Carer's Experience Medical Neglect

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Health Service Commissioners Act 1993

Report by the Health Service Ombudsman
for Scotland
of an investigation into a complaint made by:

Mr. lain Stewart
Glasgow
G51 2LB

Complaint against:

South Glasgow University Hospitals NHS Trust
(formerly Southern General Hospitals NHS Trust)

Complaint as put by Mr Stewart

1. The account of the complaint provided by Mr. Stewart was that his mother, Mrs. Jane Stewart (aged 89 years), for whom he acted as home carer, collapsed and was admitted to the Southern General Hospital on 12 March 1998. Mrs. Stewart had a complicated previous medical history which included chronic obstructive pulmonary disease, heart disease and dementia. On admission to hospital she was assessed as having broncho-pneumonia and diabetic coma. Mr. Stewart told clinical staff that he wished his mother to receive active aggressive treatment. Mrs. Stewart's condition did not improve and she died on the morning of 17 March. Mr. Stewart was not present at the time of his mother's death as nursing staff did not telephone him about her further deterioration until five or ten minutes before her death. He subsequently complained to the Trust about several aspects of his mother's clinical care and, in connection with his mother's condition, about issues of communication between himself and clinical staff. Mr. Stewart met with Trust staff to discuss his complaints and, despite a subsequent lengthy exchange of correspondence, he remained dissatisfied with the explanations given by the Trust. A request for an independent review of his complaint was refused by the Trust's convener on 10 November 1999.

2. The complaints investigated were that:

(a)

the clinical assessment and treatment Mrs. Stewart received were below a standard to which she was reasonably entitled in the circumstances;

(b)

it was unreasonable for medical staff to decide, without consultation with Mr. Stewart:

(i)

on 12 March, that Mrs. Stewart should not be resuscitated in the event of a cardiac arrest; and

(ii)

on 17 March that no active treatment should be performed; and

(c)

communication to Mr. Stewart by clinical staff about his mother's condition was inadequate with the result that she died alone and was deprived of the comfort that he could have given her.

Investigation

3. The statement of complaint for the investigation was issued on 31 March 2000. The Trust's comments were obtained, and relevant documents including Mrs. Stewart's clinical records were examined. Two independent professional assessors, a consultant physician and a nurse manager, were appointed to advise on clinical issues: their report is reproduced in full at paragraph 20. The Ombudsman's investigator interviewed Mr. Stewart and the Trust staff involved. I have not put into this report every detail investigated, but I am satisfied that no matter of significance has been overlooked.

Mr. Stewart's evidence

4. Mr. Stewart told the Ombudsman's investigator that when his mother was admitted to the Accident and Emergency (A & E) Department a nurse asked him about his mother's previous medical history and, shortly thereafter, the A & E consultant spoke briefly to him. The consultant told him that his mother had been admitted for bronchial pneumonia. During the meeting, he told the consultant that his mother had a previous admission to hospital with double pneumonia in 1997. He explained to the consultant that, at that time, a nursing sister told him that he should prepare for the worst, as intravenous (IV) antibiotics might not work. The A & E consultant responded by saying that 'it may be the same this time'. Mr. Stewart was not sure what the consultant meant by that.

5. Mr. Stewart said that, had he been seriously concerned about his mother's condition while she was in ward ...., (Note: Mrs. Stewart was transferred from the A & E department to ward .... on 13 March and subsequently transferred to ward .... later that same day) he would have asked a nurse for a meeting with her consultant. She had previously recovered from double pneumonia: he therefore thought that she would recover again. During his mother's 1997 hospital admission he was told he could visit her at any time. At no time during her 1998 hospital admission, however, was he told that he could visit outside the arranged visiting times and consequently he was mentally unprepared when she died.

