Health

Summary

Mrs C, complained to us about the care and treatment of her late mother (Mrs A) who had a complex medical history, including bowel cancer. After falling, Mrs A was admitted to a hospital high dependency unit. She was given a blood transfusion and antibiotics for a urinary tract infection. As doctors thought Mrs A had suffered a stroke she was moved to the stroke ward at 03:30.

Shortly after admission to the stroke ward, Mrs A stopped eating, experienced constipation and complained to her daughter of knee pain. Six days after she was moved there, her condition deteriorated rapidly and Mrs C’s husband telephoned Mrs C saying that the hospital had called to say that Mrs A had taken a bad turn and Mrs C should go to the hospital. Mrs A passed away shortly afterwards. The death certificate noted Mrs A’s cause of death as toxins and a perforated bowel.

Mrs C complained about these events, saying that staff should have dealt with Mrs A’s problems sooner and that her mother was transferred from one ward to another at an inappropriate time. She also said that she suspected that the suppositories or other medical interventions might have caused her mother’s deterioration and death, and was unhappy about the attitude of nursing staff. She said that they showed unprofessional attitudes to her and her mother and failed to properly contact her on the morning of Mrs A’s death.

The board’s reply to Mrs C’s complaint recognised that there were some problems with communication between nurses and Mrs A’s family. They also recognised that the early morning transfer between the high dependency unit and the stroke ward was inappropriate as there was no clinical need for it to be done at this time. They agreed that staff should have known to contact Mrs C directly on the morning of her mother’s death. They apologised and ensured that the relevant managers were made aware of the issues.

We did not uphold Mrs C's complaints. After reviewing the board’s file and Mrs A's medical records, and taking independent advice from our medical and nursing advisers, we found that the general quality of care provided was reasonable. We also considered that the board had taken reasonable steps to resolve the issues about communication, transfer and contact. We considered that the medication provided to Mrs A during her stay was appropriate and could not reasonably be linked to Mrs A’s death. We found no evidence of unprofessional behaviour by nursing staff towards Mrs C or her family.

Summary

Mr C complained that the board failed to provide him with reasonable care and treatment for his mental health problems. He detailed a number of areas about which he was concerned, and he was also unhappy about the way in which the board handled his complaint. He said that the consultant concerned had lied in his response.

During our investigation, we took independent advice from our medical adviser who is a consultant psychiatrist. We found that that the frequency of the board’s contact with Mr C was reasonable. We also found that the frequent use of hospital admissions and the fact that a large team were involved in his assessment and treatment were examples of good clinical practice. Although some of the clinics that Mr C was to attend were cancelled, we did not consider that this was excessive. We also found that it was reasonable to arrange clinics in locations that would benefit the greatest number of patients. However, we found that Mr C had been prescribed with large doses of medication that were not appropriate for the disorder he had been diagnosed with. This led to him being over-sedated. For this reason, we upheld his complaint about care and treatment, although we noted that the board had since carried out a review of his medication. We did not uphold the complaint about complaints handling, as we found that the board’s response was reasonable and we did not consider that the consultant had lied.

Recommendations

We recommended that the board:

• issue a written apology for their failings in relation to prescribing medication, which led to Mr C's over-sedation.

Summary

Mr C complained that the medical practice had acted unreasonably in refusing him a repeat prescription for an inhaler. He had made a repeat prescription request, but this was refused and he was told to attend an asthma review clinic two weeks later. He was unhappy that he had not been given his medication at the time he needed it, which he felt was a risk to his health.

The practice's response to Mr C indicated that before he made the prescription request he had been sent four letters inviting him to attend the asthma clinic but he had not gone. The prescription record also showed that Mr C was not using his inhaler regularly. They had, therefore, felt unable to issue the prescription until he had complied with their requests for an asthma review. They said they had a clinical, ethical and legal responsibility to review his medication and clinical condition before issuing a prescription. They offered him the opportunity to have the review undertaken in a manner and at a time which suited him, and to refer him to a respiratory specialist.

