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Acute Services Division

Feedback, Comments, Concerns and Complaints Annual Report 2012/13

1 Executive Summary

The Patient Rights (Scotland) Act 2011 gave users of the NHS the legal right to give feedback, make a comment, raise a concern or make a complaint. In the past, this Annual Report has focused on reviewing performance in managing complaints received by the Acute Services Division, comparing this with the experience of previous years. Selected data have also been provided on concerns raised with the hospital Patient Affairs Managers. A range of mechanisms is available to patients and their carers to offer feedback or make a suggestion or comment about services. Much of this is unrecorded, for example thank you cards given to ward staff; other feedback can form part of a discussion directly with staff or be given in writing. There is currently no mechanism for recording all of such feedback. 681 formal complaints were received in 2012/13, a small decrease of 2% on the previous year. It is not possible at present to compare this with the experiences of other Boards as national data are not made available until the autumn. The ratio of complaints to patient episodes was 1:1315, compared with 1:1143 in 2011/12 and 1:1348 in 2010/11. This is against the background of ever-increasing activity within our services. In line with previous patterns, the principal issues raised in formal complaints continued to be around staff attitude, behaviour or oral communication (32% of issues raised); and clinical treatment (38%). The national target for responding to complaints is set at 20 working days. This was achieved locally in 97% of cases and again compares extremely favourably with available national comparisons (the national average for responding within 20 working days in 2011/12 was 65%). Achieving this high standard is becoming increasingly challenging due to the growing complexity of complaints. When the response is sent to a complaint an offer is generally made to the complainant for them to meet with senior staff if they have any outstanding concerns. However, they have the right to raise the issue with the Scottish Public Services Ombudsman. During 2012/13 the Ombudsman laid before Parliament one investigation report relating to a complaint about acute services provided by NHS Lanarkshire; and issued 33 decision letters, 14 of which contained recommendations. Complaints and the learning from them is widely discussed at clinical and management forums, either on an anonymised basis or as case discussions in clinical settings. Twice per year the opportunity is taken to hold a complaints stocktake, chaired by the Divisional Nurse Director and attended by the General Managers, Head of Patient Affairs and the Patient Affairs Managers. Discussion at these stocktakes focuses on trends in complaints (issues, specialties, staff groups concerns); complaints put to the Ombudsman; the results of audits against required process;

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analyses of complaints, for example by age of the patient concerned; staff groups and issues; response time performance; and reports issued by the Patient Advice and Support Service. 2 Complaints Received A total of 681 complaints were received between 1 April 2012 and 31 March 2013, a slight decrease of some 2% on the previous year. All but three were acknowledged within the national target of 3 working days.

0

100

200

300

400

500

600

700

2002/03 2004/05 2006/07 2008/09 2010/11 2012/13

HairmyresMonklandsWishawTotal

Complaints are recorded against both the site and the Clinical Division, as illustrated in the table below. The figures in brackets are those for 2011/12. Emergency

& Medical Surgical &

Critical Care Women’s, Cancer

& Diagnostic Other Total

2012/13 Total

2011/12 Hairmyres 98 (90) 96 (110) 14 (15) 9 (19) 217 234 Monklands 102 (90) 90 (81) 33 (18) 14 (21) 239 201 Wishaw 101 (87) 66 (97) 48 (64) 10 (10) 225 258 Total 12/13 301 (267) 252 (288) 95 (97) 33 (41) 681 Total 11/12 693 Complaints managed by the Hairmyres Hospital site fell by 7%; Monklands Hospital rose by 19% and Wishaw General Hospital fell by 13% when compared with 2011/12. For Acute Services as a whole, the table below compares the same quarter periods in 2011/12 and 2012/13. Whilst figures for quarters 2 and 3 were relatively static, there were sizeable changes in the other two periods.

Quarter 1 (Apr – Jun) Quarter 2 (Jul – Sept) Quarter 3 (Oct – Dec) Quarter 4 (Jan – Mar) 11/12 12/13 11/12 12/13 11/12 12/13 11/12 12/13 155 182 +17% 188 191 +2% 151 159 +5% 199 149 -25%

Appendix I provides details of the specialties about which formal complaints were made. A complaint may cover more than one specialty; however, only the principal one is recorded. The most significant movements were: • The increase of 38 experienced at Monklands Hospital was felt across a range of specialties

but was mainly reflected in the larger areas of Emergency Care (up 8), Older People’s Services (up 6) and General Surgery (up 6). Equally Accident & Emergency saw a fall of 7. However, there were 6 complaints about Rheumatology compared with none the previous year.

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• In terms of Clinical Divisions, Surgical & Critical Care saw a decrease of 12%. This related largely to General Surgery at Hairmyres Hospital and Wishaw General Hospital (although Monklands Hospital increased); and to Orthopaedics at Hairmyres Hospital and Wishaw General Hospital. Counter to that Emergency & Medical Services increased by 13%, most notably in relation to Accident & Emergency across the three sites. The overwhelming majority of complaints attributed to Women’s, Cancer & Diagnostics were about Obstetrics and Gynaecology. As highlighted above complaints about Rheumatology increased, from 2 to 12 overall.