6. Mr. Stewart said that during a meeting on the afternoon of 16 March a junior house officer (the JHO) told him that his mother's pneumonia had lifted, but he needed to know Mr. Stewart's views on what to do if it were to flare up again. He told the JHO that he would discuss the matter further with a relative, but to 'take it as read' that aggressive treatment was required. The JHO also mentioned his mother's hyperosmolar diabetic state (Note: an extremely serious condition, characterised by high blood sugar and severe dehydration) and its causes: this was the first time that Mr. Stewart had been told about that. The JHO also mentioned the possibility that his mother had sustained brain damage due to glucose non-absorption and agreed to his request that his mother receive a CT scan to confirm that. At the end of the meeting, the JHO said that the consultant would probably wish to speak with him. The JHO did not mention resuscitation, nor did he suggest to him that his mother might be dying. Following this meeting, he had been no more concerned about his mother's condition than previously. Later that day he asked to speak to the JHO again to confirm that, following discussion with a relative, aggressive antibiotic treatment was required should his mother's pneumonia recur. The JHO was unavailable but a nurse agreed to pass this message on to him.

7. On 17 March a nurse telephoned him at home just after 9.00 am and asked him to come to the hospital immediately. When he arrived at the hospital, he was told that his mother had died about ten minutes previously.

Evidence of Trust medical staff

8. The A & E consultant said that fairly quickly after Mrs. Stewart's admission, he spoke to Mr. Stewart to verify the information previously given to the nurse and to explain Mrs. Stewart's condition. Mr. Stewart was extremely concerned that the fortified liquid food he fed his mother had precipitated her deterioration. His reassurances that this was unlikely to have caused Mrs. Stewart's illness formed the major part of their discussion.

9. The A & E consultant said that he definitely explained to Mr. Stewart that staff would not resuscitate his mother. He might not have used the word 'resuscitation', but he would have said something akin to 'if there was a sudden deterioration in your mother's condition then no active treatment would be performed'. The A & E consultant added that it was not common practice for a doctor to make a cardio-pulmonary 'do not resuscitate' decision in A & E. It was obvious, however, that this was the correct decision in light of the severity of Mrs. Stewart's condition. He believed that it was good practice to record the decision early to avoid the possibility of an inappropriate resuscitation call by nursing staff: this was clearly a risk if the decision was not clearly documented. Medical staff were always encouraged to discuss decisions not to resuscitate with relatives, as per the hospital policy on the subject. He believed that he had successfully communicated with Mr. Stewart on the matter.

10. The consultant physician said that he thought on 16 March that Mrs. Stewart had probably suffered a stroke involving the cerebral blood vessels. He decided, however, to continue supporting her. The same day he asked the JHO to speak to Mrs. Stewart's family. His intention was that the JHO should inform the family that Mrs. Stewart's prognosis was poor because attempts to resuscitate her biochemically had failed and because prognosis was generally poor for patients of this age group with hyperosmolar coma. It was not his intention that the JHO should discuss resuscitation with the family. He was not aware that the A & E consultant had recorded a decision not to carry out cardio-pulmonary resuscitation (CPR) in the event of a cardiac arrest. He personally made no such decision while Mrs. Stewart was under his care: she was receiving active treatment and, if required, would have received cardio-pulmonary resuscitation.

11. The JHO said that during the ward round of 16 March the medical and nursing staff were all of the view that Mrs. Stewart was dying: it was agreed that her family should be informed. He could not recall the exact nature of the conversation he had with Mr. Stewart, but in the circumstances he would have said something to the effect that Mrs. Stewart was very poorly; that she had not recovered despite attempts to biochemically resuscitate her; and that she probably had a degree of irreversible damage due to her hyperosmolar coma. He recalled that the meeting with Mr. Stewart was difficult. Mr. Stewart was intense and detailed; used a lot of technical medical terms; and wanted aggressive treatment for his mother. He felt that Mr. Stewart should have understood that his mother was dying as he explained that to him quite clearly. Mr. Stewart, however, was not accepting of the situation. After the meeting he felt pressured as, although he discussed the difficulties of the meeting and Mr. Stewart's preference for active treatment with the nursing staff, they in turn were pressing him for a decision on Mrs. Stewart's resuscitation status. In the circumstances, he considered it very likely that he also discussed matters with the senior house officer (SHO), although he could not recall doing so with any certainty. (Mrs. Stewart's clinical records for 17 March include the following entry by the SHO:

'Condition very poor. Apparently son wishes active management incl-CT-brain [including a CT scan of her brain]. Needs to be spoken to again.'

