Health

Summary

C complained about the care and treatment provided to their parent (A) when A was admitted to hospital with ongoing pain and mobility issues following a fall. A suffered from significant leg ulcers and had received a package of care while at home. While in hospital, A developed sepsis and did not respond to treatment. A died a few months after admission.

C complained of failings in how A’s leg ulcers had been managed, stating that A’s dressings were being changed less frequently than when A was in the community. C highlighted times when family members had raised the need for A’s wounds to be dressed with nursing staff who repeatedly failed to respond to these requests. C also complained of similar failures to provide catheter care and stated their belief that these were contributing factors in A’s deterioration.

We took independent advice from a nurse. We found significant failings had occurred with regards to washing and dressing the wounds, and a failure to adhere to the standard of monitoring, risk assessment and record keeping as per the relevant professional Nursing and Midwifery Council (NMC) code. We considered that the nursing care provided was unreasonable and upheld this part of C's complaint.

The adviser also highlighted concerns about the medical care and treatment provided and on this basis we took additional advice from a geriatrician (specialist in medicine of the elderly). We found that the wound care provided lacked a coherent and consistent approach, and in particular, that A’s legs were not examined until a number weeks after admission. We also found insufficient attention was given to wound swab results and blood tests, as well as A’s level of pain and overall condition. We found that the medical care and treatment provided to A was unreasonable and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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.

What we said should change to put things right in future:

• Nursing staff should act in line with the NMC Code of Conduct, in particular Section 10 relating to documentation.
• Where there is concern about possible infection, such as in a patient with a raised CRP, any wounds should be examined within 48 hours of admission. If there is urgent concern, wounds should be examined immediately.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late parent (A) during two admissions to hospital. C complained that during their first admission A was given insulin that was for another patient and C was not timeously informed. C complained that during the second admission, A was initially diagnosed and treated for sepsis but when a CT scan was later performed a major stroke was discovered. C considered that stroke should have been considered and a CT scan should have been carried out earlier. A was given an infusion of both insulin and glucose to manage diabetes. C complained that A was inappropriately given intravenous (IV) glucose for 38 hours after IV insulin had stopped, noting that A became hyperglycaemic (when the level of sugar in the blood is too high) and then developed seizures. C also complained that nursing records were incomplete and that the board’s incident management and review process did not go far enough to recognise or rectify failings.

We took independent advice from a registered nurse and a consultant specialising in medicine of the elderly. We found that the insulin error should not have happened. In relation to sepsis treatment, it was reasonable to treat the infection in the first instance but when C informed medical staff of A slumping to one side a medical assessment for stroke should have been carried out and a CT scan should have been booked. We also found that it was unreasonable to continue IV glucose after insulin had been stopped, record keeping was inconsistent and incomplete such that it could not be said that nursing care was reasonable and that incident management and review was also unreasonable. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable care and treatment provided to A. In particular in relation to the treatment of A’s constipation, the incorrect administration of insulin, the failure to undertake a detailed stroke assessment and book a CT scan, and the fact that fluids were not reviewed or considered on after A’s insulin infusion was stopped and their blood glucose increased. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the unreasonable incident management of the insulin error, for not recording a Datix incident for the glucose error, that the SAER report was not sufficiently detailed to provide reassurance in regards to the quality of incident management and review and that learning and action in relation to medical care during the second admission was not appropriately considered in the SAER. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for unreasonable record keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Errors in relation to the management of a patient’s care should be appropriately recorded e.g. using Datix. Adverse event reviews should be thorough and should appropriately identify the failings, learning and improvement from the event.
• Patients should receive appropriate treatment including any relevant checks and scans booked in accordance with their symptoms.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide their sibling (A, a prisoner) with medication in a reasonable manner. C complained that the injection for A’s condition was not administered in line with the prescribing consultant’s instructions and that the board’s view that the acknowledged delays did not negatively impact A was unreasonable. C was also unhappy with the way that A’s other medications were managed.

