The following letter is the close of the Local Resolution procedure.
SOUTH GLASGOW UNIVERSITY HOSPITALS TRUST HEADQUARTERS
23rd August 1999.
Mr. lain Stewart,
Dear Mr. Stewart,
I refer to your complaint concerning your late mother, Mrs. Jane Stewart, and to my last letter to you of 24th June 1999. In this letter I indicated to you that Dr .... Director of Medical Services, would review your complaint and having done this he has indicated that it would be in order for me to draw together the many strands of your complaint and give you a definitive response.
At the outset of your complaint arrangements were made for you to meet with Dr ...., Dr .... and Mr .... on 21st January, to discuss the many issues that you have. You also met with Dr .... on 2nd March and later confirmed all aspects of your complaint with the Complaints Officer who documented them in a letter to you dated 29th March 1999.
Turning to the meeting held on 21st January, you indicated that on admission your mother had difficulty breathing and ambulance crew had commented that there was an obstruction in her throat. The obstruction was caused by her tongue, however I understand that you were concerned that the obstruction was caused by her Complan. There was no evidence of Complan in Mrs. Stewart's throat and I understand the consultants tried to reassure you that you did not cause her unconsciousness or breathing difficulty. Mr .... also commented during the meeting that your mother had been very ill for a number of years and you had looked after her very well and had prolonged her life.
You also asked why you were not informed that your mother had suffered a heart attack during her admission. As you know her ECG reading taken on 12th March 1998 suggested that Mrs. Stewart suffered a heart attack and the consultants were able to reassure you that it had happened some time in the past before her admission. Although her heart would have been weakened by the attack, she had recovered from it. The consultants also explained that there was no way of knowing when your mother experienced the attack but they were able to advise you that she had suffered it by comparing the ECG reading taken on 12th March 1998 with her previous readings.
You were also concerned about the comments on the top of the ECG report "recent anterior infarct" and the consultants reassured you that this wording is printed by a computer and is used to give a wide margin of safety. Your mother's heart was pumping adequately at the time of the ECG reading and there was no evidence to suggest that it wasn't.
You referred to your mother's medical records and questioned the entry made on the day of her admission by Mr .... "no cardiopulmonary resuscitation to be given in the event of a cardiac arrest". You also indicated to the Complaints Officer during your telephone conversation in March that you would like an explanation as to why you were not advised of this instruction to hospital staff as you were Mrs. Stewart's next of kin. You also ask why it is stated in your mother's notes that no CPR was to be given when it was noted earlier in her Casualty Card that she was "responding well to resuscitative measures". When your mother was admitted to the A&E Department it appeared to Mr .... that you realised that your mother was dying. Mr .... has indicated to me that his discussion with you confirmed this and he explained to you that your mother's long term survival was not likely and that staff would not be making strenuous efforts to keep her alive. Whilst Mr .... probably did not use the term "cardiopulmonary resuscitation" he thought that he had explained that your mother had already been started on appropriate treatment but in the event of a cardiac arrest, further aggressive treatment was unlikely to be successful. If the medical staff had performed CPR, your mother would not have survived as she was terminally ill. It should also be noted that whilst a consultant in charge of any patient's clinical care will take into account the wishes of a next of kin, the ultimate clinical responsibility for the patient lies with the consultant.
You also ask why you were not advised that your mother was deteriorating when telephoned by nursing staff on 17th March and asked to come down to the hospital. It is the practice of nursing staff to try and not distress family members over the telephone when asking them to attend, as often they have to make the journey to hospital by car. I sincerely regret that you were not with your mother at the time of her death and I understand from Dr .... that her condition deteriorated rapidly during the morning of 17th March 1998. Evidently it should have been made clearer to you that your mother was in a critical condition and I am sorry that this was not carried out to your satisfaction. I understand Staff Nurse... spoke with you about your mother's deteriorating condition on 16th March and also that it was Dr ....'s intention to speak with you.
With regard to your feeling that clinical staff could have fought for your mother's life but decided to let her go and to the entry in her notes that states, "no active treatment", during the meeting on 21st January, Dr .... endeavoured to explain to you that it would have been more accurate to state in the records that "no active treatment would be successful". Your mother was critically ill and it would have been fruitless to aggressively attempt to resuscitate her.
With regard to the incident where your mother responded to your voice, you ask why Staff Nurse .... did not report the incident to medical staff. This happened despite your mother's nursing care plan stating, "monitor and record improvements/deterioration in conscious level". You consider that your mother's response to your voice was in stark contrast to the entry in her notes, "remains unresponsive, no verbal response, eyes remain closed". You raised this concern during the meeting in January and the consultants endeavoured to explain to you that although you had this response, your mother was correctly assessed as being unconscious. Even if Staff Nurse .... had advised medical staff, your mother would still have been assessed as being unconscious as there are different levels of unconsciousness. As I indicated in my previous letter, your mother's eye opening and squeezing of your fingers did not indicate a change in her condition and this was therefore not documented in her notes.
