Health

Summary

Ms C complained that the care and treatment provided to her mother (Mrs A) was inadequate. Mrs A suffers from multiple sclerosis (MS) which is a degenerative disease affecting the nervous system. Sufferers can have various difficulties including mobility, digestive system and urinary problems.

In November 2010, Mrs A was hospitalised with a severe urinary infection which later developed into septicaemia (a serious bacterial infection). She was in several hospitals until early 2011. Ms C complained that, during her mother's time in hospital, the board failed to provide an adequate level of physiotherapy; failed to provide a reasonable level of specialist MS nursing care; failed to adequately communicate with the family, and failed to respond appropriately to Ms C's complaint.

Our investigation included taking independent advice from two medical advisers - a physician and nephrologist (kidney specialist) and a senior nurse with experience in neurological and neurosurgical nursing (treating illness or injury affecting the nervous system). We found that an appropriate level of physiotherapy and MS nursing input had been provided to Mrs A during her hospital stay.

Mrs A was, at times, very unwell and our medical advisers considered that the important thing was to address her acute symptoms of infection. When Mrs A was able to engage with the physiotherapy team, therapy was provided. Although the MS nurse only visited Mrs A once during her stay, the nursing adviser considered that there would have been no added value from further input at the time.

We found that Mrs A's MS was regularly and appropriately reviewed during her hospitalisation. However, the physician adviser felt that there was no evidence of communication between the doctors and Mrs A and her family. There were some records of communication from nursing staff but Ms C still felt that communication in general had been poor. The board had responded that next of kin are not automatically entitled to information about a patient and the patient's confidentiality had to be protected. However, our investigation found that guidance from the General Medical Council states that while patient confidentiality should be considered at all times, common sense should also prevail when a patient is very ill and unable to either give or withhold consent to share information with their family. In this case, Mrs A was at times very ill indeed and the advisers thought that staff should have used common sense in their communication with the family.

Ms C was also dissatisfied with the time taken to respond fully to her complaint and said that there were inaccuracies in the final letter from the chief executive. Our investigation confirmed that the timescales for responding to Ms C's complaint had been breached without her being kept up to date and that there were inaccuracies in the letter.

Recommendations

We recommended that the board:

• apologise for the failings in communication and complaint handling identified;
• make staff aware of and adhere to relevant guidance on communication with family/carers/loved ones; and
• make staff aware of and adhere to the guidance on complaints handling.

Summary

Mr C complained that a hospital failed to provide his late father (Mr A) with appropriate care and treatment when he developed cancer. There were several components to this complaint that included an incomplete colonoscopy (examination of the bowel with a camera on a flexible tube), discharge from the hospital when unwell, and delays with arranging a biopsy (tissue sample) and a scan. The board had acknowledged some failings before Mr C brought his complaint to us and we also looked at the action they had taken about this.

Our investigation included taking independent advice from one of our medical advisers. We took account of his advice as well as evidence from Mr C and the board. Our investigation found that the concerns Mr C raised reflected the complexity of this difficult and involved case. This included that Mr A had a number of symptoms under investigation (not linked to the cancer) when he also developed symptoms of the cancer that caused his death. Based on all the evidence, we came to the conclusion that there were no grounds to uphold the individual components of Mr C's complaints. We did find some evidence of delay between two investigative procedures, and made recommendations to address this.

On balance, however, we considered that overall Mr A received an acceptable standard of care and treatment in terms of the way that he presented to the hospital and we did not uphold the complaint.

Recommendations

We recommended that the board:

• advise of the steps taken to ensure similar delays to those experienced do not recur;
• ensure that scans are recorded in patient case notes regarding when and where they take place;
• advise on the steps taken to address multiple consultant involvement regarding ownership and co-ordination of a patient's care;
• ensure all patient case notes are filed sequentially;
• advise on the general surgery and clinical governance group (GSCCG) decision regarding the minuting of actions after a review of a complaint has taken place;
• advise on the results of the Steering Group's investigation of this case;
• advise on the setting up of the regional working group on the investigation and management of cancers with unknown primary sources; and
• advise whether the GSCCG presentation to the Integral Care and Partner Services clinical governance steering group has taken place.

Summary

Mr C and his partner sought in vitro fertilisation (IVF) treatment on the NHS. The board, however, said that because Mr C's partner's child from a previous relationship lives with them, they were not eligible for treatment. Mr C said that this decision was unreasonable because the board's policy on assisted conception discriminates against him and other men who have no biological children. He also said that the board did not deal with his complaint properly in that there were inaccuracies and delays in their responses and that they failed to address his complaint.

We explained to Mr C that it was not for us to determine whether the board's policy was discriminatory, but that we would consider whether their actions were reasonable. We found that their decision was reasonable in light of the framework for infertility services accepted by the Scottish Government and that, in taking legal advice and ensuring compliance with Scottish Government guidelines, they had acted in line with legislation and guidance.