3 Complaints Correspondents

The graphs below illustrate the source of complaints by correspondent.

Correspondent 2012/13Patient

Relative /FriendMSP /CouncillorParent /GuardianVisitor

Solicitor

GP

Other

Correspondent 2011/12Patient

Relative /FriendMSP /CouncillorParent /GuardianVisitor

Solicitor

GP

Other

The experience of years prior to 2011/12 came to the fore again last year in that fewer than half (45%) of complaints were made by the patient themselves. Where a complaint was received from someone other than the patient, consent was sought from the patient or (where the patient had died or was incapable of giving consent) their next of kin before the complaint was investigated. 30% of complaints (an increase from 28% in 2011/12) were received via email and 37% related to patients over the age of 65. 4 Issues Raised in Complaints For national statistical purposes, a maximum of three “issues” may be recorded for each complaint received. A more detailed breakdown can be found in Appendix III. Overall the number of issues rose from 1059 in 2011/12 to 1126 on 2012/13. The main areas of concern continued to be: • Staff attitude/behaviour and oral communication which between them accounted for 336 or

32% of the issues raised (329, 31% in 2011/12). Whilst Hairmyres Hospital recorded these issues on 110 occasions (117 in 2011/12) and Wishaw General Hospital on 116 occasions (119 in 2011/12), Monklands Hospital recorded 137 instances, up from 93 in 2011/12. No specific specialty or individual has been identified. National Education Scotland and the Scottish Public Services Ombudsman has recently developed an e-learning tool to support staff in handling feedback, comments, concerns and

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complaints, launched in May 2013. The tool is being assessed to identify how it might be used to positively enhance staff interaction with patients and their carers.

• Clinical treatment accounted for 431 (38%) of issues (389 or 37% in 2011/12). Here again the sites showed some significant variations. Looking at the specialties recording the highest number of such complaints, these were, as might be expected, the higher volume areas (Accident & Emergency (75), General Medicine (83), General Surgery (52) and Orthopaedics (39) on all three sites) in addition to the Emergency Receiving Unit (15) and Urology (13) at Monklands Hospital; and Obstetrics (19) at Wishaw General Hospital. However, there were also 30 complaints about clinical treatment in Older People’s Services across the sites.

Complaints feature on the agendas of the site Clinical Governance Groups and Senior Nurse Forums, with senior medical and nursing managers reviewing these for common themes. 5 Responses Sent to Complaints The national target of responding to complaints in 20 working days was achieved in 97% of cases in 2012/13. This has continued the high level of performance seen in previous years and compares extremely favourably with national figures.

0

20

40

60

80

100

2002/03 2004/05 2006/07 2008/09 2010/11 2012/13

Hairmyres

Monklands

Wishaw

Total

6 Outcomes National arrangements require that a judgement be taken as to whether or not a complaint was justified. This is clearly a subjective decision but is one that is taken as objectively as possible by the Patient Affairs Managers in conjunction with the site General Managers. As part of an audit of files carried out twice yearly by the Head of Patient Affairs the consistency of approach is monitored.

Outcomes 2012/13

40

36

24upheld

upheld inpartnot upheld

Outcomes 2011/12

41

37

22

upheld

upheld in part

not upheld

The charts above show that the breakdown of outcomes assigned remained very consistent with 2011/12.

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An indication of actions taken in light of complaints can be found in Appendix V. Appendix VI provides summaries of the de-briefs carried out with staff. 7 Alternative Dispute Resolution Alternative Dispute Resolution (ADR - also known as mediation or conciliation) was introduced into the complaints procedure as a result of the Patient Rights (Scotland) Act 2011. It is currently funded nationally by the Scottish Government and provided by the Scottish Mediation Network. The Patient Affairs Managers participated in an awareness raising event on ADR in July 2012 delivered by the Scottish Mediation Network. There were no complaints about acute services in which alternative dispute resolution was used. However, senior staff of NHS Lanarkshire are available to meet with complainants in an effort to resolve their complaints. Independent advice and support is also available to complainants through the Patient Advice and Support Service, PASS (see section 10). 8 Scottish Public Services Ombudsman (SPSO) During 2012/13 the SPSO issued one report relating to Acute services and 33 decision letters. This represents a continuing upward trend in complaints being put to the SPSO. In 2010/11, the Board was made aware of 9 complaints put to the SPSO; 26 in 2011/12 and 41 in 2012/13. The increase is understood to be part of a national trend and not limited to the health service. As part of his engagement with authorities under his jurisdiction, the Ombudsman met with the Board Chair, the Chief Executive, the Executive Director for NMAHPs and the Head of Patient Affairs in February 2013. Discussion focused on the themes identified nationally by the Ombudsman, including the care of older people, and how the intelligence gathered by his office might more usefully be used to enhance the learning from complaints. No issues were identified in relation to NHS Lanarkshire. Hairmyres Monklands Wishaw Total Carried forward from 2011/12