Evidence of Trust nursing staff

12. A staff nurse in ward .... said that she had made an entry in the nursing care profile - 'fully aware' - under the section headed 'relative perceptions of patient's health status'. That was made on the assumption that, as Mr. Stewart was in attendance during his mother's admission through the A & E Department, he would have an understanding of her condition.

13. A second staff nurse in ward .... said that when patients were as ill as Mrs. Stewart it was normal practice to advise relatives that they could visit the ward at any time and for as long as they liked. Relatives were generally encouraged to stay and a side room for this purpose was available.

14. The ward sister in ward .... said that, as Mrs. Stewart was unconscious on admission to A & E and made no improvement, ward staff would have assumed that Mr. Stewart was fully aware of the severity of her condition. In addition, Mr. Stewart was his mother's sole carer and nursing staff would assume that he was familiar with her condition and would recognise that a significant deterioration had occurred. The ward sister said that nursing staff would not necessarily have Mrs. Stewart's full clinical notes immediately to hand on the ward. When the full notes were available, nursing staff did not have time to look through all the previous notes and would, therefore, have no awareness of any 'history', such as Mr. Stewart's very close interest in his mother's health. If there was an awareness of this history, this would have been discussed by nursing and medical staff. If any member of a patient's family asked to attend the ward more regularly, any trained member of staff could authorise that: there was always a relative's room available. There was no set policy about telling relatives they could stay in the ward: nursing staff would not want to put pressure on relatives to come in to the ward more frequently than they wanted. When a patient significantly deteriorated, nursing staff tended to know from the family when it was appropriate to contact them. Mrs. Stewart's condition was always very poor and it would have been difficult to know when a significant deterioration occurred. The change in Mrs. Stewart's condition at 9.10 am on 17 March was very slight.

15. The ward sister said that, had Mrs. Stewart suffered a cardiac or respiratory arrest, nursing staff would have made a resuscitation call as the A & E consultant's CPR decision did not transfer to the ward. In ward .... every patient was for resuscitation unless the patient's ward consultant specifically decided and recorded that resuscitation would not take place. If this was the case, the family was always informed. The resuscitation status of patients was, however, constantly under review.

16. A staff nurse in ward .... said that when patients were as ill as Mrs. Stewart, ward nursing staff always made an effort to communicate with their relatives. First and routinely they would tell relatives that there was open visiting. Particularly where relatives were worried, and especially where a patient was unconscious or deteriorating, they always asked relatives if they wished to stay in the ward overnight.

17. Mrs. Stewart's nursing notes for the morning of 17 March include:

'General condition deteriorating throughout morning .... [JHO] alerted and reviewed patient. [SHO] paged and informed of situation. No active treatment to be performed. [JHO] informed of decision. Son telephoned'.

The Trust's response

18. In his formal response to the Ombudsman's statement of complaint, the Trust's chief executive wrote:

'A full clinical assessment was undertaken on admission to [the] accident and emergency department and appropriate treatment commenced. A full medical and nursing assessment was taken on admission to ward .... and appropriate treatment commenced. A nursing care plan details care to be given. All these assessments were taken from Mr. Stewart as his mother was unconscious. Therefore Mr. Stewart was fully involved in the assessment process.'

'Every effort was made to communicate with Mr. Stewart that his mother was extremely ill and that she would not respond to resuscitation in the event of a cardiac arrest. Mrs. Stewart's condition was terminal and she was too ill and old to survive CPR. No appropriate treatment was withdrawn.'

