Investigation Report 202207986

Report no:

202207986
Date:

February 2025
Body:

Greater Glasgow and Clyde NHS Board - Acute Services Division
Sector:

Health

The complainant (C) complained to my office about the treatment provided to their late parent (A) by Greater Glasgow and Clyde NHS Board - Acute Services Division (the Board).

A had a number of pre-existing health conditions and had previously had a laryngectomy (the surgical removal of the larynx (voice box) which disconnects the upper airway (nose and mouth) from the lungs). A had a laryngectomy ‘larytube’ stoma and cannula in situ (where the trachea (windpipe) is cut and then the open end is stitched onto the front of the neck).

On 20 April 2021, A had a fall at home and was taken to the Emergency Department (ED) at Glasgow Royal Infirmary (the hospital) via ambulance. A was admitted to the Acute Medical Receiving Unit (AMRU). A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Order was put in place (meaning a patient does not receive resuscitation where their heart stops beating or their breathing stops).

On 21 April 2021, A indicated that they felt that their larytube was blocked. A student nurse provided laryngectomy care to A and was unable to replace the larytube. A experienced respiratory arrest (where breathing stops) followed by a cardiac arrest (where the heart stops beating) and sadly died.

The Board carried out a Significant Adverse Event Review (SAER). In their SAER, and their written response to C’s complaint, the Board’s overall conclusion was that the care provided to A was both appropriate and competent despite some failings having been identified.

C complained to my office about aspects of A’s laryngectomy care, including the decision to put a DNACPR Order in place and the conclusions reached by the SAER investigation.

During my investigation I sought independent advice from Consultant Physician in Acute Medicine and a Consultant Ear, Nose and Throat (ENT) Surgeon. Having considered and accepted the advice I received, I found that:

Appropriate equipment was not available at A’s bedside for laryngectomy care.
It was unreasonable that A did not receive humidified oxygen in the Emergency Department and did not receive humidification in accordance with National Tracheostomy Safety Programme (NTSP) guidelines. This may have prevented the blockage in A’s larytube from happening.
A student nurse acted without supervision in providing laryngectomy care to A.
In the circumstances, given A’s complex co-morbidities, it was reasonable for the medical team to put a DNACPR in place without discussion with the family. Notwithstanding this, it was unreasonable (both in placing the DNACPR order and in following it through) that no distinction was made between the context of an expected death/sudden cardiorespiratory arrest and an unforeseen event/ readily reversible cause. As a result, it was unreasonable that ventilation/ resuscitation was not attempted.
Airway help was not sought immediately when the larytube could not be reinserted.
There was a failure to activate the duty of candour process in this case.
There was a failure to undertake a reasonable SAER that identified key learning and improvements. This included recording conclusion Code 2 (Issues identified but they did not contribute to the event) when conclusion Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.

Taking all of the above into account, I upheld C’s complaints.

Redress and Recommendations

The Ombudsman’s recommendations are set out below:

What we are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to do for the complainant:

Rec. number	What we found	What the organisation should do	What we need to see
1.	Under complaint point (a) I found: it was unreasonable that appropriate equipment was not at A’s bedside. it was unreasonable that A did not receive adequate humidification. it was unreasonable that the student nurse acted without supervision in providing laryngectomy care to A. unreasonable that airway help was not sought immediately when the laryngectomy cannula could not be reinserted. it was unreasonable that ventilation/ resuscitation was not attempted. Under complaint point (b) I found: there was a failure to activate the duty of candour process in this case. there was a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. This included recording conclusion Code 2 (Issues identified but they did not contribute to the event) when conclusion Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.	Apologise to C and her family for: The failure to ensure appropriate equipment was at A’s beside. The failure to administer adequate humidification to A. The student nurse acting without supervision in providing laryngectomy care to A. The failure to attempt ventilation/ resuscitation of A. The failure to activate the duty of candour process. The failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. This included recording conclusion Code 2 rather than conclusion Code 3. The apology should be specific and 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: 19 March 2025

Rec. number

What we found

What the organisation should do

What we need to see

Under complaint point (a) I found:

it was unreasonable that appropriate equipment was not at A’s bedside.
it was unreasonable that A did not receive adequate humidification.
it was unreasonable that the student nurse acted without supervision in providing laryngectomy care to A.
unreasonable that airway help was not sought immediately when the laryngectomy cannula could not be reinserted.
it was unreasonable that ventilation/ resuscitation was not attempted.