3 6* 4** 13

New complaints

11^< 21+ 9 41

Decisions letters - no further action

4 10 5 19

Decision letters - recommendations

2 8 4** 14

Investigation reports issued

1 0 0 1

Decision letters / investigation reports pending at year-end

7^<

9*+

4

20

Includes: * one complaint covering Monklands Hospital, Hairmyres Hospital and Wester Moffat Hospital ** one complaint covering Wishaw General Hospital and CHP North - Mental Health Services ^ one complaint covering Stonehouse Hospital and CHP South – Out-of-Hours Service < one complaint covering Hairmyres Hospital and Wishaw General Hospital + one complaint covering Monklands Hospital and Wishaw General Hospital

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In the published report the Ombudsman upheld a complaint that during a patient’s admission to hospital in March 2010 there were unreasonable failings in his medical and nursing care and treatment in relation to pneumonia and medication. Details of decision letters containing upheld complaints and/or recommendations are set out in Appendix VII. Where an Ombudsman report or a decision letter contains a complaint which is upheld and /or recommendations are made, a synopsis and an action plan were put in place. This ensures that the findings are discussed on an anonymised basis at clinical and management forums.

9 Concerns Received Individuals may have concerns but not wish to pursue them through the formal complaints procedure. The majority of these are resolved directly with ward staff. However, in order to gain a broader picture of patient opinion, concerns raised with and resolved through the Patient Affairs Managers outwith the formal complaints procedure are also recorded. Appendix II provides details of the specialties to which concerns related. Emergency

& Medical Surgical &

Critical Care Women’s, Cancer

& Diagnostic Other Total

2012/13 Total

2011/12 Hairmyres 94 (80) 142 (114) 29 (28) 13 (76) 278 229 Monklands 83 (75) 97 (104) 27 (39) 32 (42) 239 260 Wishaw 52 (44) 37 (51) 33 (28) 15 (3) 137 126 Total 12/13 229 (199) 276 (269) 89 (95) 60 (52) 654 Total 11/12 615 10 Issues Raised in Concerns Using the ISD categories, Appendix IV provides a breakdown of issues raised in concerns. These followed a similar pattern to complaints (staff attitude/ behavior, oral communication and clinical treatment). Beyond these, there were significant increases in concerns about written communications (up from 39 to 51) and waiting times for appointments (up from 38 to 81) at Hairmyres Hospital. Conversely concerns about waiting times for admission fell from 44 to 28 overall. 11 Patient Advice and Support Service Under the provisions of the Patient Rights (Scotland) Act 2011 Patient Advice and Support Service (PASS) replaced the Independent Advice and Support Service (IASS) on 1 April 2012. The PASS is intended to provide information and help to patients, carers and members of the public; to raise awareness of their rights and responsibilities when using health services; and to support patients to make complaints if they require it. The national contract is held by Citizens Advice Scotland and the service is delivered locally by a consortium of Citizens Advice Bureaux. The Patient Affairs staff continued to meet with the PASS Patient Advisers to consider high-level details of cases handled. The themes in complaints being brought to the PASS Patient Advisers mirror those being handled by NHS Lanarkshire. 12 Feedback and Comments As previously indicated, there is a range of mechanisms available to patients and their carers to offer feedback or make a suggestion or comment about services. These include:

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• Providing verbal feedback – both positive and negative - directly to the staff caring for

them. This should generate an immediate response to any issue that needs to be addressed there and then. Depending on the issue raised this may be recorded in the patient’s case notes and / or on Datix.

• Contacting the Patient Affairs Manager based on the hospital sites. Again, if an immediate response about clinical care is needed, the matter is referred to the relevant senior member of staff, for example the Consultant or Senior Charge Nurse. The Patient Affairs Manager will follow this up to ensure that the matter has been concluded and records this on Datix.

• Sending letters or cards directly to staff expressing gratitude for the care received. With the exception of those brought to the attention of the relevant Patient Affairs Manager (who records these on Datix) there is no central record of such letters or cards.

• Completing a Comments, Compliments and Suggestions leaflet which is widely available in wards and departments and can be downloaded from the NHS Lanarkshire website. The leaflet has a Freepost return address to NHS Lanarkshire Headquarters where the recording on Datix and response to completed forms is managed by the Patient Affairs staff. A response is given where contact details have been provided.

• Calling the General Enquiry Line which acts as a source of general information and sign-posts callers. The General Enquiry Line also receives calls from patients and relatives who wish to provide feedback on services they have received. In the latter case the call handler either arranges for the most appropriate member of staff to call them back or provides details so that the caller can make direct contact. Data on the type of calls being received now being analysed with a view to identifying any changes that need to be made to services.

• Contacting NHS Lanarkshire via the Contact Us pages on the NHS Lanarkshire website. A range of enquiries and comments is received via this format, including positive feedback and complaints. The e-form is automatically sent to the General Enquiry Line caller handler’s email inbox who acknowledges the enquiry and passes it to the most appropriate member of staff to respond to.

• Participating in the national postal survey of acute inpatients.