'Mrs. Stewart's condition was not improving and by the 16th March medical notes indicate that her condition was deteriorating and that [the JHO] should speak to the family regarding 'no resuscitation'. No record of this conversation appears in the notes however a further entry on the 17th March states that 'the son needs to be spoken to again' indication he had already been spoken to by medical staff.'

'There are references to communication with Mr. Stewart both in the medical and nursing notes. Mrs. Stewart's condition from the time of her admission was extremely serious and her final deterioration was very rapid. Mr. Stewart was contacted by nursing staff on the morning of 17th March, unfortunately because of her rapid deterioration Mr Stewart did not arrive in time to be with his mother ....'

Local guidance

19. In relation to 'Do Not Resuscitate Orders', the Trust's policy manual includes the following:

'The overall responsibility as to whether a patient should be resuscitated lies with the Consultant-in-Charge of a patient's care and each Consultant should ensure that their decision is understood by all staff involved with the patient. This decision should only be made after consultation and consideration of all aspects of the patient's condition and the views of the patient and their family as well as the perspectives of the medical and nursing team will be valuable in forming this decision.'

'It is appropriate to consider "do not resuscitate" orders in the following circumstances:-'

'Where the patient's condition indicates that cardio-pulmonary resuscitation is unlikely to be effective ....'

'IF THERE HAS BEEN NO "DO NOT RESUSCITATE" ORDER MADE AND THE EXPRESS WISHES OF THE PATIENT ARE UNKNOWN, C.P.R. SHOULD BE INITIATED IF CARDIAC ARREST OCCURS.'

'If it is decided that a patient is not for resuscitation, the senior member of the Medical Team must record this in the patient's current medical admission notes as "not for cardio-pulmonary resuscitation". He/she will then communicate this to a trained member of nursing staff, who should make the same record in the patient's nursing profile, dated and signed. This will also be communicated verbally at each nursing report.'

'Where consultation with the patient or their family, regarding resuscitation, has taken place, this should also be recorded in the patient's current admission notes.'

Assessors' report

20. I set out below the report of the Ombudsman's professional assessors.

Report by the Professional Assessors to the Health Service Ombudsman
for Scotland of the clinical judgements of staff involved in the
complaint made by Mr. lain Stewart

Professional Assessors:
Dr ....
Consultant Physician
Tayside University Hospitals NHS Trust

Mr ....
Nurse Manager
Middlesbrough General Hospital

Matters considered

(i)

That the medical and nursing care, assessment and treatment of Mrs. Jane Stewart were below a standard to which she was reasonably entitled in the circumstances.

(ii)

That the communications with Mr. Stewart regarding his mother, both written and verbal, were inconclusive or inadequate.

Basis of report

(iii)

The report was based on:

(a)

Documents made available by the Office of the Health Service Ombudsman for Scotland which included the background correspondence to the complaint and Mrs. Stewart's clinical records

(b)

A written record of interviews by the Ombudsman's investigator

(c)

Separate meetings between the Ombudsman's investigator and professional assessors

(d)

Discussion of the presentation of the facts between the assessors

Report findings:

Complaint (a) That the medical and nursing assessment and treatment of Mrs. Jane Stewart were below a standard to which she was reasonably entitled in the circumstances.

Medical viewpoint

(iv)

This 89 year old lady was admitted to the Southern General Hospital on 12 March 1998 with severe pneumonia and hyperosmolar diabetic coma.

Pre morbid state

(v)

In a letter of 16 September 1997, a consultant physician comments on a home visit that Mrs. Stewart was dementing, was bedbound, doubly incontinent and required 24 hour nursing care. A previous medical history of myocardial infarction, transient ischaemic attacks and a paraprotein band (an abnormality of protein in the blood) are noted.

Course of acute illness

(vi)

An appropriate antibiotic was given within two to three hours of admission to hospital and continued treatment with fluids, insulin and diuretics led to resolution of a hyperosmolar state, control of her diabetes and near normalisation of her biochemical values. She remained unconscious, deteriorated and died on 17 March 1998.