With regard to the care of your mother's diabetes, you ask why nursing staff allowed your mother's sugar level to increase to 18.1 mmols before bringing this to the attention of medical staff. Having discussed this matter with the Senior Nurse Manager I can advise you that Mrs. Stewart's insulin was discontinued during the morning of 15th March. Her blood glucose levels were monitored 4 hourly thereafter and the prescribed intravenous fluid regime was continued as Dextrose 5% plus Potassium Chloride. At midnight her blood glucose level was elevated to 18.1 mmols and although this would not be an immediate cause for concern, medical staff were notified and your mother's intravenous fluid regime was adjusted to normal saline. By 4.00 a.m., her blood glucose level reading was 9.7 mmols.
You also ask whether a respirator would have helped your mother and the consultants endeavoured to explain to you during the meeting in January that although it might have helped her in the short term, in the long term she would have become dependent on it and would not have been able to come off it. Ventilation would not have reverted or improved her condition.
You remain concerned that you did not know the reason why your mother died, as she died before a CT scan was carried out. You also feel that if you had been made aware of your mother's deterioration, you would have requested her transfer to an Intensive Care Unit, where she would have been kept alive until able to have the scan. The consultants endeavoured to explain to you that it was very likely that your mother suffered a stroke. It is unlikely that a CT scan would have been performed as medical staff were treating the hyperosmolar diabetic coma which in itself is a life threatening condition. Given your mother's general condition, carrying out a CT scan at any time would have been hazardous and would only have been done had medical staff been certain that your mother had a condition that was treatable, which was not the case. The consultants also consider that transfer to an Intensive Care Unit would not have made any difference to the outcome.
Turning to your meeting with Dr .... on 2nd March as a result of your complaint about her entry in your mother's notes "not compatible with a history of sudden deterioration", I understand that she endeavoured to explain to you that a hyperosmolar state is something that occurs after a few days of high sugar levels and although she had been advised that your mother had had a sudden deterioration, the results of the blood tests taken were not compatible with a dramatic change. However, late blood tests showed that there had been a deterioration along with a dramatic change which is compatible with a hyperosmolar state.
Turning to the matter concerning the way in which you were advised of your mother's death, as I indicated to you in my letter of 21st April 1999, Staff Nurse .... cannot recall the incident described by you or whether she was in fact the Staff Nurse who advised you of your mother's death. Notwithstanding this, I am sorry that you were not treated in an appropriate manner and nursing staff have been reminded of our aim to treat relatives compassionately following bereavement.
With regard to your most recent questions concerning your mother's previous CT scans, I can advise you that the scan performed on 29th April 1996 showed moderate atrophy to be present with periventricular low attenuation bilaterally suggesting generalised small vessel disease. Concomitant ventricular enlargement was also reported. These changes are indicative of severe hardening of the arteries leading to the brain which has resulted in the death of many of the brain cells and a high risk of developing a stroke. It is also possible that these appearances were caused by a number of mini strokes prior to the scan.
Turning to the CT scan performed during July 1997, Dr .... has advised me that your mother was admitted under his care from 19th July until 31st July 1997. She had presented with an acute confusional state and fever and was treated with antibiotics. The confusional state resolved but because of it a CT head scan was arranged and again this showed minimal cortical atrophy and a pattern consistent with generalised small vessel disease. There was no evidence to suggest an acute stroke and no lesion which would have been amenable to any form of therapy.
I am very sorry for your loss and hope that the responses provided to you in this letter have satisfactorily addressed your points of concern.
Dr .... and I consider that your concerns have been addressed at the Local Resolution stage of the complaints procedure. If you remain dissatisfied then the next stage in the complaints procedure is to request an Independent Review. I enclose a copy of our complaints leaflet for your information. Should you wish to seek an Independent Review you should write to:
South Glasgow University Hospital NHS Trust
Southern General Hospital
You should state the specific points you wish the Convenor to consider. Any correspondence to the Convenor should be received within 28 days of the date of this letter. Should you wish any further advice on the Complaints Procedure or Independent Review, the Health Council are able to offer support.
pp Chief Executive.
The following page "Review" contains the letters regarding my request for an Independent Review.
Select a dated order Ombudsman sub-page.
Local 1a Local 1b Local 1c Local 1d
Review First Report Comments