Summary
Mrs C complained to me about the care and treatment she received from Lanarkshire NHS Board (the Board). Her concerns relate to the treatment she received following her operation to form a stoma (an opening in the stomach to divert bodily waste through so it can be collected in a bag).
Mrs C was admitted to Monklands Hospital (the Hospital) on a number of occasions after this operation, with on-going symptoms of nausea and stomach pain. In the last admission, Mrs C's small bowel perforated (a hole formed in it) and she developed sepsis (a severe complication of infection). Mrs C received emergency surgery from which she recovered, however, she developed neurological problems which have left her partially sighted and with a weakness down her left side. Mrs C raised concerns that there was a delay in recognising the seriousness of her condition and in performing surgery to treat it. Mrs C felt that if earlier action had been taken, she might not have developed these neurological problems.
We took independent advice from a general and colorectal surgeon, which we accepted.
We found that Mrs C had an incomplete small bowel obstruction (blockage) where the stoma was formed, caused by tissue swelling. We found that Mrs C's symptoms, her repeated admissions to the Hospital and the results of the investigations carried out were all suggestive of this. We considered it was unreasonable that the Board did not recognise this at the time. We also considered it was unreasonable Mrs C was not referred for surgery at an earlier point, particularly when her condition worsened. We concluded that if surgery had been carried out earlier, Mrs C would probably not have developed severe sepsis, which is the likely cause of her neurological problems. We were concerned that the Board's review did not identify any failings in the care provided to Mrs C.
We upheld Mrs C's complaint. We made a number of recommendations to address the issues identified. The Board have accepted the recommendations and will act on them accordingly. We will follow-up on these recommendations. The Board are asked to inform us of the steps that have been taken to implement these recommendations by the date specified. We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that the recommendations have been implemented.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mrs C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
There were failings in diagnosing Mrs C's incomplete bowel obstruction and an unreasonable delay in referring her for surgery, despite her worsening condition |
Apologise to Mrs C for the failings in diagnosing and treating her incomplete bowel obstruction |
A copy or record of the apology. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance
By: 20 August 2018 |
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 |
|---|---|---|
|
There were failings in diagnosing Mrs C's incomplete bowel obstruction and an unreasonable delay in referring her for surgery, despite her worsening condition |
The results of hospital tests and investigations should be carefully reviewed and in similar cases, earlier surgical intervention should be considered |
Evidence that the findings of this case have been used as a training tool for staff and that this decision has been shared and discussed with relevant staff in a supportive manner. This could include minutes of discussions at a staff meeting or copies of internal memos/emails
By: 18 September 2018
|
| Mrs C's stoma activity and output was not properly assessed and/or documented during her admissions to the Hospital |
After a loop ileostomy, stoma activity and output should be clearly assessed and documented, as it is important for assessing the stoma and bowel function |
Evidence that this decision has been shared and discussed with relevant staff in a supportive manner. This could, for example, include minutes of discussions at a staff meeting or copies of internal memos/emails
By: 18 September 2018 |
| The Board's own investigation did not identify the significant failings in the care provided to Mrs C |
The Board's complaints handling system should ensure that failings (and good practice) are identified, and that it is using the learning from complaints to inform service development and improvement (where appropriate) |
Evidence that the Board have demonstrated learning from this case and complaints in general
By: 18 September 2018 |