We took independent advice from a GP. We found that there was an unreasonable delay when one of the injections was administered and guidance did not support the board’s view that no detriment would have been caused by this delay. We also found that the record keeping for the other medications administered during that period did not indicate that other medications were provided at regular intervals. This was unreasonable. Therefore, we upheld this part of C's complaint.

C also complained that the board unreasonably failed to arrange or rearrange hospital appointments for A. We found that some elements of this complaint were outwith the board’s control, in relation to third party organisations being involved in transportation. Whilst there were instances where A’s transport requests were not sent within the timeframes set out by guidance, overall we considered that the board’s efforts to schedule transport were reasonable. Where an appointment was cancelled due to transport issues, the board took quick action to reschedule the appointment and rearrange transport. This was reasonable. Therefore, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with medication in a reasonable manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Medication should be prescribed in line with specialist advice.
• When there are multiple delays in administering medication action is taken to avoid the issue repeating.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided by the board during and after the birth of their child. Following the birth of their child, C received a perineal (space between the anus and vagina) repair. C complained that the stitching was incorrectly carried out and that this subsequently caused ongoing pain and tightening of the vagina. At a consultation with a gynaecologist (specialist in the female reproductive system) the following year, it was identified that C had a thick band of skin at the vaginal opening. There was also a concern about pelvic floor muscle tightness which indicted vaginismus (an involuntary tensing of the vagina when something is inserted into it). C was referred to physiotherapy. As this was not successful, an operation to remove the thick band of skin was undertaken with the explanation that it was unlikely to improve the tightness of the muscles. C was also referred for psychosexual counselling.

C complained that they did not receive a follow-up after the operation and that they had not received an appointment for psychosexual counselling. The board reassured C that their perineal repair was performed correctly. However, they explained that unfortunately vaginismus can occur after any vaginal repair procedure. They noted that it was not always standard practice to follow up patients after gynaecology surgery but C had been added to the routine waiting list which was approximately one year. The waiting time for a psychosexual counselling appointment was 91 weeks. They apologised for C’s wait.

We took independent advice from a consultant gynaecologist. We found that the perineal repair was reasonable and that the decision to offer physiotherapy, then the operation was reasonable. It was also reasonable to refer C for psychosexual counselling. Offering a follow-up review was not standard after elective gynaecological surgery. We considered that care and treatment, from the birth until the operation, was reasonable. We acknowledged that waiting times had been extended. However, we accepted the advice received. We noted that treatment time standards do not cover routine post-operative reviews or psychosexual counselling. Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment provided to their parent (A) over two admissions to hospital. A attended the emergency department following a fall at home and was treated with painkillers for a pain in their neck. They were admitted to the ward for further monitoring of their fast and irregular heartbeat. A was reviewed the next morning and discharged that day. However, A returned to hospital later that day after another fall. A was reviewed and admitted to the ward where they were later diagnosed with a fracture of a bone in their neck.

C complained that the board failed to diagnose the fracture on the first admission to hospital and about the decision to discharge A. In response to the complaint, the board did not identify any failings with respect to assessment of A, but acknowledged that the communication of their diagnosis and discharge could have been better. With respect to the second admission, the board explained that symptoms of neck fracture are not straight forward and the examinations carried out within the emergency department were appropriate. C was dissatisfied with the response and brought their complaint to our office.

We took independent advice from an emergency medicine consultant and a consultant geriatrician (specialist in medicine of the elderly). In relation to A’s first admission, we found that the initial assessment of A’s condition in the emergency department was reasonable, although there was a missed opportunity for further assessment before A went to the ward. However, the examination and assessment of A’s neck pain on the ward was unreasonable, as was the assessment of A’s suitability for discharge, given the failure to properly assess A’s neck injury, mobility, and cognitive function. We found that the board failed to provide A with appropriate care and treatment during their first admission and upheld this part of C's complaint.