• Participating in the local Patient Experience programme which gathers the

experiences of acute inpatients, patients attending Accident & Emergency and carers. The results of these surveys are fed back to staff and the Public Partnership Forums, together with the resultant action plans.

• Providing comments via social media.

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Moving into 2013/14 NHS Lanarkshire will participate in the nationally-funded pilot to assess the use of Patient Opinion website. Given the variety of ways in which feedback and comments can be received there is currently no single mechanism for collating them and the actions that arise from them. This will, however, be explored in the coming year to identify what can be achieved. Examples of actions taken in response to patient feedback include: • Based on feedback received, open visiting was piloted in a ward for older people. Visitors

were then asked what they thought about this and more flexible visiting was introduced.

• A web-based forum has been set up for women who want to participate in the Maternity Services Liaison Group but you are not able to come to its meetings.

• New orientation boards have been created in wards to give patients more information about

what they can expect during the course of the day.

• The role of ‘mealtime co-ordinator’ was piloted and then rolled out to ensure that patients had the support they needed at mealtimes.

• ‘Activity packs’ have been purchased for wards which staff and volunteers use with patients. Shona Welton Head of Patient Affairs 28 06 13

APPENDIX V

ACTIONS TAKEN IN LIGHT OF COMPLAINTS April – June 2012

Issue Action Taken Sharing Learning Nursing staff did not show care and compassion during attendance at Emergency Department. Did not offer patient blanket or change pad on bed. Pain not addressed. (H)

Nursing staff reminded of care and compassion policy, need to ensure patient is comfortable and not in pain. Pain score now recorded for all patients.

Discussed locally

Staff Nurse did not assist patient who required wheelchair at time of discharge. (H)

Staff reminded of the importance of ensuring safe discharge for patients and assisting relatives who require assistance at time of discharge.

Discussed locally

Discharge prescription not explained properly at time of discharge. (H)

Nursing staff reminded of importance of ensuring prescription is explained to patient or relative if patient cannot understand.

Senior Nurse to share

Patient appointment cancelled on numerous occasions. (H)

Review of process for follow up patients.

Review across Directorate

Information on consultant planner not updated timeously and patient appointed when Consultant not on duty. (H)

Secretarial staff reminded of importance of ensuring accurate information is maintained at all times.

Share across Directorate

Incorrect transport ordered for cancer patient. Taxi not suitable for wheelchair. (H)

Staff reminded of importance of ensuring appropriate transport booked timeously and if not appropriate when it arrives, help should be sought from Senior Charge Nurse.

Discussed locally

Junior doctor was rude to patient during consultation and took personal call on mobile. (H)

Lead Clinician discussed with junior doctor who was asked to reflect on their practice. Highlighted inappropriate comments and use of mobile phone during consultation.

Discussed locally

Shoulder injury not recorded at time of attendance. Patient had to return to Emergency Department on two occasions. (H)

Staff reminded of importance of ensuring accurate documentation at time of presentation and ensure all issues addressed. Second visit to A&E with same injury should be reviewed by senior member of staff.

Shared across sites

Patient had no money for transport following attendance at A&E. Patient walked home. (H)

Staff reminded of importance of ensuring that patient has appropriate transport home when discharged to ensure safe discharge.

Shared across sites

Dietary requirements not passed on to nursing home at time of discharge. (H)

Staff reminded of the importance of comprehensive handover when patient being discharged.

Senior Nurse to share across sites

DNAR documentation not returned to nursing home with patient at time of discharge. (H)

Staff reminded of importance of ensuring all documentation returned to nursing home at time of discharge.

Senior Nurse to share across sites

Patient not appropriately dressed at time of discharge. (H)

Staff reminded of importance of ensuring patient appropriately dressed for discharge in ambulance vehicle.

Discussed locally

Locker not cleared or cleaned prior to new patient being admitted. (H)

Staff reminded of the importance of ensuring that lockers are clean and empty prior to admitting new patient.

Discussed locally

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Patient left in pain in the Emergency Department. (H)

All patients now have pain score recorded at time of admission.

Shared across sites

Consultant continually interrupted during consultation. (H)

Accommodation issue currently under review.

Discussed locally

Patient not reviewed following move to alternative ward. (H)

Hospital Management reviewing patient pathway to ensure similar situation does not arise again.

To be shared across sites

Concerns regarding clinical practice of junior doctor during consultation. (H)

Discussed at length with Lead Clinician to ensure that doctor reflects on their practice and that this does not happen again.

Discussed locally

Tumour missed on radiology report. (H)

Scan had originally been done a number of years ago on scanner that did not identify tumour. New scanner now clearly shows tumour. Discussed at Radiology Error Meeting.

Discussed locally

Issues regarding the nursing care received during admission (M)

SCN acknowledges that nursing staff should have informed NOK regarding the changes to patient’s skin, and apologised for this breakdown in communication. Senior Nurse to meet with nursing staff to discuss the issues raised in complaint and review the lessons that can be learned.

