Carer's Experience Medical Neglect

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The first three letters in this page are the letters defining the complaint. It also contains material regarding my attempts to have certain other matters addressed and also to hopefully have questions answered. The last letter refers to a meeting that I had with one of the consultants who was in charge of my mother's case at an earlier stage.

Southern General Hospital NHS Trust,
Glasgow.

22 February 1999.

Mr. lan Stewart,
Glasgow.

Dear Mr. Stewart,

I refer to Mr ....'s letter of 11 February 1999 and to our telephone conversation on 18 February and write to confirm the areas which you wish to be raised as a complaint:

1. You would like an explanation as to why you were not advised of Mr ....'s instruction to hospital staff, on the day of your mother's admission (12 March 1998), not to perform cardio-pulmonary resuscitation in the event of a cardiac arrest. You consider that you should have been consulted given that you were Mrs. Stewart's next of kin.

2. You refer to an entry in your mother's medical notes on 16 March 1998 which states 'Dr .... to speak to son'. You contend that no one spoke with you about your mother's condition up until her death.

3. After requesting aggressive treatment for your mother on 16 March 1998, an entry in her medical notes on 17 March 1998 states 'no active treatment to be performed'. You would like an explanation as to why this decision was made and also why you were not informed of it.

4. Regarding the incident where your mother responded to your voice, you would like an explanation as to why Staff Nurse .... did not report the incident to medical staff. With regard to point 4, it would be helpful if you could recall when the incident took place.

I have enclosed a copy of this letter which I would ask you to sign if you agree with the points listed. This will allow me to properly investigate the concerns raised.

I enclose a stamped addressed envelope for the return of the copy letter.

Complaints Officer.

23 February 1999.

Miss ...,
Complaints Officer,
Southern General Hospital,
Glasgow.

Dear Miss ....,

Thank you for your letter of 22 February. I have enclosed the signed copy along with this letter which expands on your listed points and should be read with it.

Point One:- The lack of communication issue is unquestionable.

Irrespective of Mr ....'s views as to the outcome of attempted CPR, an arbitrary decision was made. In his discussion with me at Casualty, Mr .... made no reference to heart problems nor diabetic high blood glucose states. The understanding imparted to me was that admission was for right side lung infection.

The instruction of no CPR in the clinical notes is contradictory to the entry above it which states "responding to resuscitative measures". Letter 11.2.99 refers to Mr .... stating resuscitation not possible yet my views regarding this are in nurses' notes.

Point Two:- The entry in the clinical notes of 16 March 1998 states "Speak to family regarding future". The nurses' notes state "Dr .... to speak to son - re resuscitation". At the request of Dr ...., he had a meeting with me on the afternoon of 16 March. He said that the pneumonia had been cleared, but my views on action to be taken should it arise again, were required. I said that I wanted any infection to be given aggressive antibiotic treatment. He referred to the hyperosmolar diabetic coma and to my comment that she was not diabetic, said that she did not have to be for this condition to arise. He spoke of possible cortex neuron damage due to glucose non-absorption and at my request, confirmed that a CT brain scan would show this and it would be done. He also spoke of the future possible necessity of IV feeding and would I be able to handle it, to which I said that I could learn with nursing help. At no point did he give any indication that the Doctors considered my mother to be dying, or refer to resuscitation. I mentioned that I would consult with a relative regarding the position but that he could take it as confirmed that aggressive treatment was required. At that day's evening visit period, I spoke to a Staff Nurse and confirmed the wish for aggressive treatment and she said it would be notified to doctors. This is in the nurses' notes. The Staff Nurse was the nurse who broke the news of my Mother's death to me. The clinical notes of 17 March state "Apparently son wishes active management incl-CT-brain. Needs to be spoken to again", but there was no attempt to do so. There was no call from the hospital until approximately 5 minutes before she died.

Point Three:- This highlights the non-communication problems. If there had been consultation, my wishes would have obviously been active treatment including resuscitative measures. The notes and letter of 11 February about the meeting on the 21 January last, leave the impression that my wishes were not to be considered too much and that a negative approach was in operation. My wishes should have been paramount regarding hospital decisions.

Point Four:- The Nursing Care Plan states under Prob No.1, "Monitor and record any improvement/deterioration in conscious level". Staff Nurse .... should have written this into the notes and immediately brought it to Doctors' attention. It was in stark contrast to the entries stating "Remains unresponsive - no verbal response - eyes remain closed". Although she did not speak, her eyes opened to my saying "Mum" and she understood and carried out my request to squeeze my fingers three times. This occurred on the afternoon of Saturday 14 March, I am fairly sure. Nurse .... came into the ward to my Mother's bed immediately afterwards and was informed by me. His reply was that I should not read too much into it. It is doubtless that patients can be in coma and totally unresponsive, yet fully aware of everything said around them and about them and proceed to make a full recovery from that state.

I am,
Yours sincerely,
Iain R. Stewart.

Southern General Hospital NHS Trust,
Glasgow.

29th March 1999.

Mr. I. Stewart,
Glasgow.

Dear Mr. Stewart,

As I discussed with you, I write to confirm the areas which you wish to raise as your definitive complaint.

1.

You would like an explanation as to why you were not advised of Mr ....'s instruction to hospital staff on the day of your mother's admission (12th March 1998), not to perform cardio pulmonary resuscitation in the event of a cardiac arrest. You consider that you should have been consulted giving that you were Mrs. Stewart's next-of-kin. You ask why it says in the notes that no CPR was to be given, when earlier the casualty card states that Mrs. Stewart was "responding to resuscitative measures".

2.

