Carer's Experience Medical Neglect

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My complaint to the Health Service Ombudsman was put with the assistance of Greater Glasgow Health Council. At first, the Ombudsman declined to investigate. The Health Council advised me that I could phone the Ombudsman's Office, which I did, and spoke to a very helpful member of his staff, who advised me to write to them since the matter could always be looked at again. This I did, and this page contains these letters.

Office of the Health Service Commissioner for Scotland
(Ombudsman),
Edinburgh.

28 January 2000.

Mr. lain Stewart,
Glasgow.

Dear Mr Stewart,

Thank you for your completed Ombudsman complaints form which we received on 24 November along with a supporting letter and copy papers from Greater Glasgow Health Council. You complain about the care and treatment your late mother, Mrs. Jane Stewart, received at the Southern General Hospital from 12 March to 17 March 1998; communication failures by clinical staff during her hospital admission; delays during the local resolution of your complaint; and the refusal of the Trust's convener to grant an independent panel to review your complaint. I was sorry to learn of your bereavement and I send you my sympathy.

I have carefully considered the documents that you provided via the Health Council and I have taken advice from the Ombudsman's professional advisers, both medical and nursing, who have reviewed the clinical aspects of your complaint. I regret, for the reasons explained below, that I have decided that the Ombudsman will not investigate your complaint.

First you raised a number of concerns about your mother's clinical treatment; in particular, you were concerned that your mother did not receive the active aggressive treatment you requested. The clinical advice I have been given is that the decision to treat, but not resuscitate, a patient in your mother's condition was reasonable, and that the care and treatment which your mother received was entirely appropriate and in her best interests. In particular the Ombudsman's medical adviser does not consider that it would have been in your mother's interest to put her through the ordeal of intensive care. The Trust have provided you with detailed explanations of your mother's treatment.

You also complain that there were failures of communication by medical and nursing staff. You say that medical staff did not advise you that your mother was unlikely to survive in the long term. I note from the papers you provided that Dr .... has stated that he discussed this matter with you. As there was no witness to the oral exchanges which took place, and both you and Dr .... seem firm in your recollection of what was or was not said, I do not consider that an investigation by the Ombudsman into this aspect of your complaint would be successful in resolving this issue. You raise two other concerns about communication. First you complain that medical staff failed to inform you of their decision not to resuscitate your mother. Secondly, you complain that a member of the nursing staff did not inform the medical staff that your mother had reacted to your voice by squeezing your hand. I appreciate that with regard to these two aspects of your complaint you are not satisfied with the explanations given by the Trust. However, I consider that the Trust has taken these complaints seriously and has adequately addressed them in the chief executive's letter of 23 August 1999.

Taking account of the advice of the Ombudsman's professional advisers, I do not consider that an investigation by the Ombudsman would achieve any more than you have done by your own efforts. Parliament has given the Ombudsman discretion to decide which complaints he shall, and shall not, investigate. In exercising that discretion on his behalf I have decided not to investigate your complaint.

I turn now to the concerns that you have about the Trust's handling of your complaint. You complain that there were lengthy delays during the local resolution of your complaint, and you question the validity of the convener's decision not to grant a review by an independent panel. The Ombudsman can in principle look at the administrative handling of a complaint by the Trust. While the Ombudsman would not condone the delays which occurred, he rarely conducts an investigation which deals only with the administrative handling of a complaint because experience has shown that such investigations are seldom of value to the complainant. The decision on whether to convene an independent review panel is entirely up to the convener once he has taken appropriate advice. It is not up to the Ombudsman to judge whether or not a convener's decision is 'right'. I note that, in reaching his decision, the convener took clinical advice from the Trust's medical director who had already been involved in the local resolution of your complaint. The Scottish Executive Health Department's guidance on complaints handling states that clinical advice at the convening stage should not come from a person who has previously been involved, in any way, with the complaint. While it would have been appropriate for the convener to take clinical advice from a source other than the medical director, in this case I do not consider that a different source of clinical advice would have altered his decision. I have, nevertheless, written to the Trust chief executive to remind him of the need to ensure that complaints are dealt with in accordance with the guidelines.

I am sorry to send what I appreciate will be a disappointing reply but I regret that the Ombudsman cannot help. I have sent a copy of this letter to Greater Glasgow Health Council for information.

Investigations Manager

Cc Ms ...., Greater Glasgow Health Council

Ibrox,
Glasgow.

17 February 2000.

Office of the Health Service Ombudsman for Scotland,
Edinburgh.

Dear Sirs,

Thank you for your letter of 28th January last. I am writing as advised by your office in a recent phone call after receiving your reply to my complaint, when I was told that a more detailed response could be given.

Why was it reasonable to "not resuscitate" when she had already responded to resuscitation at Casualty upon admission and her vital signs were stable with blood glucose levels brought within normal ranges by the day after admission?