Comment

(vii)

On admission to hospital this lady had many of the risk factors known to predict death in patients admitted to hospital with Pneumonia, namely, a respiratory rate of over 50, diastolic hypotension (low blood pressure), raised urea (possibly due to kidney failure), hypoxic acidosis (low oxygen and excess acid in the blood due to the pneumonia and poor blood supply to the body), bilateral involvement on chest x-ray (changes suggesting pneumonia in both lungs), change in mental status, major comorbid illness. Given these indices, this lady had a negligible chance of surviving her pneumonia despite being given optimal treatment. Given her prognosis and underlying disease, there is no question that admission to an intensive care unit and ventilation would have been totally inappropriate treatment. There can be minor criticisms of the treatment she received (as can be made in every case admitted to hospital). This lady received appropriate assessment and treatment for her pneumonia and metabolic disturbance (alterations in her bloodstream due to diabetes). The outcome was in no way related to any shortcoming in her management.

Nursing viewpoint

(viii)

Mrs. Stewart was admitted as an emergency patient to the Southern General Hospital on 12 March 1998 by the Accident and Emergency Department. A full nursing assessment was undertaken and appropriately recorded, including:

(a)

Glasgow Coma Score chart;

(b)

recording of all vital signs;

(c)

waterlow pressure care assessment;

(d)

fluid intake and output chart.

(ix)

Mrs. Stewart was diagnosed as being in a hyperosmolar coma and suffering from bronchial pneumonia. She was unconscious upon admission and remained so throughout her hospital stay and until her eventual death on 17 March 1998.

(x)

Mrs. Stewart was transferred initially to ward .... on 13 March and subsequently transferred to ward .... later the same day.

(xi)

Mrs. Stewart was allocated a named nurse. A full nursing assessment was carried out on ward .... and then an appropriate nursing care plan was formulated and recorded in the nursing notes. Mrs. Stewart was nursed on a pressure relieving mattress in the light of her high-risk Waterlow score (20+). She was fed intravenously, her medication, intravenous therapy and insulin charts were completed and signed throughout her period of hospitalisation.

(xii)

It is my opinion that Mrs. Stewart received appropriate nursing care consistent with her needs throughout her period of hospitalisation.

Complaints (b) & (c) That the communications with Mr. Stewart regarding his mother, both written and verbal were inconclusive or inadequate.

Medical view

It was unreasonable for medical staff to decide without consultation with Mr. Stewart:

(b)(i) That Mrs. Stewart should not be resuscitated in the event of a cardiac arrest

(xiii)

Given Mrs. Stewart's severity of disease and pre morbid condition and the very small likelihood of her survival, I believe it would have been inappropriate and unkind to Mrs. Stewart for cardio-pulmonary resuscitation to have been performed in the event of a cardiac or respiratory arrest. Ideally, such a decision should be discussed with the patient and/or the next of kin. The casualty consultant and Mr. Stewart seem to have a different memory of what was discussed when his mother came into casualty. There is no written record of this discussion in the notes with which I have been supplied. The casualty consultant's decision not to resuscitate Mrs. Stewart in the event of a cardiac or respiratory arrest apparently did not continue to apply following Mrs. Stewart's transfer to wards .... and .... After leaving casualty, Mrs. Stewart's resuscitation status was not fully reviewed until the morning of her death. In the circumstances, this lack of clarity surrounding her resuscitation status was inappropriate.

(b)(ii) On 17 March that no active treatment should be performed

(xiv)

On 16 March the consultant physician wrote in the notes 'speak to family regarding future'. Whilst not entirely clear this indicates to me that the consultant physician thought that the prognosis was extremely poor and wished this information conveyed to the family. On 17 March a junior doctor writes [son] needs to be spoken to again'. There is no record of any preceding discussion of medical staff with Mr. Stewart, however, the following occur in hand-written letters by Mr. Stewart:

'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.'

'There was no pneumonia at this time he said but wanted my views on action should it arise, just keep comfortable or other?'