You state that you were never advised that your mother's condition was declining, despite there being an entry in the nursing notes stating that Dr .... to speak to son. The clinical notes for the 16th March 1998, note the obvious change in your mother's condition however you were never informed of this. You state that your mother had the right not to die alone and yet you were not there at the time of her death.

3.

You have the feeling that clinical staff could have fought for your mother but decided to let her go. This is confirmed in an entry into her medical notes on 17th March 1998, which states " no active treatment to be performed". This is despite you requesting aggressive treatment for your mother on 16th March 1998. You would like an explanation as to why this decision was made and also why you were not informed of it.

4.

Regarding the incident where your mother responded to your voice, you would like an explanation as to why Staff Nurse .... did not report the incident to medical staff. This happened despite the nursing care plan stating under problem No. 1, "monitor and record improvement /deterioration in conscious level". You feel that your mother's response to your voice was in stark contrast to the entry in the notes stating "remains unresponsive, no verbal response, eyes remain closed". You also feel that it is doubtless a patient can be in a coma and totally unresponsive, yet fully aware of everything said around them and about them, and proceed to make a full recovery from that state.

5.

With regard to the care of your mother's diabetes, you ask why nursing staff allowed your mother's blood sugar levels to go up to 18.1 before bringing this to the attention of medical staff. You ask if this had been reported earlier whether this would have made a difference to the final outcome.

6.

You wonder whether a respirator would have helped your mother. When her oxygen levels dropped on the 17th March, you wonder why she was not put on a respirator.

7.

You remain extremely concerned that you do not know the reason why your mother died, as she died before a CT scan could be carried out which could have confirmed if she had suffered a stroke. You are extremely concerned that if you had been told of Mrs. Stewart's deterioration, you would have requested her transfer to the intensive care unit where she could have been kept alive until able to go for a CT scan.

8.

The next point refers to the nurse who broke the news of your mother's death in an extremely unsympathetic manner. You state that it was not Nurse .... who broke the news of your mother's death but the nurse who spoke to you with regard to the removal of your mother's ring, the person whom you advised of your wishes for aggressive treatment for your mother, and the person who advised you that Dr .... was not available to speak to you when you requested.

9.

When you spoke with me on Tuesday 16th March, you requested a copy of the middle sheet of the physiotherapy treatment records regarding your mother as you did not receive this with the rest of her notes. Accordingly I enclose a copy for your attention.

10.

When you spoke with me on 25th March 1999, you requested a copy of the Insulin Infusion Pump Charts and Insulin Sliding Scale Prescription Chart for your mother. Accordingly I enclose copies for your attention.

I have enclosed a copy of this letter which I would ask you to sign if you agree with the points listed. This will allow me to property investigate the concerns raised.

I enclose a stamped addressed envelope for the return of the copy letter.

Yours sincerely,

Complaints Officer.

Southern General Hospital NHS Trust,
Glasgow.

7th April 1999.

Mr. I. Stewart,
Glasgow.

Dear Mr. Stewart,

As you discussed with the Complaints Officer, I now detail below the matters discussed at your meeting with Dr .... and Mrs .... on the 2nd March 1999.

You opened the meeting by stating that you had never been informed that your mother was in a hyperosmolar state. You advised that you had only been told that she had bronchopneumonia and there was never any mention of her having high glucose levels.

Dr .... explained that the hyperosmolar state occurs following a few days of high glucose levels.

You questioned Dr ....'s entry into the notes of the 13th March 1999, "89 year old with bronchopneumonia and non ketotic hyperosmolar state. Not compatible with a history of sudden deterioration". You asked what Dr .... had meant by this. Dr .... replied that she had been told that your mother had suffered a collapse following a sudden deterioration. However the later blood test showed that your mother had suffered a dramatic change in her health along with a slow deterioration. She explained that this is compatible with a hyperosmolar state. Dr .... apologised if you had been upset by this statement. You responded that you were not upset by the statement but simply wanted to know if Dr .... was aware of any other reason why your mother's health had deteriorated.

You then asked Dr .... whether she felt that the Complan which you had been giving to your mother had caused her diabetes. Dr .... advised that this was not the case and that some people just develop diabetes.

You then asked various questions with regard to the tests carried out on your mother. Dr .... advised that the yeast specimen showed a moderate growth which was not serious. She also explained that your mother's white blood cell count was raised which is often the case where an infection is in place. Dr .... also advised that your mother's ESR level was compatible with a person suffering from pneumonia.

Your mother's haemoglobin level was at the lower limit at 104 however, Dr .... explained that this was not dangerously low and could result for a variety of reasons. Dr .... explained to you, that in her opinion, you did not do anything wrong and did not cause your mother's death. You then raised a question of whether your mother had suffered a stroke. Dr .... advised that she could not say whether your mother had suffered a stroke and advised that at the time she saw your mother, there was no evidence of acute brain injury.

However you asked whether your mother could have suffered a brain injury as a result of her oxygen level being at 46% on admission. Dr .... replied that this did not mean that your mother had suffered a brain injury as her level quickly rose to 93%. She advised that a loss of oxygen for a short time will not cause a brain injury.

Following the meeting you spoke with Mrs .... and advised her that my response to you of 22nd February 1999 was incorrect. You advised that you had never stated that the nurse who broke the news of your mother's death to you was in fact Nurse... You advise that Nurse .... had completed the nursing notes for that day however it was another nurse who spoke to you. You advise that this nurse was the same person who spoke with you regarding the removal of your mother's rings if her fingers remained swollen.

Mrs .... advised that she would pass this information onto the Senior Nurse Manager of the Medical Directorate to allow her to re-investigate this part of your complaint.

Yours sincerely,

pp Chief Executive.

The next page, Local Resolution 1c, contains letters regarding the file note details of the first meeting on the 21st January 1999.

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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