Why do your medical advisors consider it was in her best interests not to be put through intensive care and said ordeal? Surely it would have been beneficial to have had respirator use to aid blood oxygen saturation along with better intensive attention, to reduce the likelihood of brain damage. My Mother had displayed generally good signs at Casualty regarding the Central Nervous System with PERLA and symmetrical reflexes. Also Dr ...., as in the letter of 7th April 1999, said that there was no evidence of acute brain injury and that a loss of oxygen for a short time at 46% lowest did not mean that there was automatically a brain injury.

I know that after glucose levels have been corrected, the syringe pump driven insulin infusion is stopped so as to check that the patient's endocrine system is capable of functioning normally, but I feel, as I stated in my request for an Independent Review, that there was a disadvantageous lack of attention on this point.

The British Diabetic Association states rightly that blood glucose levels should be within 4-8 mmol/L between meals and no more than 10 mmol/L after a meal, and although my Mother's levels were reduced, they still remained uncorrected at higher than normal.

In this, I fail to see how the increased stroke risk was apparently not considered by Clinical Staff, in that reduced oxygenation and high blood glucose levels lead to sticky blood. It was after that figure of 18.1 mmol/L that my Mother's pupils became unequal, which is usually a sign of apoplexy.

I have not found the Trust's explanations of my Mother's treatment to be without contradictions and inconsistencies and I ask how your office can consider that the Trust has taken my points on clinical care and non-communication seriously, in the 23rd August 99 letter and the Convener's letter of 10th November 99.

Regarding the lack of communication, the Trust in not discussing resuscitation with me, as Nurse's notes of 16th March 1998 state as to be carried out is surely unfeeling at least, and my views on this issue are being glossed over. The Trust's medical notes indite the Trust with the glaring contradiction shown, as I pointed out in my letter to the Convener under Point One, specifically Mr ....'s, letter of 21st April 1999 and the Nurse's notes of 16th March 1998.

Furthermore, I consider that the failure of a nurse to record my achieved response provided Doctors with false reports. Local Resolution/Convener letters left me wondering what my Mother had to show before she was to be classed as conscious in any way. Any elderly person after bronchopneumonia could hardly be expected to be fully conscious in double quick time. She was wrongly classed as always in coma but was not when she responded to me. She obviously recognised my voice and understood my words. Her memory banks, acoustic nerves, integration centres and primary motor cortex were all functioning. On the Glasgow Coma scale she would have had a higher rating than was ever given to her, and at that point she could never have been classed as unconscious.

In this, and the knowledge that they had, but never truly imparted to me:-

1. about the oedema noted in nurse's notes at 7pm/16th March and her unequal pupils in clinical notes on 16th March;

2. clinical notes of 17th March stating that I needed to be spoken to again but never was and her blood pressure at 0600/17th March down to 58/24, but no medical record of my being informed until 5 to 10 minutes before she died, to come to the hospital;

and in this total lack of communication they committed their most inhumane act. That act was against, not myself, but my Mother.

They took from her the most important Right of the Dying, which is not to die alone. Doctors assume that because a patient shows no response to their standard tests, that the patient is unaware of everything. In this, they are wrong. Their view should have been that my Mother may have got comfort from my presence, my voice and the touch of my hand, but none of this was considered and I feel very strongly that they need to be taken to task over it and I see no sign of this.

Regarding the Convener's response, I was not surprised to receive a rejection since Conveners are part of the Trust but I am surprised that the Ombudsman apparently has no authority over Trusts/Conveners. It appears to me that if the Ombudsman cannot judge the "rightness" of a Convener's decision, then they can autonomously continue to be biased in their approach and the public will not receive a truly independent fresh approach to their complaints, and their decisions, as I feel in my complaint, will be coloured by wrong advice and an unquestionable acceptance that any practice operated by a hospital is automatically correct.

I am,
Yours faithfully,
Iain R.Stewart.

Office of the Health Service Commissioner for Scotland
(Ombudsman),
Edinburgh.

31 March 2000.

Mr. lain Stewart,
Glasgow.

Dear Mr. Stewart,

Thank you for your letter of 17 February to the Health Service Ombudsman further to your complaint against South Glasgow University Hospitals NHS Trust (formerly the Southern General NHS Trust). Having considered the additional information you provided, I propose that the Ombudsman should investigate aspects of your complaint relating to your late mother's clinical care as set out in the enclosed statement, which describes the terms of the investigation.

I also enclose some notes providing general information about investigations by the Ombudsman.

The Ombudsman's investigations can vary considerably in their format and length. Some require no more than a detailed examination of the clinical records and correspondence before a conclusion can be reached. Others require more, including interviews with those involved. At this stage it is not possible to say what form the investigation will take in your case. However the enquiries may take some time and the investigating officer, Ms ...., may need to visit you. If that is necessary Ms .... will either write to you or telephone to make the arrangements. A telephone number where, if possible, you can be contacted during the day would be helpful.

When the investigation has been completed you will be sent a report.

Yours Sincerely,

Investigations Manager.

The following page is the Ombudsman's Report.

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

Iain R. Stewart, Ex-Carer
excarex@excarex.com

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