These remarks suggest that there has been some discussion about the appropriateness of active treatment with Mr. Stewart, however, I can find no written record of such discussions in the notes supplied to me.

(xv)

South Glasgow University Hospital NHS Trust must accept some criticism for the lack of documentation of the issues discussed by medical staff with Mr. Stewart. Because of the lack of documentation, it is not possible to be sure whether adequate discussion took place. Circumstantial evidence suggests that there was an intent to discuss the severity of his mother's illness with Mr. Stewart and some discussion did take place.

(xvi)

The evidence from previous letters in the notes suggests that communication with Mr. Stewart was a problem for staff who found it difficult to focus his mind on relevant issues and were concerned that he had a poor understanding of his mother's fundamental problems and the extent of her deterioration before she was admitted to hospital. On balance, I believe that Mr. Stewart did not appreciate or did not wish to appreciate what was discussed with him, however, given the previous evidence of his failure to understand or grasp past medical issues concerning his mother, it would have been advisable to spell out and document the current medical position very clearly.

Nursing response

(xvii)

I think it is unfortunate that little reference was made to any discussions between the nursing staff and Mr. Stewart regarding the seriousness of his mother's medical condition or of the potential for his continuing involvement in her care whilst in hospital.

(xviii)

Given previous references to the difficulties in communications and levels of understanding of Mr. Stewart, it is both sad and of concern that earlier clinical notes appear not to have been readily available, and that even if they had been according to the notes of the interview with the ward .... nursing sister the nursing staff did not have time to look through all of the previous notes and would, therefore, have no awareness of any history, such as Mr. Stewart's very close interest in his mother's health.

(xix)

I think that on the evidence of the nursing notes and the nurses' witness statements of interview, combined with an overall impression of work overload, the nursing team failed to demonstrate adequate communication and therefore support of Mr. Stewart, particularly during the last 24 hours of his mother's life. The clinical, medical and nursing notes do in my opinion register sufficient concern, which should have been relayed to Mr. Stewart and appropriately recorded in the nursing notes and he should clearly have been given the opportunity to have stayed with his mother during the last 24 hours.

(xx)

As a last general comment, I can find no documented evidence during Mrs. Stewart's stay on wards .... and .... of any discussion taking place between the medical and nursing staff with regard to the resuscitation plans for Mrs. Stewart in the light of her having a respiratory or cardiac arrest.

Findings
(a) Assessment and treatment

21. Mr. Stewart was concerned that the clinical assessment and treatment his mother received were inadequate. In reaching my findings on this aspect of the complaint, I have taken account of the advice provided by the Ombudsman's professional assessors. The assessors find that, on admission to hospital, Mrs. Stewart had a negligible chance of surviving her illness as she had many of the risk factors known to predict death in patients admitted to hospital with pneumonia. The assessors conclude that Mrs. Stewart was properly assessed and received appropriate treatment and that the sad outcome was in no way related to any shortcoming in her management. I accept that advice. I do not uphold the complaint.

(b)(i) Decision not to resuscitate

22. The ultimate responsibility for deciding whether a patient should be resuscitated lies with the consultant responsible for that patient's care. However, good medical practice, as reflected in the Trust's policy manual (paragraph 19), is to discuss such decisions, where possible, with patients and their families. The clinical assessors have commented that, given the severity of Mrs. Stewart's disease, her pre morbid condition, and the very small likelihood of her survival, it would have been unkind and inappropriate for cardio-pulmonary resuscitation (CPR) to be performed. I accept that advice. The A & E consultant recognised immediately that CPR for Mrs. Stewart was inappropriate and made an active and timely decision to that effect. Mr. Stewart, however, complains that this decision was not discussed with him. The A & E consultant clearly recorded his CPR decision in Mrs. Stewart's clinical notes and following his meeting with Mr. Stewart, believed that he had communicated that decision effectively to him. However, he did not record his discussion with Mr. Stewart in the clinical records as required by the Trust's policy manual. The conversation between Mr. Stewart and the A & E consultant took place shortly after Mrs. Stewart's admission, at a time when Mr. Stewart was distressed that his actions might have caused his mother's deterioration. These circumstances may well have affected the extent to which Mr. Stewart was able to understand what was discussed.

