Decision Report 201600035

Summary

Ms C complained about the medical and nursing treatment she received over a series of hospital admissions to Wishaw General Hospital. Ms C suffered from problems with the discs in her spine and had required spinal surgery on more than one occasion. Ms C said that she had been subjected to lengthy delays during each admission and that there had been an absence of medical review. Ms C said her nursing care had been unprofessional and had resulted in some humiliating incidents. Ms C also complained that she had not been referred for physiotherapy. Ms C further complained that the board's communication with another health board regarding her care was unreasonable.

We took independent medical advice from a consultant neurosurgeon, a nursing adviser and a physiotherapist. We found that Ms C had received inadequate treatment and that there were delays in her receiving scans. This meant that the outcome of a surgery Ms C had to treat cauda equina (a disorder that affects the nerves) was not as good as it might have been. The board had accepted this and had taken appropriate action to improve the diagnosis of cauda equina. We found that, during the later admissions, Ms C had suffered from extended trolley waits in the A&E department before being reviewed by an appropriate specialist. We found it to be unreasonable that Ms C had been left for long periods of time without being seen by medical staff due to failures in communication between the on-call team and Ms C's original consultant. We recommended that the board implement a protocol to cover the re-admission of patients with recurrent problems, so that staff are aware of when they need to refer the patient to the original consultant who had been responsible for treating them. We found that Ms C was, on occasion, denied access to the radiography department due to capacity issues. We considered this inappropriate and said the board should alter their procedures to allow for urgent scanning in spinal cases.

We found that the board had correctly acknowledged the failures in Ms C's nursing care across all of her admissions. We found that, whilst some of the failings were significant, they were due to poor judgement by individual staff members rather than procedural failings. We noted that the board had made reasonable efforts since Ms C's experience to improve and monitor standards of nursing care.

We found that Ms C should have been referred for physiotherapy treatment. We did not agree with the board's view that treatment was not appropriate for Ms C and found that the failure to commence physiotherapy could have delayed her recovery.

We did not find that the communication between the board and another health board regarding Ms C's care was unreasonable and we did not identify any significant failings in this regard. We did not uphold Ms C's complaint about communication between health boards.

We found that Ms C had received an unreasonable standard of medical and nursing care during her admissions to hospital. The board had accepted this and made the appropriate changes to address the failings she experienced in most areas. We found, however, that on the basis of the advice we had received, there were still areas where the board needed to improve and we therefore upheld Ms C's complaints about her care and treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing for failing to provide physiotherapy. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• A protocol should be developed to ensure that scans for patients with suspected cauda equina are not delayed.
• A protocol should be developed so that when patients are re-admitted with a recurrent problem, staff are clear when care should be transferred to a patient's original consultant.
• The general assessment of when physiotherapy is justified should be reviewed.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.