In relation to A's second admission, we found that A’s neurological examination did not include a cervical spine assessment. The board acknowledged in their correspondence with our office that the care provided at this time was not to an acceptable standard. Therefore, we determined that the care provided in the emergency department was unreasonable. We found that the care and assessment provided during A's admission to the ward was reasonable, and there was no delay in arranging further investigations. Given our findings in respect to the care provided in the emergency department, we upheld C's complaint regarding A’s second admission to hospital.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Clinical staff should be familiar with relevant NICE guidelines on the management of suspected cervical fractures. Relevant departments concerned should review their practices regarding the assessment of pain and investigation of potential head/neck injury.
• Patients should only be discharged following appropriate review and assessment of all clinical factors relevant to the decision to discharge a patient from hospital.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their parent (A) who passed away in hospital. During the admission, A was diagnosed with B cell lymphoma (a type of blood cancer) and received palliative radiotherapy treatment.

C complained that A’s pain medication was incorrectly managed as they experienced both delirium and extreme pain, that A’s nutrition and fluid intake was incorrectly managed as A became dehydrated and lost weight, that A was left in a general ward rather than being moved to a cancer ward and that A was not offered chemotherapy. C complained that there had been a lack of communication regarding A’s palliative treatment plan, A’s deterioration and death.

The board advised that A’s pain medication had been appropriately reviewed and adjusted. C’s fluid intake was difficult to manage but there was no indication for nasal gastric feeding. They apologised that there were gaps in the records in relation to fundamentals of nursing care, including nutrition, fluids and skin care and that nurses had since undertaken training. They noted that A was deemed too unwell to tolerate chemotherapy or a move and they stated that a number of discussions took place with the family to explain A’s changing condition.

We took independent advice from a consultant geriatrician, a registered nurse and a consultant haematologist. We found that A’s pain had been reasonably controlled and the decision not to offer chemotherapy was reasonable. However, medical staff should have considered nutrition support earlier and nursing care had been unreasonable in relation to nutrition, fluids and skin care. Communication from doctors and nurses on the ward was reasonable, but there had not been any communication from a specialist about A’s cancer prognosis and palliative radiotherapy treatment. Therefore, we upheld all aspects of this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that no specialist explained the lymphoma diagnosis and treatment plan to the family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that nursing care and recording was unreasonable, in regards to pain assessment, nutrition, hydration and skin care. Apologise to C that medical staff did not offer nutritional support at an earlier stage. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Person centred care plans should be recorded and followed for each patient. If radiotherapy patients are treated in general wards, nursing staff in those wards should be trained on how to manage radiotherapy skin damage. Nutritional support should be considered for vulnerable patients and medical staff should be aware of alternative methods of weight loss assessment in patients with oedema.
• A specialist explains the cancer diagnosis and treatment plans to the patient and family.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that their spouse (A) received from the board whilst they were a patient of the cardiology ward. C complained that A collapsed on arriving home having been discharged after undergoing a coronary angiogram (a type of x-ray used to take pictures of the heart’s blood vessels, the coronary arteries) and stenting procedure. A was found to have experienced a vascular complication (a large haematoma, where blood leaks from a large blood vessel) in front of the femoral artery (the main blood vessel supplying oxygen rich blood to the lower body) and had surgery to remove the haematoma. Following the second surgery, A developed an infection in the wound site.

The board said that due care was taken to weigh up the risks and benefits of various treatments in A’s case. Whilst there were signs of a haematoma at the puncture site after the procedure, this was not increasing in size when A was discharged, and A’s blood pressure was normal.

C complained to SPSO highlighting concerns about the decision to carry out an angiogram, the decision to discharge A, infection control and failures to follow protocol and use an ultrasound to assess the puncture site.