23. When Mrs. Stewart was transferred from the A & E Department via ward .... to ward ...., however, the CPR decision did not transfer with her. The consultant physician has said that he was unaware of the A & E consultant's CPR decision and did not make an active decision about Mrs. Stewart's resuscitation status. The Trust's resuscitation policy states that it is appropriate to consider 'do not resuscitate' orders where the patient's condition indicates that CPR is unlikely to be effective. The clinical assessors have commented that, in light of the severity of Mrs. Stewart's condition, there was a lack of adequate discussion in ward .... between medical and nursing staff and a lack of clarity surrounding Mrs. Stewart's resuscitation status. In the event, no ward CPR decision was made until the morning of Mrs. Stewart's death: in the circumstances, the assessors consider that was inappropriate. I agree. I recommend that the Trust ensures that all staff are familiar with the Trust's policy on resuscitation; that, in future, CPR decisions are made and recorded in a timely manner; that such decisions are discussed fully with relatives; and that the timing and content of discussion with relatives is clearly recorded in the patient's clinical records.

(b)(ii) Decision not to treat actively

24. During a ward round on 16 March, the consultant physician concluded that Mrs. Stewart's prognosis was poor and asked the JHO to convey this to her family. At that stage Mrs. Stewart continued to receive active treatment. The JHO recalls having a difficult meeting with Mr. Stewart later that day. During this meeting the JHO thought he was conveying quite clearly to Mr. Stewart that his mother was dying, but was unable to get Mr. Stewart to accept that. Mr. Stewart's recollection of the meeting was of advising the JHO that aggressive treatment was required and of feeling no more concerned about his mother's condition than before the meeting. With no independent witness to events, it is impossible to say whether the JHO failed to communicate matters adequately to Mr. Stewart, or whether Mr. Stewart was unable or unwilling to accept what he was being told. Furthermore, there is no contemporaneous record of the meeting as the JHO failed to record the discussion in Mrs. Stewart's clinical records. I criticise him for that omission. The JHO was a relatively inexperienced member of the medical staff and found the meeting difficult. On the other hand, clinical staff in the past had found difficulty in getting Mr. Stewart to understand his mother's fundamental problems. For whatever reasons, the JHO and Mr. Stewart parted with very different perceptions of their meeting. Nevertheless, attempts were made to communicate with Mr. Stewart about his mother's condition and his preferences for her treatment.

25. Due to Mrs. Stewart's very poor condition, the JHO was concerned that Mr. Stewart wished further active treatment for his mother. At the same time, nursing staff were pressing him for a decision about her resuscitation status. In these circumstances, it seems likely that the JHO advised the SHO of his concerns. Indeed, the SHO made an entry in the clinical notes in the early hours of 17 March which noted that Mr. Stewart wished aggressive treatment for his mother; that he 'needed to be spoken to again'; and that active treatment should continue meanwhile. However, before any further conversation with Mr. Stewart could take place, Mrs. Stewart's condition deteriorated further and shortly before she died the SHO concluded that, due to her extremely poor condition, active treatment should be withdrawn. Mr. Stewart was immediately contacted by nursing staff and asked to attend the hospital. Unfortunately, Mrs. Stewart passed away before Mr. Stewart arrived at the hospital.