We took advice from our medical adviser, who considered Mr C's medical records. He said that treatment cannot be given without reasonable and correct supervision, and that the practice had given Mr C various opportunities to attend for the review. Given the pattern of inhaler use, he also considered that such a review would be good clinical practice. We concluded that the practice did not act unreasonably, and did not uphold the complaint.

Summary

Ms C's mother (Mrs A) was admitted to hospital with community-acquired pneumonia. During her stay, Mrs A also complained of constipation, nausea and vomiting. On the final day of her admission, Mrs A’s condition worsened considerably. She was transferred to the hospital’s medical high care area and, within hours, to the highest level of care within the intensive care unit, where she died.

Ms C considered that the care provided to her mother was inadequate. In particular, she felt that staff failed to properly address Mrs A’s constipation and that nursing staff acted rudely and unprofessionally towards Ms C and her family. Ms C also considered that medical staff failed to act quickly enough to transfer Mrs A to medical high care and felt that, if Mrs A had been transferred earlier, she might not have died.

We did not uphold Ms C's complaints. After obtaining independent advice from our nursing adviser, we decided that the nursing care provided to Mrs A was reasonable, that nursing staff acted appropriately to the reports of constipation and that recorded communication with Ms C and her family was reasonable. As there was no corroboration of events, we were unable to come to an accurate conclusion about the manners of particular nursing staff. We also obtained independent advice from our medical adviser, and found that medical staff took appropriate action to monitor Mrs A’s condition and investigated and addressed her medical problems reasonably. We found that the timing of Mrs A’s transfer to medical high care was reasonable and saw no evidence to suggest that staff should have taken the decision to transfer her earlier.

Summary

The hospital introduced a new clinical model in September 2011, setting up new hub and cluster units. Each of the four hubs supports a cluster of three

12-bedded wards, with various therapeutic, physical, creative and social activities taking place in the hub. There is also a central unit where more formal therapies and educational activies are held.

Mr C, who is a patient in the hospital, complained that when the new model was introduced he was unreasonably pressurised to attend activities in the hub area even though he did not like it there. He described it as little more than a corridor, and found it cold and uncomfortable. The board acknowledged that there were teething problems in the early days of the new model while both staff and patients got used to the new regime. This sometimes meant that wards were closed, or patients relocated to other wards, to allow staff to be suitably deployed while ensuring patient and staff safety.

Our investigation found that since Mr C made his original complaint to the board - which they upheld - matters had improved. The board had addressed staff recruitment and training issues and reviewed some policies to allow a more flexible use of resources. This had allowed them to keep more wards open while still staffing the hubs, and they confirmed that in the last few months Mr C's ward had not been relocated. Mr C said that he considered that this had only happened because he had complained. However, we explained that the purpose of the complaints system is for issues to be raised and addressed and for solutions to be found.

We did not uphold Mr C's complaint. Although work is still on-going to fully implement the new clinical model, the independent advice received from our adviser was that good and positive progress had been made. We found no evidence that Mr C had been forced or unreasonably pressurised to attend the hub. Our adviser said that staff often have to find a balance between encouraging patients to engage with therapies and activities and making them feel pressurised. However, our adviser said that staff would be failing in their duty of care if they did not try to encourage patients to engage with treatment programmes.

Summary

Mr C complained that he was given conflicting advice about what happened to his wife (Mrs A) after she had undergone a coronary procedure to address the narrowing of her arteries. Mr C was unhappy that the doctor did not reflect the seriousness of Mrs A's condition in his reports despite him being taken aside and being advised that she had a 50 percent chance of survival.

Mr C was also unhappy that the doctor maintained that there were no changes to Mrs A's electrocardiogram (ECG - a test that measures the electrical activity in the heart), despite Mrs A having very low blood pressure and a low heart rate.

In response to the complaint, the hospital said that the doctor performed a technically difficult procedure which unfortunately was associated with a complication, which was treated effectively by placing a second stent (an artificial tube) to open up the artery. The hospital advised Mr C that he was told at the time that his wife's condition was not stable and that the doctor was of the view that his reports were an accurate reflection of the events that had taken place. They also said that one of the ECGs was normal and a further one carried out the following day showed inflammation which was not felt to be serious.

