Carer's Experience Medical Neglect

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This page contains the letters regarding the official File Note of the first meeting on 21st January 1999 which had been organised by the Glasgow Health Council, and regarding other actions of staff which I considered as failings on their part. To certain questions that I had raised, I never got definite satisfactory answers. Throughout the 7 months of the Complaints Procedure first stage, there were many phone calls as I tried to get answers to the points regarding the manner in which I was informed of my Mother's death and the neglect displayed in connection with my Mother's response to my speaking to her and her obvious recognition of my presence. Certain hospital letters refer to this with the same unchanging answer which to me was no answer at all.

Southern General Hospital NHS Trust,
Glasgow.

21st April 1999.

Mr. I. Stewart,
Glasgow.

Dear Mr. Stewart,

I refer to your recent request for a copy of our note of the meeting which took place on 21st January 1999. I have contacted the consultants who attended the meeting for their approval that the items documented are factually correct. I will send you a copy of the note as soon as I have heard from the consultants.

With regard to your complaint concerning the way in which you were advised of your mother's death, this has been raised with Staff Nurse .... but she cannot recall the incident described by you or whether she was the staff nurse who advised you of your mother's death.

In the circumstances I can only advise you that Staff Nurse .... is a bright, caring member of staff and it would not have been her intention to speak to you unsympathetically. As I indicated in my letter to you of 22nd February, I would like to reassure you that our aim is to ensure that relatives are treated in a proper and compassionate manner following bereavement.

Regarding your concern over the entry in your mother's notes by Staff Nurse ...., "son in attendance during visiting time". It is normal practice to comment on relatives being in attendance with a comatosed patient and her comment was not an indication that your mother was deteriorating. Your mother's condition had been poor since her admission on the 12th March 1998.

With regard to your complaint concerning Staff Nurse .... not advising medical staff of your mother's response to your voice, I can assure you that he considered that the response from your mother did not represent a significant change in her condition. Occasionally there are such responses from unconscious patients when care is being carried out by nursing staff and this would not necessarily represent a significant change.

The phrase, "do not read too much into this" is not a phrase Staff Nurse .... would normally use however if it was said, it would have only been used to emphasise to you that your mother's reaction was not a significant change in her condition.

I hope my comments have helped to address the complaints you have concerning your mother's nursing care. With regard to your complaints concerning your mother's medical treatment, I am presently looking into this and will write to you again in due course.

pp Chief Executive.

Southern General Hospital NHS Trust,
Glasgow.

6th May 1999.

Mr. Iain Stewart,
Glasgow.

Dear Mr. Stewart,

Please find enclosed a copy of the File Note of the meeting which took place on the 21st January 1999. I have contacted the consultants who attended the meeting for their approval that the items documented are factually correct.

Yours sincerely,
Chief Executive.

File Note

Meeting with Mr. Stewart, Mrs ....(Local Health Council Representative), Drs .... and ...., Mr .... and Miss .... on 21 January 1999.

At the outset of the meeting Mr. Stewart explained that he has been attending CRUSE for bereavement counselling. They have been unable to help Mr. Stewart with his questions concerning his mother's clinical treatment. Mrs. Stewart died on 17 March 1998.

Mr. Stewart referred to the day he telephoned for an ambulance for his mother (12 March) and commented that he should have requested it sooner. She had fallen unconscious and had difficulty breathing. Mr .... commented that it would not have made any difference to the outcome. Mr. Stewart added that the Ambulance Crew felt that there was an obstruction in her throat, possibly her tongue. Mr. Stewart felt his mother stopped swallowing prior to her unconsciousness.

Mr. Stewart referred to his mother's medical records and asked if a 'resuscitation chart' is used for everyone. Mr .... explained that the chart is used for every patient brought into the Resuscitation Room. Patients in this room are given a more intensive level of care. Mr. Stewart asked what 'CXR' referred to. Mr .... explained that it is the abbreviation for 'chest x-ray'.

Mr. Stewart asked why he was not informed that his mother suffered a heart attack. The Consultants endeavoured to explain that Mrs. Stewart did not suffer a heart attack during her admission. The ECG reading suggests that she had an attack at some time in the past. She had evidently come to no harm and had recovered from it. Mr. Stewart referred to the computer ECG report and the Consultants explained that the comments made at the top of the sheet are for guidance only. There is no way of telling when Mrs. Stewart had her heart attack. The reading taken on 12 March 1998 compared to other readings shows the attack. The comment 'Recent Anterior Infarct' printed by the computer is for guidance only and is used to give a wide margin of safety. Mrs. Stewart's heart was pumping adequately at that time - there was no evidence to suggest that it wasn't.