We did find that the board delayed in responding to the complaint and that their responses should have provided a clearer explanation about the framework for infertility services from the outset. However, we made no recommendations about this, in light of the fact that the board reviewed their complaints management system earlier this year.

Summary

Mr C's elderly mother is cared for in hospital. He told us that one day when he was visiting her, the nurse in charge spoke to him in an inappropriate way. He was unhappy because when he complained to the board about the incident, he said they did not investigate or handle his complaint properly. He said that the board did not ask a witness for information and that there was an unexplained delay in passing his complaint to the board's complaints team.

We upheld his complaint about the investigation. We found that the board did the correct thing by interviewing the nurse involved, and we were satisfied that they did so as soon as they could after the complaint reached the complaints team. We could reach no conclusion about whether all the correct witnesses were interviewed, as accounts of who was there were different. We were, however, concerned that two witness statements appeared to have been taken after the date on which the board responded to Mr C's complaint, and made recommendations to address this.

We did not uphold his concerns about the complaints handling. Our investigation found that Mr C initially asked for his complaint to be handled on the ward, but later decided that he did not want to meet the member of staff who was handling it. Although there were typing errors in the board's letters and we identified a minor issue about the time it took to provide a final reply to his complaint, we noted the board's policy that staff made aware of a complaint should handle the matter locally as far as possible. We, therefore, found that the reasons for the delay in passing the complaint from the ward to the complaints team were understandable. We also noted that, as Mr C and his family had repeatedly expressed concerns about his mother's care, the board had appropriately arranged for reviews of her nursing and medical care.

Recommendations

We recommended that the board:

• remind staff to ensure that, in future, relevant witnesses to events are interviewed or asked to provide a statement as soon as possible after the event, and in any case, during the investigation of the complaint;
• provide specific guidance on obtaining witness information (in their advice to staff about operating the complaints policy); and
• review their practice for checking draft letters to be issued by the complaints team, with the aim of minimising the chance of typing errors. The board should let the Ombudsman know the steps that they put in place as a result.

Summary

Mr C complained about the board’s management of his wounds. He advised that he had to wait up to four days to have the wound dressings changed, whereas he felt they should be changed every two days. In responding to Mr C, the board indicated that, due to the nature of the skin breaks, the healing tissues should not be disturbed unless necessary.

We took independent advice from one of our clinical advisers, who said that the frequency with which dressings should be changed varies depending on factors such as clinical need, dressing type and physical conditions. Having reviewed the schedule for Mr C's dressing changes, she was content that he was having his wounds cared for in the most appropriate manner. We accepted this advice and did not uphold the complaint. However, we identified that, on occasion, the board had failed to record details of Mr C's dressing changes, and our adviser confirmed that the record keeping could have been better in this case. In responding to our enquiry, the board acknowledged this deficiency, apologised and confirmed they had raised it with the staff involved. We considered this reasonable and had no further recommendations to make.

Summary

Mr C complained about the care and treatment that his father (Mr A) received when the board referred him to a private hospital as an NHS patient for an operation. Mr C said that his father's discharge from the hospital was unreasonable, as he had not passed urine. He also complained that his father was discharged in severe pain with pain relieving drugs co-codamol and paracetamol, despite the fact that he had told the hospital he could not take co-codamol as it contained codeine. A nurse had recorded in Mr A's notes that he had passed urine before being discharged. In response to the complaint, the nurse said that although she could not remember Mr A, she had noted this in the records, and he would not have been allowed to leave the hospital had he not done so. We found that there was no evidence to support Mr C's complaint that the record had been falsified. However, we found that Mr A was prescribed co-codamol in error, as the hospital had previously recorded that he was not to be given codeine. We upheld this complaint and made recommendations to address this. Mr C also complained that the hospital's response was unreasonable when his mother contacted them about his father's pain after his discharge. We found no evidence to support this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr A for administering co-codamol in error; and
• review this matter in order to identify how they can prevent such errors.

Summary

Miss C's father (Mr A) was admitted to hospital via the accident and emergency department after a fall. Mr A had suffered two previous falls and had become increasingly forgetful over a period of seven to ten days. Mr A's level of consciousness was recorded as being normal upon admission, but dropped shortly afterward. A scan showed that he had had a cerebral bleed (bleeding on the brain). Although he made a slight improvement while in hospital, he developed pneumonia and died the next month.

Miss C raised a number of concerns about the treatment that Mr A received from the hospital's staff and the level of attention paid to his needs whilst he was an in-patient. She also complained about the board's communication and handling of her complaint.

We took independent advice from two of our medical advisers, and upheld almost all of Miss C's complaints. We found that the overall level of care and treatment provided to Mr A was reasonable, but there were some specific issues that concerned us and we considered these to be serious failings. Specifically, we found that insufficient nursing care was provided throughout one day, when Mr A was in a single room. A lack of written notes cast doubt as to whether certain tasks had been performed and, in particular, whether a swallow screen test (a test to check the patient’s ability to swallow) was carried out by a suitably qualified member of staff.