After taking advice from our medical adviser, we considered that the doctor's discharge summaries sufficiently detailed the seriousness of the complication that had resulted. We also agreed with the hospital's interpretation of the ECG readings and that it was not unreasonable of the doctor to conclude that there were no changes to the first ECG. That said, we were of the view that it appeared that Mrs A had sustained a mild heart attack, but there was insufficient evidence overall to support that Mr C was given conflicting information about his wife's condition.

Summary

Mr C complained that a hospital unreasonably cancelled his late partner (Ms A)'s heart bypass surgery scheduled for May 2010. He also complained that the hospital did not take appropriate remedial action following a report commissioned by the Procurator Fiscal's Office.

Our investigation found that Ms A, who had a history of heart and other health issues, had a second heart attack in February 2010. She was assessed and was first admitted for heart bypass surgery in April 2010, in late May 2010. Although the surgery was successful, Ms A developed complications and died five days later.

Our investigation found that the hospital cancelled all elective (non-emergency) surgery in early May 2010 due to the sudden death of a senior colleague of the team who died in the unit on the day Ms A's surgery was scheduled. The hospital decided to cancel elective surgery as members of staff in the unit were affected by their colleague's death.

We took advice from our medical adviser, a cardiothoracic surgeon (a specialist in surgical treatment of organs found inside the chest). Our adviser said that due to the unusual circumstances it was not unreasonable to decide to cancel elective surgery. Our adviser reviewed Ms A's medical notes and was of the opinion that there had been no deterioration in her condition between her discharge and her readmission for surgery. He was of the view, therefore, that the delay had no bearing on the eventual outcome.

Throughout the complaints process the hospital assured Mr C and our office that a 'careful assessment' had been made of the conditions of all the patients who were discharged that day, including Ms A. Our findings did not support those assurances. Our adviser described the discharge entry in Ms A's notes as 'perfunctory and brusque'. We were concerned that the note contained no references to any examination of Ms A, to test results, or to any standard observations such as pulse, temperature, respiration rate etc. Although we did not uphold the complaint about the decision to cancel surgery in early May 2010, we made two recommendations in relation to the failings found in the discharge process and assessment.

On the matter of the report commissioned by the Procurator Fiscal's Office, the adviser said that the hospital's response to Mr C was reasonable. They noted that one issue raised in the report (the level of a blood clotting agent in Ms A's blood three days after surgery) had not been addressed in the response. However, the adviser was satisfied that staff caring for Ms A took appropriate action and that there had been no failure in care and, therefore, no need for any remedial action. The report for the Procurator Fiscal's Office did not find any evidence of service failure and made no recommendations for remedial action. We agreed that no remedial action was required.

Recommendations

We recommended that the hospital:

• review the discharge processes where surgery is cancelled or postponed for non-clinical reasons and ensure that appropriate examinations are made and recorded; and
• reflect on the quality of their responses on the specific issue of the assessment said to have been done before the patient was discharged and issue a written apology for the failings identified.

Summary

Mrs C suffered from lung cancer and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). She was receiving chemotherapy but after the second cycle her condition deteriorated and she was admitted to hospital, where she died a few days later.

Her daughter, Miss C, was concerned that while her mother was in hospital one of her medications, which was given by injection, was not always administered. She said that at times the injections were prepared and then left by her mother's bedside if they were not given. Miss C also complained that a pain relieving patch was not administered. The board said that the patch had been administered but was later removed. There was conflicting information from the board and Miss C about when this happened.

We investigated and took independent advice from one of our medical advisers, a senior and experienced nurse. She said that the Nursing and Midwifery Council (NMC) issue guidance on the preparation and administration of drugs and that the practices demonstrated in this case did not comply with that guidance. We upheld both complaints.

Miss C said that there were inaccuracies in the fluid monitoring charts, but we could not establish the accuracy of these, given the time that has passed since. The board did say that Mrs C, who was a retired nurse, liked to maintain her independence where possible and preferred to go to the bathroom when she was able. They said that this may have introduced some inaccuracy to the charts. Our investigation found that it was reasonable to allow Mrs C to maintain her independence where possible. The nursing adviser reviewed the charts and had no concerns, and we did not uphold this complaint.

