Carer's Experience Medical Neglect

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The first letter in this page is my request for an Independent Review followed by the Convener's letter refusing same, which did not surprise me in the slightest. At the same time as the complaints procedure, I had received from Greater Glasgow Health Council a survey that had been distributed via the Health Councils in the UK, and had been sent out from "Which" (Consumers Association). Its purpose was to acquire information on the general public's views on the NHS. In response to my completion of the survey, I received a complimentary copy of the "Which" publication regarding health. In that copy there was reference made regarding people stating that if they had known how long the complete procedure was going to take then they would never have started their complaint in the first place. The article also referred to Independent Conveners questioning their own supposed independence since they were part of the Trust that had the complaint placed against it.

10 September 1999.

Mrs ....,
South Glasgow University Hospital NHS Trust,
Southern General Hospital,

Dear Mrs ....,

I am writing to request an Independent Review of my complaint regarding the death of my Mother Mrs. Jane W.H.Stewart, Patient Number 713420 in the Southern General Hospital on the 17 March 1998.

There has been a long exchange of correspondence and telephone calls over an inordinate period of time from the outset to the conclusion of Local resolution. I remain dissatisfied with the inconsistencies and untruths in the definitive response conclusion of Local Resolution letter of 23rd August last and inconsistencies in comparison to previous correspondence on file with the Complaints Officers.

In the letters of 22nd/23rd February between Miss .... and myself and the letter of 29th March from Mrs ...., along with the medical notes, the salient points are:-

1. Lack of consultation regarding the position, negativity and false assumptions on the part of the hospital. It is stated in the medical notes that I was fully aware of my mother's condition and in the 23rd August letter that it had been explained to me at Casualty by Mr .... that her long term survival was unlikely and that no strenuous efforts were going to be made to keep her alive. This is untrue, as is the statement that Staff Nurse .... spoke to me about my Mother's deteriorating condition on 16th March. Regarding deterioration, Mr ....'s letter of 21st April, in contradiction, states that a nurse's notes entry of 16th March which I had questioned, was not to be read as an indication of deterioration. The contradictions and negativity also exist over the Nurse .... issue and the ignoring of my wishes for active aggressive treatment, after they had asked for and recorded my wishes in both Nurses and Doctors notes.

2. Throughout, her respiration was considered dyspnoeic, yet there was no use of a respirator, which it has been admitted, would have helped her. It appears obvious to me that my Mother was not given every fighting chance.

3. My Mother's blood glucose level on admission was 21.2 mmols with a high serum osmolarity of 404, which were clearly considered excessive. From the start of Intravenous Insulin Infusion to the stopping of it on 15th March at 0930, any glucose level above 8 mmols was brought down by an insulin increase. Afterwards, glucose levels were allowed to rise to an excessive 18.1 before Ward .... brought it to the attention of Doctors. This level of 18.1 is being trivialised as of no immediate concern. For the hospital to correct the blood biochemistry; provide physiotherapy to clear lung secretions; provide antibiotics to clear pneumonia; provide re-hydration and correct the hyperosmolar high blood glucose levels, it seems detrimental to then let the glucose levels thereafter climb to and remain at various excessive levels. This, along with the non-maximising of the blood's oxygen saturation through non-use of a respirator could hardly be advantageous.

The letters on file are as follows:-

10th December 1998 from Mr ..../Health Council to Dr ....
11th January 1999 from Miss .... to myself.
A copy of my notes/questions for the 21st January meeting.
11th February from Mr .... to myself.
22nd February from Mr .... to myself.
22nd February from Miss .... to myself.
23rd February from myself to Miss ....
29th March from Mrs .... to myself.
7th April from Mr .... to myself.
21st April from Mr .... to myself.
6th May from Mr .... to myself.
27th May from Health Council to Mr ....
24th June from Mr .... to myself.
23rd August from Mr .... to myself.

I have spent 7 months trying to get consistent answers but remain dissatisfied. I consider that the negativity of the "no strenuous efforts" has applied in general and that the decision of "no active treatment to be performed" on the 17th March was its culmination.

