Carer's Experience Medical Neglect

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Page modified July 2012.

The following notes indicate the contradictions/inconsistencies that I found in the Staff evidence given to the Health Service Ombudsman's office.

Evidence of Trust medical staff in Report page

In Paragraph 8, I do not recall being extremely concerned about the fortified liquid food. It was only sometime after my mother's death when I discovered from her medical records that she had diabetes Type 2 that I had some misgivings about such products.

In Paragraph 9, the A & E consultant did not definitely explain that staff would not resuscitate nor did he refer to "no active treatment". Nor did he have a discussion, as referred to in Local Resolution 1d letter of 23 August 1999, about my mother dying which he claims that I was aware of and somehow confirmed to him. This I can only look upon as total imaginings. He referred to the fact that, as we age, the epiglottis loses sealing efficiency allowing food to slip down into the lungs and cause infection to arise and that had happened. My mother was being admitted regarding treatment for a lung infection.

In Paragraph 10, the communication failure between hospital units is shown regarding "NO CPR" at A & E, and the ward consultant's unawareness of this. Although it is stated that CPR would have been given if required, I wonder if that SHO who decided "no active treatment to be performed" made that decision without consultation with colleagues. Having said that, I recognise that it was probably the only decision, since shortly before my mother's death she had displayed Cheyne-Stokes respiration and cyanosis which is invariably a precursor to death and is indicative of an attack upon that section of the brain stem named the "medulla oblongata", wherein are the electro-chemical computers regulating respiratory and pulse rates. I doubt if even the myelin sheathing around the brain stem can be unwrapped and the stem cannot be touched.

In Paragraph 11, another doctor, the JHO on the ward, also states the falsity that I should have understood my mother was dying. Like the A & E consultant, he did not explain that to me quite clearly. His saying that I used a lot of technical medical terms is a nonsense since I do not know them.

Evidence of Trust Nursing Staff in Report page

In Paragraphs 12/13/14/15/16, the evidence shows the contradictions and false assumptions. These paragraphs are full of waffle.

In Paragraph 12, the first false assumption appears that I had an understanding of the severity of my Mother's condition.

In Paragraph 13, as the report shows, I was never advised that I could visit at any time for as long as I liked nor mention made of a side room.

In Paragraph 14, there is a repeat of that false assumption of my understanding, and also that I would recognise that significant deterioration. The fact that the Nursing staff did not have the time to read my mother's notes, once they were to hand, is that failing that I lay at the door of all the useless manager pen-pushers, who waste NHS resources on their own self-serving nonsenses. They are known to squander resources on diversity courses and fancy expensive dinners which are well documented on the web and are resources that should be utilised instead to provide proper staffing levels and training.

It is a puzzle as to how nursing staff tended to know from the family when it was appropriate to contact, and also for who it was difficult to know when a significant deterioration had occurred. This nursing evidence is a collection of contradictory statements. With no medical training, I was expected to recognise when the deterioration had occurred, when they simultaneously state that the change would have been difficult to recognise. They seemed to expect that I should have known, and also at the same time, they state, and the Report accepts their claim that they had difficulties getting me to understand my mother's problems and to focus my mind on issues. The medical/nursing evidence along with the Trust response's further waffle is a pack of hogwash. Other similar material regarding NHS evidence and Ombudsman Reports on the web record similar nonsenses!!

In Paragraphs 15 & 16, there was little effective communication between Staff and myself regarding resuscitation, which was unsurprising since this Report shows that there was poor communication among the staff.

In comparison to their claims about dying, there were two occasions which caused me to think the opposite. The staff nurse, with a Bachelor of Science degree in nursing, who did not report my mother's response to doctors, said on one occasion that he could see that I was very worried about my mother. He went on to say that he felt that she would be OK but that it would be a long haul. Another female nurse told me that the doctors appeared to be quite happy with my mother. These words did not lead me into thinking that my mother was dying.

The Trust's Response in Report page

In Paragraphs 18/19, again the Trust Executive repeats the erroneous statement that I was advised that my mother would not respond to resuscitation. It further says that it was decided that the JHO should speak to me about "no resuscitation", which contradicts Report Paragraph 10 where the consultant did not intend that the JHO should discuss resuscitation with the family. The reference to "the son needs to be spoken to again" could just as easily have been triggered by my confirming to a staff nurse on the evening of the 16th, that aggressive treatment was my wish, as against it having been caused by the JHO's possible discussion with the SHO.

As another example of waffle, the Trust states that since my mother was unconscious on admission, the full assessments were taken from me and hence I was fully involved in that assessment process. Having no medical training I could not possibly have been fully involved in any initial assessments. That statement is a piece of self-contradictory utter nonsense when elsewhere in the report there is reference to them having difficulties in getting me to understand the situation. In one breath, I was seemingly considered to have sufficient medical knowledge and understanding; and simultaneously to be lacking in same. The report states its appreciation of the trouble that medical staff have in trying to communicate bad news to people. In numerous cases it will not be in the slightest manner surprising, since this Report cannot be unique in clearly displaying an incapacity of medical staff to communicate with each other!!

The requirements of the Trust's policy manual on "Do Not Resuscitate Orders" in Paragraph 19 were barely, if at all, complied with. I wonder if there is a sub-conscious medical staff reaction at times that creates a defeatist response when faced with "MR. DEATH".

While open to correction, I do not believe that there is any detailed part of a Doctor's training that deals with the matter of death and dying. It is an insult to the ethos of their profession. Those within the medical profession who deal with the subject are the thanotologists; thanotology being the branch of psychiatry that is the specific study of the dying process. Even there, Doctors can still shy away from the matter, and hope to evade certain aspects of it, and the book titled "Dying"/Author: Professor John Hinton (Thanotologist) refers to same.

There are numerous books on the subject, and the books written by the late Doctor Elisabeth Kübler-Ross and her associate David Kessler also deal with the subject more or less head on, along with the book titled "Who Dies? - An Investigation of Conscious Living and Conscious Dying"/Author: Stephen Levine. Stephen Levine became the Director of the "Hanuman Dying Foundation Project" in America that acts as a consultancy to Hospitals and Hospices.

In his pithy sayings, the French essayist La Rochefoucauld (1613-1680) said "Neither the sun nor death can be looked at with a steady eye".

Further relative comments regarding my mother's care are in Article 5, along with my beliefs on the future that I have little doubt will occur due to increasing knowledge.

The next page Final of these sub-pages is that which ended the complaints procedure.

Select a dated order Ombudsman sub-page.
Local 1a Local 1b Local 1c Local 1d
Review First Report Comments

Iain R. Stewart, Ex-Carer

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