Discussed locally

Medical and nursing treatment received and concerns regarding discharge of patient (M)

Doctor who made the decision to discharge the patient has been spoken to both by the consultant who initially discovered the error and by their Educational Supervisor. Nursing staff have been reminded at the daily safety brief of the importance of ensuring they check the cannula has been removed prior to the patient being discharged home.

Discussed locally

Concerns regarding treatment and agreed procedures not being adhered to (M)

A management plan has been developed to ensure that the patient is comfortable and their needs are met in a respectful and compassionate manner.

Senior Nurse to share

Letter from hospital was not franked and complainant had to collect it from the post office at a cost of £1.36 (M)

Head of Hotel Services will contact TNT to remind them of the need to be extra vigilant when processing outgoing NHS Lanarkshire mail.

Action taken locally

Unhappy with care patient received during admission to ward (M)

Senior Nurse to meet with nursing staff to discuss the issues raised in complaint and review the lessons that can be learned.

Discussed locally

Medical staff could not find anything wrong with patient (M)

Concerns regarding the quality of documentation have been discussed with clinical staff. Junior medical staff will be reminded that protocol stipulates if they are considering the possibility of pulmonary embolism to the extent they do a Geneva score then a d-dimer must also be carried out.

Shared across Directorates

Complainant wants to establish patient's medication regimen during admission and on discharge (M)

A review will be carried out by senior clinicians, pharmacy staff and the Clinical Governance Lead.


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Patient questioned staff why they were being given IV antibiotics - the medication was for another patient in the room (M)

Consultant and Senior Nurse have liaised with the nursing and junior medical teams to highlight the concerns raised to ensure more robust inter-disciplinary communications. Senior Charge Nurse has spoken to staff at the ward safety briefs and reiterated the importance of checking patients’ wristbands and ensuring the accuracy of documentation at all times.


Lack of treatment received and staff attitude (M)

The importance of providing analgesia advice has been re-iterated to all junior doctors and MINTS nurses in the Emergency Department and discharge advice information to be reviewed.

Shared across sites

Issues regarding the nursing care received during admission (M)


Discussed locally

Concerns regarding ongoing treatment and communication (M)

Department leaflets have been reviewed and a reference to the clinette room is now included.


Issues re misdiagnosis, complete breakdown in communication and lack of care and compassion (M)

Action plan developed to address issues raised. ADN to meet with nursing staff to discuss the issues raised in complaint and review the lessons that can be learned.


Issues regarding staff attitude (M) Senior Nurse to meet with nursing staff to discuss the issues raised in complaint and review the lessons that can be learned.

Discussed locally

Concerns regarding staff attitude towards patient and patient being discharged with family members not being notified (M)

SCN has reminded staff of the importance of patients and their families being treated with dignity and respect and staff should be non judgemental at all times. Senior Nurse to meet with nursing staff to discuss the issues raised in complaint and review the lessons that can be learned.

Discussed locally

Medical records not present at Chronic Pain clinic (W)

All staff reminded of the importance of ensuring that patients medical records are present

Shared across sites

Patient’s appointment letter found in dirty instrument bag by company who clean the instruments (W)

Senior Nurse to meet with staff and medical records to review the process of notifying nursing staff that patient has arrived at outpatients. Debriefing session to be held with nursing staff


Discharge plan provided to patient was illegible and contained incorrect information (W)

Member of staff reminded to change ink cartridge in printer/been reminded of the need for accuracy

Discussed locally

Patient prescribed medication that she was allergic to despite wearing wristband and documentation in notes (W)

Medial staff have been informed that they must review medical records before prescribing any medication and not just rely on allergy being documented on drug kardex

Discussed locally

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Patient overheard staff discussing whether she should be treated at Wishaw or transferred to GRI as she had previously attended this hospital (W)

Staff advised that conversation should have taken place in private and not overheard by patient

Discussed locally

Patient given another patient’s medication (W)

Nursing staff involved are working through core competencies for the safe administration of drugs/being supervised for period of time. Incident discussed with all staff at daily safety briefs.

Shared across sites

Patient attended A&E outwith Lanarkshire and required follow-up at fracture clinic. Unhappy that he had to visit A&E at Wishaw before being allocated an appointment for Fracture clinic (W)

Review of process to be discussed as other 2 sites in Lanarkshire operate a different system

Action to be taken locally

Patient unhappy with standard of nursing care and communication (W)

Senior Nurse has discussed concerns raised with all staff and reminded them of professional and caring manner we would expect at all times. Reminded them of standard of care we would expect and asked them to reflect on their practice.

Discussed locally

Urgent referral to another hospital not faxed by secretary resulting in delay in appointment (W)

Secretarial staff to be reminded of process for dealing with urgent referrals


Patient denied access to main car park (W)

Car park attendants reminded of the need to ensure appropriate information provided to the public re car parks

Discussed locally

Patient with dementia discharged from Day Surgery on his own (W)

All staff now ensure that patients with dementia or confusion are clearly identified and this is communicated to all staff at the beginning of each working day. A green sticker is now placed on front of patients’ paperwork to alert staff.