I do not believe that further investigation under local resolution will be productive, and would appreciate the matter being examined by independent people.

I am,
Yours sincerely,
Iain R. Stewart.


10 November 1999.

Mr I. R. Stewart,

Dear Mr. Stewart,

I write in response to your letter of 10 September 1999, addressed to ...., requesting that an Independent Review Panel be convened to consider your complaint regarding the treatment your mother received during her stay in the Southern General Hospital from 12 March 1998 until she died on 17 March 1998.

Before responding, can I offer our apologies that this response has been delayed. Greater Glasgow Health Board took longer to appoint an Independent lay Chairman than is normally the case because of the demands on the Panel of lay Chairmen. I also did not help by going on holiday just as the name of the Lay Chairman was notified to the Trust.

My role in the complaints procedure is not to deal with substantive issues raised by the complainant, but along with an Independent Lay Chairman appointed from Greater Glasgow Health Board's Panel to consider whether the complaint has been adequately dealt with at local resolution and to decide if there are outstanding issues that would be appropriate to be dealt with by an Independent Review Panel.

Both the Independent Chairman and myself have carefully reviewed all the information and correspondence associated with your complaint.

I understand the sad loss you suffered when your mother died and appreciate that you are having difficulty coming to terms with your grief while you consider that the issues raised in your complaint have not been satisfactorily dealt with.

However, having given the issues very careful consideration and discussed them at some length with the Independent Chairman, I have concluded that it would not be appropriate to refer your complaint to an Independent Review Panel. My reasons for this conclusion can be summarised as follows:-


Over the time where this complaint has been considered, extensive efforts have been made to try to explain to you the reasons why the clinical decisions were taken by the doctors who were in charge of your mother.


I realise that you made specific requests for clinical intervention in your mother's case, but it has been explained to you that the treatment you requested was not appropriate and would not have affected the outcome.


All the clinical issues you raised, including your mother's response to your voice, the blood sugar level, the decision not to ventilate your mother, the dangers of carrying out the CT scan on your mother and the decision not to transfer your mother to the Intensive Care Unit, have been responded to and the view given that none of these issues you raise would have saved your mother's life.


The Trust's Medical Director, Dr ...., has reviewed all the clinical information and has concluded that your mother's clinical management was in keeping with her condition and is also of the view that the suggestions you made for clinical intervention would not have saved your mother's life.


I cannot discern any discrepancies between the clinical treatment given to your mother and the views of the Trust's Medical Director on how your mother should have been treated.


Explanations have been given to you in regard to your view that you were not adequately informed of your mother's critical condition on 17 March 1998 when you were asked to come to the hospital. These views are outlined in Mr ....'s letter of 23 August 1999 and reflect the practice operated by the hospital in these circumstances.


One of the aspects of your complaint is in regard to the way you were told about your mother's death. There is clearly a dispute between your version of events and the staff member, who does not recall the incident. Nevertheless the Trust has apologised for the incident and the staff have been reminded of the appropriate manner to treat relatives in cases of bereavement.


Your general complaint of the lack of consultation has been dealt with and explanations given at successive meetings and in correspondence.

In summary, I have concluded that the issues you have raised have been properly addressed at local resolution and explanations given. Clinical issues have been reviewed and the conclusion reached that the clinical care given to your mother was appropriate for her condition. There are therefore, in my view, no outstanding issues which would be appropriate for an Independent Review Panel to consider and this view is shared by the Independent Lay Chairman.

You have, of course, the right to refer your complaint to the National Health Service Ombudsman, who can be contacted at:-

Health Service Commissioner for Scotland,
Thistle Street,

and, further, to seek help and advice from the Local Health Council to prepare any submission you would wish to make to the Ombudsman. The Chief Officer of the Local Health Council is:

Mr ....,
Greater Glasgow Health Council,
Florence Street,

Yours sincerely,

The next page First contains the letters regarding the first approach to the Ombudsman.

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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