We were concerned to note that Mr A's family were not told that a decision had been made not to attempt resuscitation (ie that a doctor was not required to resuscitate Mr A if his heart stopped). We also found that this decision was taken without the input of a senior clinician as is required. Generally, we did not consider that the lead clinician caring for Mr A was sufficiently involved in his care. We were satisfied that the information contained in Mr A's clinical records was reasonable, but were critical of the board for the number of omissions in the records. We made a number of recommendations to address the failings we found.

We did not uphold the complaint about complaints handling, as we found the board's handling of Miss C's complaint to be reasonable.

Recommendations

We recommended that the board:

• draw our adviser's comments on the use of anti-sickness medication in syringe drivers to the attention of clinical staff;
• provide the Ombudsman with details of the outcome of their 'care round' document trial and any changes to their patient monitoring procedures that result from this trial;
• review the level of involvement of senior clinical staff in patients' treatment;
• remind their staff of the need to discuss 'do not resuscitate' decisions with patients and their families;
• remind nursing staff of the need to maintain full and accurate nursing records in line with Nursing and Midwifery Council guidance; and
• apologise to Mr A's family for the issues highlighted in our investigation.

Summary

Mr C’s late wife (Mrs C) was diagnosed with a thickened area of the womb due to complex hyperplasia (the result of the formation of extra cells) and was referred to a waiting list for a hysteroscopy, dilatation and curettage (a D&C - treatment to correct this). Mrs C had the operation as a day procedure. Mr C said that following the procedure and on discharge home that day, Mrs C became increasingly unwell. Two days after the procedure, he phoned the local medical practice GP for a home visit, and the GP arranged for Mrs C to go to hospital. Mrs C was taken to the intensive care unit where she died four days later. A post mortem was carried out and the death certificate stated the cause of death as septic shock (severe infection), intrauterine sepsis (a viral infection in the womb), acute renal (kidney) failure and cardiomegally (enlarged heart).

Neither the board nor the Procurator Fiscal’s post-mortem could establish the reason for Mrs C’s death. Mr C and his family complained to the board about this. The board investigated the case, held an internal review and met with Mr C, his family and an independent caseworker. Mr C believed that the board had a responsibility for his wife’s death and had failed to provide an explanation for it. He also said the board failed to communicate with him and Mrs C and that there was a failure to act on nursing staff's concerns about Mrs C's discharge.

Our independent medical adviser considered all aspects of Mr C’s complaints. Having taken account of his advice alongside the evidence provided by Mr C and the board, we concluded that there was no proof of the cause of Mrs C’s infection. In the absence of such evidence, we found that the board had not in fact failed to provide Mr C with a reason for the cause of infection. We also carefully considered all aspects of the communication between the board, Mr C and Mrs C. There was no evidence to support the complaint of failure to communicate, or that the risks of the operation were not explained to Mrs C, and that Mr C had not been advised of the warning signs to observe on Mrs C’s discharge. There was also no evidence that nursing staff had raised concerns about Mrs C before she was discharged. Although we did not uphold Mr C's complaints, we did make recommendations to address issues that had emerged during our investigation.

Recommendations

We recommended that the board:

• ensure that medical staff (and patients) legibly complete every section of a consent form at the time consent is obtained;
• ensure all staff complete a record or document outlining the information leaflets they provided to patients; and
• provide the Ombudsman with an update on their review of the written information provided.

Summary

Mrs C complained to the board that hospital staff failed to clearly explain to her late father (Mr A) or members of his family, the seriousness of his condition and that he had pancreatic cancer. The family only found out when they opened a letter which was intended for Mr A's GP.

We did not uphold this complaint. Our investigation found that there was evidence in the clinical records that staff had explained to Mr A on many occasions that there was a possibility that he had cancer. Mr A had, however, told staff that he did not wish any of his family members to be present when he received the results of investigations and said that he would tell them himself.

Summary

Mrs C complained that reception staff at the medical practice failed to allow her granddaughter, who was taken by her mother and father to the surgery, to see a doctor. The family had attended in person because they could not get through on the phone and they were concerned about their daughter's deteriorating health. When they could not see a doctor, they took their daughter to hospital where she was diagnosed with meningococcal meningitis. Mrs C also complained about the way the practice dealt with her complaint.

We found that the reception staff had failed to deal with this incident appropriately. We were of the view that they should have sought advice from the clinical team who would then, in all probability, have arranged emergency transport to hospital. We also agreed that they did not handle the complaint well. As a result of this, we upheld Mrs C's complaints. However, we did note that when this matter came to the attention of clinical staff, the practice had taken it very seriously. They carried out a significant event analysis and introduced procedural changes and staff training to try and minimise the likelihood of a similar situation arising in the future. On the basis of their actions, and their apology to Mrs C's family, we did not make any further recommendations in this case.