Summary
Mrs C complained about the care and treatment her husband (Mr C) received at the Victoria Hospital, Kirkcaldy.
Mrs C said that her husband suffered a fall getting out of bed while on holiday abroad which had caused him to hit his head and lose consciousness for approximately ten minutes. On arrival home a few days later, Mr C attended the hospital's emergency department. He was treated as a minor head injury and discharged home the same day with head injury advice. Mrs C complained that Mr C was not provided with appropriate treatment, and, in particular, that a CT scan was not carried out.
Eleven days later, Mr C returned to the hospital as he had a constant headache. Mrs C said that, although on this occasion a CT scan was carried out, she had to beg staff to carry it out. The scan showed Mr C had suffered a brain haemorrhage. He was transferred the same day to another hospital where he had a craniotomy for an acute subdural haematoma.
Mr C was subsequently transferred back to the Victoria hospital and admitted to a ward. Mrs C was unhappy with the nursing care Mr C received there.
During our investigation we took independent advice from three advisers: a consultant in emergency medicine, a consultant neurosurgeon and a nurse. We found that given his presenting symptoms, an urgent CT scan of Mr C's head should have been carried out when he first presented to the emergency department, and the decision not to do was a significant and serious failing. We also found that the failure to carry out a CT scan had delayed Mr C's diagnosis and treatment and adversely affected his outcome. If the diagnosis and treatment had been made sooner there would in all probability have been a significantly improved prognosis for Mr C. Given this we upheld this aspect of Mrs C's complaint.
We considered, however, that the treatment Mr C received when he returned to the emergency department was timely and was of an excellent standard. Therefore, we did not uphold this part of Mrs C's complaint.
In relation to the nursing care which Mr C received, the board said they had identified a number of issues where Mr C's care and their communication with Mrs C had at times fallen short of the standard Mrs C expected and they had apologised. The board said these matters were also addressed with the nursing staff concerned. We received advice that Mr C's brain injury had caused him to exhibit behaviour which was at times difficult for staff to manage. While there were many aspects of Mr C's nursing care which were reasonable, we found that he should have been observed for falls better. We also identified shortcomings in how Mr C's nursing records were kept. We considered that, on balance, and in the circumstances of this case, the nursing care provided to Mr C was not reasonable and we therefore upheld this aspect of Mrs C's complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mr C and Mrs C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
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The Victoria Hospital's Emergency Department failed to carry out a CT scan of Mr C's head when he attended on 22 August 2015 |
Provide a written apology for the failure, that complies with the SPSO guideline on making an apology (available at https://www.spso.org.uk/leaflets-and-guidance) |
Copy of the apology letter By: 19 August 2017 |
We are asking the Board to improve the way they do things:
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|
|
The Victoria Hospital's Emergency Department failed to carry out a CT scan of Mr C's head when he attended on 22 August 2015 |
The Board should reflect and learn from the comments of Adviser 1 and Adviser 2 for the management of patients with a head injury. This review should consider how learning from the specific incidents of this case, in particular, where patients present with a sudden onset of severe headache (whether following a head injury or spontaneously). The review should be used to inform the need for systemic improvement in this aspect of the Board's service |
Documentary evidence that reflection has taken place and learning captured, such as copies of minutes of discussions of this report with the relevant staff and managers, internal memos/emails, or reports, and documentation showing feedback given By: 19 September 2017 |
|
The Victoria Hospital's Emergency Department failed to carry out a CT scan of Mr C's head when he attended there on 22 August 2015 |
The Board should demonstrate they have acted on their learning to ensure their procedure for the management of patients with a head injury, in particular, where patients present with a sudden onset of severe headache. (whether following a head injury or spontaneously) are fit for purpose and reduce the likelihood of a recurrence of the circumstances of this case |
Documentary evidence of procedural review and subsequent change. This should include revised procedures with changes highlighted. It could include: copies of process audits, internal meeting minutes, review reports or a detailed explanation of the review and its conclusions / any resulting process changes By: 19 September 2017 |
|
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|
Nursing staff caring for patients who have suffered a brain injury and for patients with challenging behaviour were not sufficiently well trained |
The Board should ensure nursing staff caring for patients who have suffered a brain injury, and for patients with challenging behaviour, receive appropriate learning and development and that mechanisms exist to ensure this is kept up-to-date |
Documentary evidence that these training needs are being met, or planned (with definitive timescales, not simply a broad intention) By: 19 September 2017 |
|
There were omissions in record-keeping in relation to the assessment of capacity and consent/violence and aggression assessment |
The Board should ensure that systems are in place that ensure nursing records are maintained in accordance with the nursing and midwifery code of practice |
Documentary evidence such as discussions about this report, changes that are (or have been) made as a result, and revised procedures or instructions to staff about the application of current procedures By: 19 September 2017 |
Evidence of action already taken
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
|
What we found |
What the organisation say they have done |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|
|
The Board acknowledged that Mr C's care had at times fallen short of the standard Mrs C would expect |
The Board said Mrs C's concerns had been shared with the nursing staff and staff had been asked to reflect on this and consider how Mr C's care could have been better |
Documentary evidence of discussion of Mrs C's concerns with the relevant nursing staff at a staff meeting By: 19 September 2017 |
Feedback for Fife NHS Board
Complaint Number (c)
Points to note: Given the comments of Adviser 3, the Ombudsman recommends the Board give consideration to having a dedicated ward/part of a ward where patients who have suffered a brain injury and/or exhibit challenging behaviour can be cared for jointly by acute and mental health teams with appropriate staffing levels.
When responding to a draft of this report, the Board told me that, having considered it, it would not be practicably possible to deliver the point noted in my feedback. Even so, they will make every effort to accommodate patients with this presentation within two specific wards of Hospital 1 where they have an acute psychiatric liaison service/unscheduled care team. The Board have also informed me that the supervision procedure for patients requiring one-to-one intensive supervision is currently under review. It is ultimately a matter for the Board, and I am pleased that they considered the feedback in relation to their services, seriously.