Finally, we upheld Miss C's complaint about complaints handling. We found that there were unacceptable delays in responding to Miss C's complaints. The final response took four months rather than the 20 working days required by the NHS guidance on complaints handling. In addition, our investigation found that although it largely reflected the NHS guidance, the board's complaints procedure did not fully comply with it.

Recommendations

We recommended that the board:

• apologise for the deficiencies identified by our investigation;
• provide an update on the changes to the evening medication round;
• ensure all staff are aware of and comply with the NMC standards and board policy on administration of medication;
• report on the integration of the policy on the administration of medication to the board's staff induction programme;
• provide an update on the progress of changes to the complaints and advice team; and
• ensure that their complaints procedure fully reflects the NHS guidance on complaints handling.

Summary

Mr A had abdominal pain in the early hours one morning. The pain had been present the previous day, but had got much worse. Mr A's wife (Mrs C) contacted the ambulance service for assistance, but they did not send an ambulance so Mrs C took her husband to hospital. Mr A had acute appendicitis (sudden inflammation of the appendix). His appendix was removed that afternoon. He was discharged from hospital seven days later. Mrs C complained that the service failed to attend when she called them for Mr A, and did not deal with her complaints appropriately.

We did not uphold Mrs C's complaint that an ambulance was not sent. We took advice from one of our medical advisers, who said that Mr A's condition was not detrimentally affected by not being taken to hospital by ambulance, and that the decision not to send an ambulance was correct in terms of the service's protocol. We listened to the telephone call and reviewed the service's records and procedures together with information provided by Mrs C. We decided that although the emergency medical dispatcher's communication with Mrs C was not as helpful as it could have been, the decision not to send an ambulance was reasonable in the circumstances.

We upheld Mrs C's other complaint. We found that she received a response to her complaint after eight weeks, which was longer than the 20 working days the service aimed to work to, and she was not updated with an explanation of why there was a delay. We found evidence that service staff disagreed on who was responsible for sending the update. Our adviser thought that because the service's review of Mrs C's call focused on technical aspects, rather than taking a holistic view that included Mrs C's experience, it lacked any real empathy with her situation. Their investigation report recommended that Mrs C be given a more detailed explanation of the reasons for not sending an ambulance, but we noted that this was not provided.

Recommendations

We recommended that the service:

• review this call with the emergency medical despatcher involved, and ensure that they receive appropriate support for their customer care skills to achieve the standard aspired to in the service's 999 procedure;
• review how they respond to complaints relating to incidents where callers dispute the outcome, such as this case, to ensure that investigations and responses acknowledge and take into account the service user's experience, rather than being solely driven by compliance with protocol; and
• ensure all staff dealing with complaints know who is responsible for updating complainants at particular stages of the complaints process.

Summary

Mrs C complained about the care and treatment her father (Mr A) received while in hospital. Mrs C said that her family were asked to contact the ward on the day of Mr A's operation. She said that when they did this, they were made to feel over-anxious. Mrs C complained that after his operation, Mr A had been left alone without access to his buzzer, that staff failed to give Mr A prescribed laxatives, and that staff were generally rude and uncaring. However, Mrs C was mainly concerned that a nurse harshly treated Mr A.

We investigated the complaint and took advice from our nursing adviser. Our investigation found that because of Mrs C's allegation, action was taken under the health board's disciplinary policy and procedure. We also found that there was no evidence in the medical notes that Mrs C's family had been asked to contact the hospital. However, on the balance of probability, we upheld that Mr A had not had access to his buzzer and that staff failed to communicate adequately. We also upheld Mrs C's complaint that Mr A had not been given the laxatives as there was evidence of this in his medical records. We did not uphold the complaint alleging harsh treatment as there were conflicting statements about this, and there was no independent evidence to allow us to reach a decision.

Recommendations

We recommended that the board:

• remind staff to regularly ask patients about the accessibility of their buzzer on the ward and give consideration to completing a ward audit to establish that buzzers are accessible;
• make Mrs C and Mr A a formal apology for their failure in this matter; and
• provide evidence that remedial action has been taken to ensure a similar situation does not reoccur.