Action taken across sites

Patient unhappy with nurse’s attitude (W)

Senior Charge Nurse has addressed concerns raised at daily safety briefs and reminded all staff of the professional and caring manner we would expect at all times

Discussed locally

Unhappy that patient fell in ward and for poor communication with family (W)

Staff reminded of importance of completing falls risk assessment. Staff reminded that Datix should be completed and family contacted.

Discussed locally

Unhappy with attitude of nursing staff/overheard staff discussing another patient (W)

Staff reminded of professional and caring manner we would expect at all times/ reminded of patient confidentiality and to ensure conversations take place in private

Discussed locally

Unhappy that review appointment continues to be rescheduled (W)

Earlier appointment provided Action taken locally

Unhappy with communication received at postnatal visit (W)

Communication and transfer of postnatal women to health visitors outwith their own area to be reviewed.


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Patient overheard staff discussing her management (W)

Staff reminded of the need to discuss patients management in private

Discussed locally

Patient has documented allergy to codeine but prescribed medication that contained codeine (W)

Staff reminded to review patient’s medical records/check for allergies before prescribing


Patient discharged without discharge prescription (W)

Datix completed and incident fully investigated to ensure this does not happen again


Unhappy that patient affairs manager did not arrange clinic appointment as agreed (W)

Member of staff reminded of the importance of completing agreed actions


July – September 2012

Issue Action Taken Sharing Learning Patient referred to EPAS service at Wishaw General instead of Hairmyres Hospital (H)

Doctor made aware of service on site. Specialist Nurse to do talk to A&E staff to highlight EPAS service.

Discussed locally.

Family concerned lack of basic nursing care. Not recorded in medical records. (H)

Staff reminded of the importance of ensuring all care documented in appropriate sheet.

Discussed locally.

Police brought in to interview confused patient without relatives present. (H)

Staff reminded of the importance of keeping family fully informed at all times and ensuring vulnerable patients protected.

Discussed locally.

Lack of explanation regarding potential side effects of procedure. (H)

Staff reminded of importance of explaining procedure fully and ensuring that patient fully understands.

Discussed locally.

Wrong relative given bad news. (H) Staff reminded of importance of ensuring they are speaking to correct person regarding any confidential information.

Discussed locally.

Patient distressed at not being reviewed by Consultant at out patient clinic. (H)

Staff reminded of importance of explaining that they may not be reviewed by Consultant at every clinic visit.

Discussed locally.

Patient in extreme pain during procedure and doctor did not stop. (H)

Discussed at length with junior doctor to ensure that they are aware of the patient’s pain threshold and stop when it is clear that the patient does not wish to continue with procedure.

Discussed locally.

Wrong insulin administered with discharge drugs. (H)

Staff reminded of importance of checking correct medication available in prescription.

Senior Nurse to share across sites.

Patient given an appointment for bank holiday. (H)

Staff reminded of importance of ensuring that all appointments are booked via trakcare to ensure clinic slot available.

Discussed locally.

Visitor fell over bollard whilst carrying baby in hospital grounds. (H)

Bollard to be removed as serving no particular purpose.

Action taken locally.

No toilet or shower facility within ward area. (H)

Currently investigating cost for installation.


Advised by telephone that referral had been sent because smear result was abnormal. Patient had not been aware of this. (H)

New policy introduced to advise patients to discuss any referrals with their general practitioner.

To be shared across sites.

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Patient upset as staff had shouted at her because she was deaf. (H)

Staff reminded of importance of being courteous at all times.

Discussed locally.

Patient with dementia moved to a number of different wards causing further confusion. (H)

Currently reviewing policy for decanting patients.

Policy being reviewed.

Patient not treated with dignity. (H) Staff reminded of importance of ensuring dignity retained at all times. Policy redistributed.

Discussed locally.

Nurses attitude poor. (H) Nurse counselled.


Issues raised regarding nursing care (M)


Discussed locally.

Waiting time at outpatient appointment (M)

Staff have been reminded of the importance of ensuring that when making appointments at short notice they inform patients that delays may be incurred at the orthopaedic clinic.

Discussed locally.

Issues regarding communication and confusion regarding treatment plan (M)

Secretarial staff have been reminded of importance of effective communication with patients and the need to follow up telephone enquiries in a timely manner.

To be shared across Directorates.

Concerns regarding patient’s discharge (M)

Nursing staff have been reminded of the need to ensure that patients are discharged home with any medication that has been prescribed for them.

Discussed locally.

Concerns regarding follow up treatment further to clinic appointment (M)

Complaint highlighted issues that can occur when multiple referrals are received and the impact this can have on the patient. Consultants and other staff who vet referrals have been made aware of the issues. We are currently exploring ways of amending our current procedures to prevent a similar situation in the future.

Procedures being updated.

Communication regarding transport for an inpatient to attend another hospital within NHS Lanarkshire (M)

Senior Nurse for the ward to reflect on this with the staff concerned.

Discussed locally.

Waiting time to be seen and attitude of staff to family members (M)


Discussed locally.

Concerns regarding clinical treatment given to patient, staff attitude and concerns regarding fall of patient whilst in ward (M)


Discussed locally.

