treatment might lead to a stroke.

After taking independent advice from a medical adviser, although we recognised Mrs C's concerns, we did not uphold her complaints. After inspecting Mrs C's medical records, the adviser said that her care and treatment was entirely reasonable, and that the shunt was not too short, but had probably moved, which is a common and recognised complication of that procedure. He was clearly of the opinion that this could not have caused the stroke. He also said that there was no sign of delay in identifying that Mrs C had experienced a stroke, and no identifiable risk that the treatment might lead to one. It was not unreasonable that Mrs C was not warned of this.

Summary

Mr C complained that his medical practice refused to update him on changes in his son (Master A)’s medical file, about which his estranged wife had not told him. Mr C also complained that the practice had prevented him from transferring his son to an alternative practice in the area.

We looked at the information provided by Mr C and obtained information from the practice. We also took independent advice from our GP adviser. Our investigation found that the practice were not required to keep Mr C informed, and that it was a matter for him and his estranged wife to resolve. We also found that the practice had acted correctly dealing with Mr C's request to transfer Master A, as it was not reasonable for one parent to try to re-register a child without the other parent's knowledge.

Summary

Ms C has multiple allergies. In September 2011, she was admitted to hospital with severe abdominal pain and vomiting. She was diagnosed with appendicitis and had an operation later that day. The surgeons found that the appendix had ruptured and she had peritonitis (inflammation of the tissue lining the abdomen). The consultant anaesthetist noted that she had at least one anaphylactic shock (a severe, potentially life-threatening allergic reaction) the day after the operation. A week later, her condition deteriorated and she needed another operation.

Several days after being discharged, Ms C was re-admitted to hospital with abdominal pain. She was discharged the next day and staff arranged for her to be seen as an out-patient. In December 2011 she was admitted again with abdominal pain and vomiting. She was prescribed two forms of pain relief and an antibiotic and considers that she had an anaphylactic shock as a result. Ms C was discharged just over a week later to attend the pain and surgical clinic as an out-patient. She was admitted to the intensive care unit at the hospital at the end of February 2012 following an anaphylactic reaction to a barium solution (a liquid used when carrying out scans and x-rays) in the x-ray department. She told us that she also had further reactions to medical wipes.

Ms C complained that as a result of the board’s failures, she endured a second avoidable operation, and developed hernias, constant abdominal pain and abnormal bowel movements. She said she had a number of anaphylactic attacks, which were avoidable had staff taken reasonable steps to prevent them. She also complained that while she signed consent forms, she was not physically or mentally capable of giving consent to treatment, and raised concerns about the way the board handled her complaint and the delay in responding.

After taking independent advice from two of our medical advisers, a surgeon and a nurse, we did not uphold Ms C's complaints about her care and treatment. The advice we received and accepted was that the care and treatment she received in relation to the operations, including post-operative care, was reasonable. There was clear evidence that she consented to both operations and that staff communicated with her and her family, although the family felt that this did not meet their needs. In relation to the complaint about her care while an out-patient, particularly in relation to her allergies, on the whole we found that the care and treatment was reasonable. We found that the medical assessments and notes contained many references to Ms C's allergies, although we noted the board had acknowledged that radiology staff had not received information about these and had taken steps to address this.

We did, however, uphold her complaint about the complaints handling. We found that the board had carried out a thorough investigation of Ms C's complaint and responded to all the issues raised. However, they took eight months to do so. Ms C had agreed with the board that they would respond to all her complaints in one letter, although it was not clear when this happened. This approach had made the delay worse, however, as draft responses were prepared but not issued. We noted that each time Ms C had raised further complaints, the board had started a fresh investigation. We took the view that they could and should have managed this better.

Summary

Mr C complained that staff failed to involve him and his brother in discussions about future care plans for their mother (Mrs A). He said that staff decided that their mother was to be moved to another hospital to be assessed for a nursing home without any consultation with the family. We found that this was a difficult situation where Mr C and his brother, along with the health care team, were trying to get the best outcome for Mrs A. It appears that Mrs A was not able to return home and staff did their best to involve Mr C and his brother in the discharge arrangements. There was clearly some confusion regarding Mrs A's transfer to another hospital. The records showed that Mr C was told that his mother would have a further assessment for a nursing home there. The doctor also tried to contact Mr C again to discuss this before Mrs A was transferred, but there was no answer.

We did not uphold Mr C's complaint about this, as we found that the records provided evidence that staff spoke to Mr C and his brother very frequently throughout their mother's stay in hospital. There was no evidence of shortcomings in relation to communication and we were satisfied that staff took on Mr C's concerns about Mrs A's future care plans when he later complained about this.

Mr C also complained that staff inappropriately assessed Mrs A without ensuring that her hearing aid was in place. Although Mrs A lost her hearing aid on several occasions, we were satisfied that staff took reasonable steps to obtain replacements. Ideally, a patient should be wearing a hearing aid when being assessed. However, where this is not possible, as in Mrs A's case, it is reasonable for staff to carry out an assessment without the hearing aid in place, providing that they speak clearly and loudly during the assessment. Finally, Mr C complained that staff failed to adequately investigate his concerns that some of Mrs A’s clothing had been lost. We were satisfied that staff adequately dealt with his concerns about this.

Summary

Mrs C complained about a number of matters related to her caesarean section (c-section - an operation to deliver a baby, which involves cutting the front of the abdomen and womb) and her subsequent care. Mrs C experienced a combination of complications including heavy bleeding and deep vein thrombosis (DVT) requiring hospitalisation.

After taking independent advice from a medical adviser, we found that most of Mrs C's medical and nursing care was reasonable. However, we upheld her complaint as we considered that the board did not take all possible precautions to reduce the likelihood of her developing DVT and heavy bleeding. We identified that Mrs C was given a combination of drugs that was likely to have caused her bleeding to worsen. We also considered that Mrs C should have been given compression stockings before and after the c-section until she regained full mobility. This did not happen in line with national guidelines on thrombosis and embolism in pregnancy. Mrs C also developed pressure sores following her c-section - the board acknowledged that she had not been properly assessed in this respect and agreed that this was unacceptable.

Recommendations

We recommended that the board:

• provide evidence to show that they have updated their policy on DVT to include the use of compression stockings;
• provide evidence to show that they have reminded relevant staff of the importance of assessing those mothers at risk of developing pressures sores following c-section;
• consider developing a template for documenting pressure sore risk assessments; and
• apologise to Mrs C for the failings we identified.

Summary

Mr C complained on behalf of his son (Mr A). Mr A had mental health problems but although he was twice on the waiting list for treatment for this, the board removed him from the list because he was either being investigated by the police or was awaiting trial. Mr C complained to the board, who confirmed that as there were outstanding charges against Mr A, his name had been removed. They said that this was in accordance with their usual protocol.

As part of our investigation we obtained independent advice from one of our medical advisers, a consultant forensic psychiatrist. Our adviser said that the board's protocol was contrary to the NHS policy of individualised care according to need. Mr A had been removed from the waiting list without due consideration for his needs and circumstances. We upheld the complaint as Mr A had received no treatment, and had significant psychological needs that went unmet.

Recommendations

We recommended that the board:

• formally apologise to both Mr C and Mr A for failings in this matter;
• look again at their protocol in terms of the Healthcare Quality Strategy for NHS Scotland 2010; and
• assure themselves that any outstanding mental health needs for Mr A are now addressed.