Summary
Mr A was admitted to Borders General Hospital with a heavy nose bleed and in considerable pain. He had lung cancer and several other medical conditions, and he was terminally ill. Mr A was initially admitted to the emergency department and then transferred to the medical assessment unit (MAU). Mr A's partner (Ms C) said that there were a number of failures in the care and treatment Mr A received in hospital. She complained that the bedside oxygen equipment did not work, that Mr A was not given adequate pain relief or his own medication, and that he was shown a lack of compassion by nursing staff. She said that Mr A discharged himself from hospital the day after his admission because of the poor care and treatment he had received, and so that he could receive the medication he needed. He died at home three days later.
I obtained independent advice from a nursing adviser and a medical adviser who is a hospital consultant in acute internal medicine. Ms C complained that the medical treatment Mr A received in hospital was unreasonable. My medical adviser noted that the failure of the oxygen equipment in the emergency department would have increased Mr A's feelings of distress. The board said they had already made changes to ensure that equipment was checked more often, so I asked to see evidence of this. I also asked to see evidence of the other positive action the board said they had made following Ms C's complaint. This was to make sure that patients arriving in the MAU were assessed within sixty minutes, whereas Mr A's medical review took place over two hours after arriving on the ward.
My medical adviser said that there was no record of a pain assessment in the emergency department though, on arrival in the MAU, Mr A was assessed as experiencing severe pain. My adviser considered that pain relief should have been provided earlier in the emergency department. There was also no record of pain assessment overnight in the MAU. The advice I have received is that Mr A, who was in acute pain and terminally ill, appears to have received inadequate pain control and was left in pain for considerable periods. I noted my medical adviser's comment that he could imagine Mr A's frustration at having been left in pain. In his view, this led Mr A to discharge himself from hospital, leaving his symptoms untreated and with no investigation into the cause of his pain. Therefore, he was potentially put at significant risk of harm or death. I upheld the complaint and made several recommendations.
The nursing advice I received identified a number of serious failings in Mr A's nursing care and found that, overall, the nursing care Mr A received in the MAU was unacceptable and poor practice. My nursing adviser found that nursing staff had failed in their duty to appropriately assess, monitor and alleviate Mr A's pain and did not appear to have followed Nursing and Midwifery Council Standards regarding the prescribing of pain relief medication to Mr A. My nursing adviser considered that Mr A must have been frustrated not to have had his severe pain relieved despite having his own pain relief medicines with him, which he should have been allowed to self-administer. My adviser also considered that written statements from the nurses involved in Mr A's care showed a lack of compassion for, or understanding of, his situation and feelings. I am critical of the board for these failings and the lack of compassion shown to Mr A. I am concerned that he had such a painful and distressing experience, and I also acknowledge the upset and distress this has caused to Ms C. I upheld this complaint and made the following recommendations.
Redress and recommendations
The Ombudsman recommends that the Board:
- provide evidence of the action to ensure that oxygen equipment checks are made between patients in addition to standard twice daily checks carried out;
- provide evidence of the action taken to ensure that the assessment of a patient is completed within sixty minutes of the patient arriving in the MAU;
- ensure the comments of the medical adviser in relation to the treatment of Mr A's pain control are brought to the attention of relevant medical staff and they reflect on this;
- apologise to Ms C for the failings identified in Mr A's medical care and treatment;
- reflect again on Ms C's complaint by reviewing what went wrong and what learning has taken place;
- consider implementing learning and development training in early resolution of concerns and complaints for front line nursing staff in the MAU;
- carry out a review of nursing in the MAU to explore the leadership and culture within the ward - to include a review of pain assessment and monitoring of patients in the hospital and, in particular, in the unit; and
- apologise to Ms C for the failings identified in Mr A's nursing care and treatment.