Under complaint point (b) I found:

there was a failure to activate the duty of candour process in this case.
there was a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. This included recording conclusion Code 2 (Issues identified but they did not contribute to the event) when conclusion Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.

Apologise to C and her family for:

The failure to ensure appropriate equipment was at A’s beside.
The failure to administer adequate humidification to A.
The student nurse acting without supervision in providing laryngectomy care to A.
The failure to attempt ventilation/ resuscitation of A.
The failure to activate the duty of candour process.
The failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. This included recording conclusion Code 2 rather than conclusion Code 3.

The apology should be specific and 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: 19 March 2025

We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to improve the way they do things:

Rec. number	What we found	Outcome needed	What we need to see
2.	Under complaint point (a) I found it was unreasonable that A did not receive adequate humidification.	Patients with laryngectomies should receive appropriate humidification as set out in The National Tracheostomy Safety Programme (NTSP) guidelines.	Evidence that: these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions). the learning from these events is reflected in policy/ guidance and staff training with details of how this will be disseminated to relevant staff. By: 19 August 2025
3.	Under complaint point (a) I found it was unreasonable that airway help was not sought immediately when the laryngectomy cannula could not be reinserted.	Where there is a difficulty reinserting laryngectomy cannulas, airway help should be sought without delay.
4.	Under complaint point (a) I found it was unreasonable that ventilation/ resuscitation was not attempted in the circumstances of A’s case.	Decisions in relation to ventilation/ resuscitation when a DNACPR is in place should be taken in line with relevant national guidance. Where a decision is taken not to follow relevant national guidance this decision, and the reasons for it, should be clearly recorded.
5.	Under complaint point (b) I found that there was a failure to activate the duty of candour process in this case.	When an incident occurs that falls within the duty of candour legislation, the Board’s Duty of Candour processes should be activated without delay.	Evidence that the Board have reviewed their Duty of Candour processes, including their process for identifying and activating the process. By: 19 May 2025
6.	Under complaint point (b) I found that there was a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements.	Local and Significant adverse event reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward. Adverse event reviews should be held in line with relevant guidance.	Evidence that the Board have reviewed their process for carrying out adverse event reviews to ensure these reviews properly investigate, identify learnings, and develop system improvements to prevent similar incidents occurring. By: 19 May 2025
7.	Under complaint point (b) I found that the Board unreasonably recorded a conclusion of Code 2 (Issues identified but they did not contribute to the event) on the SAER when a conclusion of Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.	Conclusion codes on adverse event reviews should reflect the findings.	Evidence that the Board have noted the incorrect conclusion code on the SAER report and have ensured this is a matter of record either by reissuing a revised SAER report, or by issuing an addendum, in line with any relevant Healthcare Improvement Scotland guidance and advice. By: 19 May 2025

We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to improve their complaints handling:

Rec. number	What we found	Outcome needed	What we need to see
8.	There was a failure to fully investigate and identify the significant failings in this case in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. There was also a failure to apologise to C as part of the complaint response.	Complaints should be investigated and responded to in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified.	Evidence that: the Board have carried out a review of the management of this case from a complaint handling perspective these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions). By: 19 May 2025

Rec. number

What we found

Outcome needed

What we need to see

There was a failure to fully investigate and identify the significant failings in this case in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. There was also a failure to apologise to C as part of the complaint response.

Complaints should be investigated and responded to in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified.

Evidence that:

the Board have carried out a review of the management of this case from a complaint handling perspective
these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 19 May 2025

Feedback

Response to SPSO investigation

The Board’s response to our enquiries initially provided us with the accounts of different specialists employed by the Board which differed in opinion on some significant points, without providing the Board’s overall view. This resulted in delays to our investigation while we established what the Board’s overall view was. When responding to SPSO enquiries, the Board should ensure that their response reflects the Board’s overall position. I am including this as feedback for the Board to reflect on.

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