Health

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.

Summary

Mr C complained that he was prescribed the wrong dosage of his medication and that clear instructions were not given as to how many tablets he could take at a time. The practice provided us with copies of their records, clearly showing the appropriate dosage and instructions attaching to Mr C's prescription. We found no documentary evidence to support Mr C's account of events and we did not uphold the complaint. Mr C also said that he mistakenly received a letter from the practice about test results and complained that the practice had not explained why this had been sent. The practice confirmed that the letter was not intended for Mr C but, for data protection reasons, they could not offer an explanation to him. However, they provided us with sufficient information to satisfy us that there had been no administrative error and we did not uphold the complaint.

Mr C also complained that a meeting was set up for him to discuss his complaint with the practice manager and one of the doctors. He said that when he turned up the doctor did not know why he was there and the practice manager was not in attendance. Upon reviewing the records, we noted that the practice manager had documented that she set up this consultation for Mr C to discuss his medication with the doctor. It, therefore, appeared that both parties had differing recollections of the purpose of the meeting. We had no way of reconciling these different interpretations and we did not uphold the complaint. Finally, Mr C complained about the practice's handling of his complaint. We found that they failed to respond to him within the timeframe set out in their complaints procedure. We acknowledged that this may not always be possible but considered that Mr C should have been kept up to date. This did not happen and we, therefore, upheld the complaint.

Recommendations

We recommended that the practice:

• review their complaints procedure in order to ensure that, where complaint investigations are likely to take longer than their published timescales, they notify complainants of this and provide a revised target response date.

Summary

Mrs C complained that the care and treatment given to her young son (Master A) by his medical practice was inadequate. Master A had become increasingly unwell over the Christmas holiday period of 2011/12. He was eventually seen at hospital, but Mrs C complained that GPs in the medical practice had failed to diagnose her son properly and that it was largely due to luck that the second GP he saw referred him to hospital.

We investigated the complaint and took all the relevant documentation into account. We obtained independent advice from one of our medical advisers and reviewed Master A's clinical notes. We did not, however, uphold the complaint. The advice received was that the progression of Master A's illness had been slow and insidious. However, in the face of his presenting symptoms, his care and treatment had been satisfactory and appropriate.

Summary

Mrs C complained about the care and treatment given to her son (Master A) by out-of-hours GPs. Master A became increasingly unwell over the Christmas holiday period of 2011/12. He was twice seen by out-of-hours GPs in hospital but Mrs C said that he was not diagnosed properly or quickly enough, as a consequence of which he became severely ill. She also said that the board failed to properly deal with her complaint about this.

We investigated the complaint and took all the relevant documentation into account. We obtained independent advice from one of our medical advisers and reviewed Master A's clinical notes. We did not, however, uphold the complaint. Our adviser said that Master A's situation was a rare one and that most children with his symptoms would have recovered without hospital intervention. However, both out-of-hours doctors had responded appropriately and treated him satisfactorily.

Summary

Mrs C had rectal cancer. She underwent radiotherapy and chemotherapy before being admitted to hospital for an operation to remove the tumour. After surgery, Mrs C complained of abdominal pain and became very unwell. A scan showed that she had a leak in her bowel and she underwent an emergency operation. She was admitted to the intensive care unit and then transferred to the high dependency unit. A few days later, she was moved from the high dependency unit to a general surgical ward. The surgeon noted in her medical records that medical input was not sought before this move. She was discharged from hospital several weeks later, after which she received care at home from nurses and had an out-patient appointment.

Mrs C complained about communication with her and her family about the first operation. She said that they were unprepared for the nature and scale of the operation and that staff failed to identify post-operative complication within a reasonable time. She was also concerned about her move from the high dependency unit to a general ward, where staff appeared unable to cope with her serious condition. Finally, she complained about her post-operative care generally, the care she received from a nurse specialist at home following her discharge from hospital and confusion over the follow-up appointment at the hospital.

The board acknowledged that their failure to ensure that Mrs C and her family had a full understanding of the magnitude of the initial surgery and how it was to be carried out had caused considerable distress. This should have taken place at the pre-assessment stage through discussion with the clinical team and provision of written information leaflets. The board said it was also clear that Mrs C and her family had not been properly prepared for the immediate post-operative period. They apologised for these failings and set out an action plan to address them. They also agreed that they had failed in respect of the provision of specialist nursing after Mrs C returned home, and had since initiated a comprehensive and robust action plan.

After taking independent advice from our medical advisers, our investigation found that although Mrs C signed a consent form at an out-patient appointment the day before the operation, the notes on the form did not mention any complications or facts relating to the procedure. We, therefore, found that the board failed to record any discussions about the procedure and its complications or to provide written information before the operation took place. We also found that they failed to provide counselling from a specialist nurse in relation to the surgery, contrary to the relevant guidelines. Although Mrs C was moved from the high dependency unit to a ward that could attend to the monitoring that she needed at the time, this was only ascertained after the event and no medical input was sought before the move. Finally, although we found that the post-operative care was reasonable in all aspects except the lack of involvement of a specialist nurse, this was a significant failing. As the board had already taken significant steps to address most of the failings identified, we only found it necessary to make one recommendation.

Recommendations

We recommended that the board:

• ensure that the patient is formally assessed as being clinically appropriate to move from the high dependency unit in a similar situation.

Summary

Mrs C complained about the care and treatment her late husband (Mr C) received in hospital. Mrs C said that a locum (temporary) assistant had not carried out the correct procedure for referring Mr C to a specialist chest consultant at the hospital; that records from another patient were found in Mr C’s notes and that an occupational therapist (OT) had conducted an assessment on Mr C using water from a tap with a blocked sink.

We took independent advice from a medical adviser, who considered all aspects of Mrs C’s complaint and Mr C’s care at the hospital. He said that the board had failed to ensure that an abnormality on Mr C’s chest x-ray was appropriately investigated after it was noted by the radiologist (a medical specialist that uses imaging to diagnose and treat disease). The board had acknowledged and addressed this, and apologised to Mrs C before the complaint was brought to us. We, therefore, upheld this complaint. Mr C subsequently died of cancer, but our adviser said that it was not possible to say whether the outcome for Mr C would have been different had a diagnosis been made earlier.

Although our investigation found no evidence that another patient’s records were included in Mr C’s notes, we acknowledged that such an event can occasionally occur and noted that the board had expressed regret about this. We upheld the complaint.

We found no evidence that water from a blocked sink had been used in the OT assessment and so we did not uphold this complaint.

Recommendations

We recommended that the board:

• provide an update on the implementation of their protocol, with specific reference to how results of investigations undertaken whilst a patient is an in-patient are reconciled with their case notes after discharge.