C complained about the care and treatment provided to their adult son (A) when they were admitted to Queen Elizabeth University Hospital for a total thyroidectomy (complete removal of the thyroid gland) and right neck dissection (surgical removal of lymph nodes) due to cancer. On the day of the surgery, the consent form was completed and it mentioned a number of risks, including risk of bleeding.
The surgery went well and two surgical drains were inserted into the right side of A's neck. Three days after surgery, the first drain was removed by a nurse, following instruction by an Ear, Nose and Throat (ENT) Registrar. The second drain was removed the following day. Shortly after, A's neck was numb and swelling and they became distressed with a shortness of breath. A had developed a haematoma (localised bleeding outside of blood vessels) and a subsequent cardiorespiratory arrest. An emergency procedure was performed to relieve the pressure in A's airway. A recovered but was left with mobility and speech difficulties and seizures.
C complained about the nursing care provided to A. They said that A was not appropriately monitored and the removal of the tube was not performed correctly given the haematoma developed. They also complained about the medical care provided, that they were not told of the risk of hypoxic brain injury or of the Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) order that was put in place.
We sought independent clinical advice from a registered nurse (Adviser 1) and a Consultant ENT Surgeon (Adviser 2). Adviser 1 noted that A's drains were removed in accordance with the postoperative and ENT Registrar's instructions and that they were monitored frequently. We concluded that A was appropriately monitored and we did not find any evidence that the removal of the tubes was performed incorrectly. As such, we concluded that the nursing care provided was reasonable and we did not uphold the complaint.
In respect of the medical care provided, Adviser 2 explained that a secondary haemorrhage is a known complication of this kind of surgery and the SCOOP protocol should be followed to help relieve the pressure on the airway. SCOOP protocol advises to open the wound and remove the haematoma.
Our investigation found that while Greater Glasgow and Clyde NHS Board (the Board) said they followed the SCOOP protocol, it was not followed correctly. There was a limited opening of the wound and the haematoma remained present for over 90 minutes, whereas it should have been removed as quickly as possible. If this had been done, it would have most likely prevented A's cardiorespiratory arrest that led to a hypoxic (reduced supply of oxygen) brain injury. Following this event, the Board discussed the case at a morbidity and mortality meeting, however they failed to identify the SCOOP protocol was not followed correctly. Our investigation found that the risk of a blood clot in the neck causing breathing difficulty was not mentioned and this should have been listed on the consent form and discussed. We also concluded that while there was evidence of regular discussion with the family about A's condition and prognosis, it was not recorded that DNACPR was specifically mentioned or that the family fully understood this.
Overall, we concluded that the Board failed to ensure A was provided with a reasonable standard of medical care and treatment during their admission, specifically in the way the emergency situation was handled and we upheld the complaint on that basis.
We made a number of recommendations to address the issues identified and we will follow up on these recommendations. The Board are asked to ensure guidance on the SCOOP protocol is fully implemented and that staff are aware of the relevant guidelines for DNACPR orders by the date specified. We will expect evidence 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 C:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
(b) |
We found that the Board failed to follow the SCOOP protocol correctly, by ensuring that the family understood fully the DNACPR process, and by explaining that a bleed in the neck causing breathing difficulty was a risk. |
Apologise to C and A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. |
A copy or record of the apology. By: 24 January 2022 |
We are asking the Board to improve the way they do things:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
(b) |
We found that the Board did not follow the SCOOP protocol correctly. |
BAETS guidelines should be fully implemented in the relevant department(s).
|
Evidence that appropriate learning has been implemented in the relevant department(s). By: 22 March 2022
|
| (b) | We found that the Board did not ensure that family members fully understood the DNACPR process. | All staff should be aware of the Resuscitation Council UK guidelines for DNACPR orders. |
Evidence that all staff have appropriate understanding of DNACPR procedures. By: 22 March 2022 |
Feedback
Points to note
Adviser 1 reported that the patient's case record lacked chronology and that some of the notes were difficult to read and it was not always evident who wrote the note or their designation/profession. Whilst appreciating it is not always possible to complete notes at the time of a significant event, someone allocated to noting the timing of events and personnel in attendance should take care to note these details and ensure that records are correct and as full as they can be.