Waiting time for post-operative appointment and content of leaflet issued to patient not accurate (M)

Patient information leaflet has been updated To be shared across sites.

Concerns regarding lost property of patient (M)

In order to prevent a similar situation “patient’s valuables” labels have been printed, and a patient’s belongings book is in the department to record details of valuables. Staff are aware that all belongings should be

Discussed locally.

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logged for patients who are confused or patients that pass away in the department.

Concerns regarding drugs prescribed to patient, poor medical treatment and communication issues (M)

Since the patient’s admission the junior doctors have been given additional training on appropriate prescribing of analgesia in elderly patients.


Waiting time to be seen by medical staff (M)

The Surgical Unit is currently exploring the possibility of establishing a direct GP assessment area within Ward 4. This should eliminate a waiting period in the Emergency Department for patients who meet the appropriate criteria, which includes patients being referred by their GP.

Arrangements being revised locally.

Brother unhappy with the number of calls made to his home by nurse requesting that he collect patient as he was next of kin (W)

Call records identify that a substantial number of calls were made to the brother's home. Senior Nurse to address with the nurse in question and action taken via appropriate channels.

Discussed locally.

Patient died - family unhappy that brain bleed was not detected earlier. Daughter unhappy that documentation does not reflect her own observations of her mother's condition. (W)

Debriefing to be held with nursing staff. Medical Directorate continues to review process for sending patients to Hairmyres.


Daughter unhappy with nursing care provided to her mother (W)

Debriefing session to be held with staff.

Discussed locally.

Unhappy with treatment and delays in treatment and medication (W)

Debriefing to be held with nursing staff

Discussed locally.

Waiting time for prescription on discharge (W)

Doctor to be reminded of the importance of accurately completing prescription and providing information about patient’s allergies.

Discussed locally.

Unhappy with treatment and waiting time in A&E (W)

Emergency Department ran out of Latgel (local anaesthetic gel). Pharmacy technician omitted to order in weekly stock order. Pharmacy have put number of measures in place, including increasing the supply to the department. Plan to use complaint as a learning tool for technical staff/pharmacists to avoid situation happening again. Department plan to review management of children's wounds and ensure lessons are learned from the case.


Concerns about collation and sharing of information (W)

Issues raised in complaint will be shared with staff in A&E and ECU to allow them to reflect on their practice. In addition, we will review our procedures to ensure communication with relatives is accurate and that information is communicated between clinicians effectively.

Discussed locally.

Daughter unhappy that her mother Debriefing session to be held with staff. Discussed locally.

16

was given general anaesthetic instead of spinal. Also unhappy that mother collapsed in toilet and subsequently died (W)

Patient given diclofenac in error and family upset about impact this had on his overall condition (W)

Case to be used as a case study by both medical and surgical directorates when delivering training to junior doctors on drug reconciliation.


Unhappy with process of referral to Nuffield (W)

Patient sent to Nuffield in error. Staff reminded of the importance of ensuring patients are added to the correct waiting list.

Discussed locally.

Patient unhappy with delay in being appointed for scope procedure (W)

This was due to administrative error and member of staff has been reminded of the importance of ensuring patients are listed appropriately.

Discussed locally.

Broken heel missed (W)

The Radiology Department have discussed case and the reporting Radiographer has had the opportunity to review the x-ray images and would like to apologise that this was not picked up at the time. Regular audits are already carried out within the department and if the Radiologists felt that there was an issue with an individual member of staff this would be dealt with via the appropriate route.

Discussed locally.

Unhappy with treatment received in A&E (W)

Wound stitched inappropriately by doctor and had to be re-stitched.

Discussed locally.

Incorrect information contained within discharge letter (W)

Senior Nurse has addressed with the staff and new forms produced to send to GP/patient. To be discussed at daily safety brief and documentation to be reviewed as part of ongoing audit carried out by nursing staff.


Wrong size of needle used to carry out lumbar puncture resulting in patient suffering PRDH (W)

Review undertaken and needles have since been updated.


October – December 2012

Issue Action Taken Sharing Learning Excessive waiting time within Ophthalmology Department Out Patient Clinic (H)

Management team are working closely with the clinicians and nursing staff to continue to redesign the patient pathways through the Ophthalmology Service Redesign Group.


Patient and wife upset by manner in which they were given bad news and difficulties experienced at outpatient consultation. (H)

Consultant will reflect on practice and ways of improving. Will also carry out patient feedback survey in near future.

Discussed locally.

Patient feels communication with consultant could have been better with Consultant. (H)

Consultant will reflect on practice to ensure that this type of situation does not arise again.

Discussed locally.

Patient extremely anxious whilst Staff acknowledged that in hindsight Discussed locally.

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awaiting scope. (H) could have arranged for patient to be first on the list and will reflect on this.

Duplicate appointment requested for patient which caused confusion and upset. (H)

Staff reminded of importance of ensuring patient follow up is appropriate.


Medical records not available for outpatient clinic as member of staff was on lunch break. Not highlighted to Directorate Support Manager timeously. (H)

Staff reminded of the importance of tracking medical records to outpatient department timeously for patient appointment.