We took independent advice from an appropriately qualified consultant cardiologist. We found that carrying out an angiogram was appropriate in the circumstances. We considered the care and treatment following the procedure and on A’s readmission to be reasonable. However, there were a number of factors which should have triggered staff to consider delaying discharge and seeking an ultrasound scan. We found that the need for an ultrasound scan was clinically indicated and that the decision to discharge was unreasonable. As such, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• 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.

What we said should change to put things right in future:

• The threshold for considering an ultrasound scan should be lowered for patients who have a higher bleeding risk and who develop painful haematomas post procedure. A lack of pulsatile haematoma should not preclude performing an ultrasound scan if there is clinical concern.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the practice unreasonably refused to offer a face-to-face appointment to their child (A) who is immunosuppressed with asthma and had a cough for over three weeks.

The practice advised that if A had shown symptoms of shortness of breath or wheezing, a face-to-face appointment would have been arranged. C did not identify these symptoms and so C was advised to double the dose of A’s inhaler and get in contact if A worsened. It was also noted that A had an appointment with paediatrics later that day.

We took independent advice from a GP. We found that it was not reasonable to rely on a parent / carer to determine whether a child is wheezing or short of breath. A was immunosuppressed and at higher risk of infection. While it is acknowledged that A had a paediatrics appointment later that day, there is no record that this rationale for declining to see A was a factor in their decision making at the time. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

What we said should change to put things right in future:

• The clinicians involved should reflect on the findings of this case and the relevant guidelines.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, a support and advocacy worker, complained that the board failed to provide reasonable nursing care and treatment to their client (A).Specifically, they had concerns that while A was a patient in hospital, there was an unreasonable lack of attention, poor attitude from nursing staff and unreasonable nursing care. C was also unhappy about the board’s complaint handling.

We took independent advice on this complaint from a nursing adviser. We found that the board’s nursing documentation was a poor standard, not in line with guidance and was in breach of the Nursing and Midwifery Council: The Code requirements. We also found that board’s lack of documentation had led to the board being unable to evidence that care was carried out to a reasonable standard. Lastly, we found that the board unreasonably failed to respond accurately to the complaint. We therefore upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for breaching the NMC Code requirements. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the failings around poor person centred care planning and poor record keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully and accurately to the issues raised in accordance with The Model Complaints Handling Procedure. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Complainants should also be kept updated on their complaints in line with the Model Complaints Handling Procedure. Learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their parent (A) who suffered from dementia and was admitted to hospital with multiple medical issues including a chest infection, delirium, kidney failure and poor mobility including recent falls.

C raised a number of complaints, including that there were failures in the medical care provided to A with respect to falls and post falls care and seizures. C also complained of failings in nursing care relating to diet and nutrition, hygiene and cleanliness, and the general monitoring and awareness of A’s condition. Lastly, C complained regarding restrictions on visitation and poor communication.

We took independent advice from a consultant specialising in the care of the elderly and a second experienced nursing adviser. We found that the medical care provided appeared to have been reasonable. We therefore did not uphold this complaint, however, we were critical of the standard of medical record keeping and we provided feedback to the board about this.

We found that there were failures to complete the necessary risk assessments and care documentation including the risk assessment tool for malnutrition, monitoring fluid balance and applying appropriate wound care and a failure to identify and respond to a deterioration in A’s condition. We therefore upheld this complaint.

We found that general communication with the family appeared reasonable, and that pandemic restrictions were an unfortunate reality for many patients and families. However, it appeared that there had been a failure to notify the family that A had significantly deteriorated. This resulted in the family not being present when A passed away and on this basis we upheld the complaint regarding communication.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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.

What we said should change to put things right in future:

• Patients should be appropriately assessed by nursing staff in particular in relation to malnutrition, fluid balance, wound care and nursing care provided in line with the assessments carried out. Any significant deterioration should be appropriately recognised and acted on as required. Records about a patient’s care and treatment and decisions made should be clearly and accurately documented and accord with the relevant professional standards and guidelines. Patient’s records should include clear details explaining why a decision about care and treatment has been made.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.