Summary
Ms C complained about the care and treatment provided to her late father, Mr A, by Greater Glasgow and Clyde NHS Board (the Board) in the Enhanced Recovery Area at Glasgow Royal Infirmary (the Hospital). Mr A was admitted to the Hospital with a history of recent weight loss and abdominal pain. He had a laparotomy (an incision in the abdomen), which showed a lump in his colon.
Mr A underwent a primary anastomosis (where sections of the intestine are reconnected following the removal of diseased tissue). After the operation, he was admitted to the High Dependency Unit (HDU). Ms C has stated that the nursing care Mr A received there was excellent and that the family were welcomed to actively participate in his recovery. She also told us that her father was improving and was mobile in the hours prior to his transfer out of the HDU. He was then transferred to the Enhanced Recovery Area in the Hospital. Ms C complained to us about both the medical treatment and the nursing care her father received in the Enhanced Recovery Area when his condition deteriorated. Following transfer back to HDU, Mr A had further surgery, however, he died there several days later.
We took independent advice from a consultant general surgeon (Adviser 1) and a general nursing adviser (Adviser 2). In relation to Ms C’s complaint that the Board did not provide reasonable medical treatment to Mr A in the Enhanced Recovery Area, we found that there were a number of failings. In summary:
- communication with Ms C’s family had been unreasonable and staff had failed to act on their concerns;
- had Mr A been assessed and examined proactively by an experienced doctor earlier, it was likely that they would have recognised his deterioration and escalated his care sooner. Had this happened, there would have been a greater chance of survival;
- a CT scan should also have been carried out sooner and this would have alerted staff to the anastomosis leaking and gross abdominal infection;
- there were case note entries from a variety of junior doctors, but little documented evidence of Consultant involvement;
- there was delay in providing a dietician assessment;
- the majority of medical interventions appeared to be reactive rather than proactive.
In view of these failings, we upheld Ms C’s complaint that the Board did not provide reasonable medical treatment to Mr A.
Ms C also complained that the Board did not provide reasonable nursing care to Mr A in the Enhanced Recovery Area. We found that the actions of nursing staff in relation to Mr A’s transfer to the Enhanced Recovery Area had been reasonable. This included their actions in relation to mobilising Mr A and in maintaining his fluid and nutritional intake. However, we also found that the monitoring and observation of Mr A had not been reasonable and was not carried out in line with the relevant guidance. In view of this, we upheld Ms C’s complaint that the Board did not provide reasonable nursing care to Mr A in the Enhanced Recovery Area.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Ms C:
|
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|
|
The Board did not provide Mr A with reasonable care and treatment in the Enhanced Recovery Area |
Apologise to Ms C for failing to provide Mr A with reasonable care and treatment in the Enhanced Recovery Area. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology
By: 19 October 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 was little documented evidence of Consultant involvement in Mr A’s care in the Enhanced Recovery Area and the majority of medical interventions appeared to be reactive rather than proactive. The medical documentation was poor with limited notes of poor quality that were difficult to read
|
Patients in the Enhanced Recovery Area should receive appropriately regular senior review to ensure proactive care. This should be documented appropriately |
Evidence that these matters: > consultant review/proactive patient care > record-keeping have been fed back to staff in a supportive way and, where appropriate, action has been taken and any changes disseminated By: 19 November 2018 |
|
There was a delay in carrying out a CT scan, which would have alerted staff to gross abdominal infection and breakdown in the anastomosis |
All staff in the Enhanced Recovery Area should be aware of the potential for anastomotic leak in patients who have a primary anastomosis and that this may present with subtle deterioration. There should be a low threshold for senior review and CT scan in these cases |
Evidence that this matter has been fed back to staff in a supportive way and that they now have the appropriate level of understanding By: 19 November 2018 |
|
There was a delay in providing a dietician assessment for Mr A
|
Patients appropriately referred to dieticians should be assessed within a reasonable time
|
Evidence that this matter has been considered and, where appropriate, action has been taken and any changes disseminated By: 19 December 2018 |
| Communication between medical staff and Ms C’s family was unreasonable and staff failed to act on the concerns Ms C and her sister raised. On the few occasions where there was communication between medical staff and Ms C’s family, this was with junior staff |
Communication with patients and/or families should be proactive and when a consultation with the medical team is requested, this should be facilitated at a senior level |
Evidence that this matter has been considered and, where appropriate, action has been taken and any changes disseminated By: 19 December 2018 |
| The monitoring and observation of Mr A was unreasonable and was not carried out in line with the relevant guidance |
Monitoring and observation of patients should be carried out in line with the relevant guidance |
Evidence that this matter has been considered and, where appropriate, action has been taken and any changes disseminated By: 19 December 2018 |
Feedback
Points to note
The Board should note Adviser 2’s comment in relation to the entry in the nursing records that the family were, ‘to be encouraged not to visit at mealtimes.’
Complaints handling
The Board are encouraged to reflect on their own handling of the complaint and why their investigation did not identify the good and poor practice in the provision of care.