Mr. Stewart referred again to his mother's Medical records and asked Mr .... why CPR was not to be given. Mr .... endeavoured to explain that his mother would not have survived - she was too ill and too old. Mr. Stewart asked what had caused her death and Dr .... explained that Mrs. Stewart was vulnerable to chest infection or pneumonia. She was admitted with hyperosmolar diabetic coma. It was likely that she suffered a brain stem infarct (stroke). Mrs. Stewart never regained consciousness. Broncho pneumonia is very common in elderly people and can take hold very quickly. Mr. Stewart commented that he had requested aggressive treatment. Dr .... explained that no appropriate treatment was withdrawn. Mr. Stewart referred to his mother's notes and to a comment that someone was to speak to him about his mother. No member of medical staff spoke with him again. Mr. Stewart referred to a comment in the notes 'no active treatment'. Dr .... explained that it would have been more accurate to write 'no active treatment would be successful.' Mrs. Stewart's condition was terminal and it would not have been possible to resuscitate her.

Mr. Stewart went on to explain that he was unaware that his mother's condition was as bad. He was telephoned by nursing staff on 17 March and asked to come down to the hospital and given no explanation. Dr .... explained that Mrs. Stewart's condition deteriorated rapidly during the morning of 17 March 1998.

Mrs. Stewart had difficulty breathing due to poor oxygen exchange in lungs. Mr. Stewart referred again to the Ambulance Crew's comment that there was an obstruction in Mrs. Stewarts throat. The obstruction was possibly caused by Mrs. Stewarts tongue. Mr. Stewart commented that his mother stopped swallowing her Complan in the house. The Consultants reassured him that this did not cause the obstruction. There was no evidence of Complan in Mrs. Stewarts throat. The Consultants reassured Mr. Stewart that he did not cause his mother's unconsciousness or breathing difficulty.

Mr. Stewart reminded Mr .... of their meeting on 1 June 1998. Mr .... commented that he did his best to communicate with Mr. Stewart during that meeting. Mr. Stewart asked if an inhaler would have helped Mrs. Stewart's difficulty breathing. Mr .... commented that this would not have helped her pneumonia. Mrs. Stewart was extremely ill for a number of years and Mr. Stewart looked after her very well.

Mrs. Stewart suffered double pneumonia during October 1997 and recovered. Mr. Stewart asked why did she not recover from pneumonia in her right lung. Mr .... explained that the pneumonia in the right lung was more severe because of his mother's clinical conditions.

No one explained to Mr. Stewart that his mother may be dying. Although her condition was stable she was very unwell. The Consultants cannot be certain that she suffered a stroke as a post mortem wasn't performed. It is most likely that she did suffer a stroke. Mrs. Stewart developed diabetes due to her infection. Prior to this she was not a diabetic. Mr. Stewart asked if a respirator would have helped his mother. The Consultants explained that although it would have, she would have become dependent on it and would have not been able to get off it.

Mr. Stewart referred to an incident where, although his mother was in a diabetic coma, he got a response from her. When he advised Nurse .... of this he was not very encouraging. 'Don't read too much into that'. This incident was not brought to the Consultant's attention. The Consultant endeavoured to explain that although Mr. Stewart got this response from his mother, Mrs. Stewart was correctly assessed as being unconscious. There are different levels of unconsciousness.

Mr. Stewart referred to the way in which he was told by Nurse .... that his mother had died. When he arrived at the hospital on 17 March he met the nurse in the corridor. She allegedly said, "your Mum's gone - 10 minutes ago" in an off-hand manner. She walked past Mr. Stewart and he called after her "was it a heart attack" - "No it wasn't a heart attack" she replied. Mr. Stewart was advised that this matter would be investigated through the complaints procedure.

At the end of the meeting the Consultants reassured Mr. Stewart that he had looked after his mother very well and indeed had prolonged her life. Mr. Stewart should not blame himself for the deterioration in his mother's condition.

Complaints Officer,
26 January 1999.

Mr. Stewart produced a list of questions during the meeting.

Southern General Hospital NHS Trust,
Glasgow.

24th June.

Mr. I. Stewart,
GLASGOW.

Dear Mr. Stewart,

Thank you for contacting the Complaints Office requesting an explanation as to why Staff Nurse .... did not document in the medical records the matter concerning your mother's response to your voice. As I advised in previous correspondence, your mother's eye opening and squeezing of your fingers did not indicate a change in her condition and as such was not documented in the medical records. I am sorry if the fact that this was not documented has caused you further distress, as I can appreciate that your mother's response would have been significant to you and obviously still is.

I hope the above information addresses this remaining concern regarding the nursing care offered to your mother.

With regard to your complaints concerning your mother's medical treatment, Dr ...., Director of Medical Services is currently looking into this and we will contact you again in due course.

Yours sincerely,

pp Chief Executive.

The next page, Local Resolution 1d, contains the closing letter of the Local Complaints procedure.

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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