26. I find that the medical staff involved in Mrs. Stewart's care did make efforts to consult with Mr. Stewart about his mother's treatment and initially made efforts to comply with his express wishes for active treatment. However, Mrs. Stewart's prognosis was already extremely poor and, when she deteriorated further, a decision was taken to withdraw treatment during the last few minutes of her life. The professional assessors have commented that Mrs. Stewart's clinical management was appropriate. While the views of relatives should be taken into account, the final decision on the clinical management of a patient rests with medical staff. Had Mr. Stewart been present in the hospital, it would have been appropriate to discuss this decision with him. However, Mr. Stewart was at home at the time (Note: I comment on the reasons for his absence later in this report) and nursing staff telephoned him to ask him to attend the ward. In these circumstances, the important issue was to advise Mr. Stewart to attend the hospital as quickly as possible. It would not have been sensitive or appropriate to delay his arrival further by discussing his mother's treatment with him on the telephone. Nor would it have been reasonable or in the best interests of Mrs. Stewart to further delay a decision about appropriate clinical management. I do not uphold this aspect of the complaint.

(c) Communication with Mr. Stewart

27. It is clear from the discussions Mr. Stewart had with the A & E consultant and the JHO that he did not understand the seriousness of his mother's condition and that his expectations of her chances of survival were unduly optimistic. I do not underestimate the difficulties faced by clinical staff in trying to communicate bad news to relatives who are unwilling or unable to accept what is being said. In my view, however, there were missed opportunities during Mrs. Stewart's admission to identify Mr. Stewart's misconceptions and make further attempts to communicate matters to him. Indeed the professional assessors have commented on the worrying lack of reference in Mrs. Stewart's nursing notes to discussion between nursing staff and Mr. Stewart about his mother's condition. They also note with concern that nursing staff would not have had time to read any of Mrs. Stewart's previous clinical records even if these were readily available. I share their concern.

28. It seems to me that nursing staff in wards .... and .... made the assumption that all necessary communication with Mr. Stewart took place in the A & E Department. After admission, Mrs. Stewart's condition remained static ie her condition did not improve. The nursing staff therefore saw no necessity to communicate further with Mr. Stewart about her condition or likely prognosis. In preparing the care plan, the admitting staff nurse in ward .... made an entry to the effect that Mr. Stewart was fully aware of his mother's condition. That was based, however, on an assumption of what Mr. Stewart had been told in the A & E Department. As the same care plan was used by ward .... nursing staff following Mrs. Stewart's transfer, this false assumption continued. In my view, completing a care plan on the basis of assumed information is a highly undesirable and potentially dangerous practice: I strongly criticise this approach to care plan recording.

29. Whereas Mr. Stewart had difficulty understanding the implications of his mother's clinical condition, his experience of his mother's 1997 admission with pneumonia was that relatives were invited to attend the ward on an open basis when the patient's prognosis was poor or their condition was critical. I consider that, given Mr. Stewart's version of events and his understanding of the significance of open visiting, it is highly unlikely that he was informed that he could openly visit his mother on ward .... or ward .... Indeed, I can find no evidence in the nursing notes of any communication taking place with Mr. Stewart between the day of her admission and the day before her death. Of further concern is the lack of any entry in the nursing notes to suggest that any discussion took place with Mr. Stewart regarding when and where he should be contacted should his mother's condition deteriorate. I consider that the lack of such appropriate communication contributed to Mr. Stewart's inability to understand the significance of what was being conveyed to him by the JHO on 16 March. Furthermore, it reduced his awareness of his mother's terminal status and thus denied him the choice of being present in the hospital during the last hours of her life. I uphold this aspect of the complaint. I recommend that the Trust consider staff training needs in relation to the shortcomings in communication and record keeping which are identified in this report.

Conclusion

30. I have set out my findings in paragraphs 21-29. The Trust have agreed to implement my recommendations in paragraphs 23 and 29, and they have asked me to convey to Mr. Stewart - as I do through this report - their apologies for the shortcomings I have identified.

Investigations Manager
duly authorised in accordance with
paragraph 12 of Schedule 1 to the
Health Service Commissioners Act 1993

12 January 2001.

In the navigation order, the next page is the Comments page relating to the Report, the NHS evidence and also my personal views. After receiving the Report, a letter from the Ombudsman's Office asked for my opinions with regard to the Report. The final letter from myself concluded the 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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