Patient admitted to day surgery unit because of shortage of beds. (H)

New clinical decisions unit opened. Action taken locally.

Stoma care not explained to patient during stay and not referred timeously to stoma care nurse. (H)

Staff reminded of the importance of referring patient to stoma nurse timeously and to ensure stoma care explained in the meantime.

Discussed locally.

Special needs patient requires spare pair of glasses but NHS Lanarkshire have no funding policy for children with this issue. (H)

Case referred to scrutiny group for consideration of funding.

Policy being reviewed.

Surgery postponed because of failure in communication between two consultants. (H)

Consultant will discuss at next directorate meeting to ensure robust system in place to prevent this from happening again.

To be discussed across Directorate.

Miscommunication at clinical appointment. Patient unhappy with results and proposed plan. (H)

Consultant will review patient and discuss issues raised along with proposed clinical management plan.


Reception staff did not return patient’s call when querying information relating to equipment. (H)

Manager called patient and arranged formal review. Staff reminded of the importance of following up all enquiries timeously.


Attitude of nursing staff, communication and discharge procedure (M)

SCN has reminded nursing staff of the importance of ensuring that patients are given relevant information when they are discharged from the ward.

Discussed locally.

Poor nursing care, buzzers and drinks left out of reach of patient (M)


Discussed locally.

Staff attitude (M) Senior Nurse to meet with nursing staff to discuss the issues raised in complaint and review the lessons that can be learned.

Discussed locally.

Request for patient to have their delegated cancer nurse present at review appointments (M)

Senior Nurse has asked that concerns raised be discussed at next team meeting. All staff will be reminded to advise patients on the team’s philosophy with the emphasis that clinic attendance is covered by the CNS’s on a rota basis and that patients should be made aware that they may see any member of the CNS team.

Discussed locally.

18

Attitude of member of staff (M) Medical staff have been reminded of the importance of ensuring that the offer of a chaperone is made to a patient when an intimate examination is being carried out.


Communication regarding requests to meet with medical staff (M)

Senior Nurse has reminded nursing staff of the importance of ensuring that all messages are dealt with in an appropriate and timeous manner.

Discussed locally.

Attitude of member of nursing staff and patient discharged from hospital with cannula in situ (M)

CN has reminded nursing staff of the importance of remaining professional at all times when communicating with patients. Senior Nurse has also asked that CN reminds staff of the Peripheral Vascular Catheter (PVC) bundle and reinforce the importance of removing venflons when they are no longer required.

Discussed locally.

Concerns regarding treatment of patient and time taken for diagnosis (M)

Case discussed with the consultant team, including discussion at the department clinical governance and risk meeting.

Discussed across Directorate.

Concerns regarding staff attitude and communication issues (M)


Discussed locally.

Patient was not measured for TED stockings (M)

SCN has spoken to all staff on duty on the day in question and reiterated the correct procedure when fitting TED stockings.

Discussed locally.

Lack of communication (M) SCN has advised staff it is essential they communicate effectively with patients, relatives and carers at all times. SCN has asked staff to ensure that any issues are escalated to more senior members of staff within the department and all communication is recorded in the nursing documentation.

Discussed locally.

Issues regarding nursing care (M)


Discussed locally.

Member of staff was inappropriately parked in a disabled parking space and when asked by a member of the public they would not move their car (M)

Email sent to all staff at MH requesting the car in question was immediately moved. ADN discussed the complaint at the SCN Forum and SCNs asked to speak to their teams regarding inappropriate parking. Issues also discussed at the Operational Group Meeting where all heads of department are represented.

Discussed across site.

19

Concerns regarding treatment of patient and time taken for diagnosis (M)

The Emergency Department is introducing a policy that all triage category 2 and 3 patients will be discussed with a Registrar or Consultant within 30 minutes of presentation to ensure timely and appropriate care.

Policy under review.

Poor nursing care, buzzers and drinks left out of reach of patient (M)


Discussed locally.

Lack of care and treatment received over the past 36 months (M)

Department information booklet has been updated to ensure that patients know who they should contact out with department opening hours.


Waiting time for appointment, poor medical/nursing care, lack of communication, concern regarding discharge of patient and prescription issues (M)


Discussed locally.

Patient discharged from hospital with cannula in situ (M)

Senior Nurse has asked that CN reminds staff of the Peripheral Vascular Catheter (PVC) bundle and reinforces the importance of removing venflons when they are no longer required.

Discussed locally.

Communication issues, poor nursing care and staff attitude (M)


Discussed locally.

Unhappy with nursing care (W) Debriefing to be held with nursing staff Discussed locally. Unhappy with nursing care (W) Debriefing to be held with nursing staff Discussed locally. Repeat appointment not required (W)

Staff have been reminded about the importance of appointing patients appropriately.

Discussed locally.

Unhappy with nursing care (W) Debriefing to be held with nursing staff Discussed locally. Wrong diagnosis given in A&E (W)

Emergency Department plans to review the training provided in assessment of calf/ankle injuries to ensure that achilles tendon ruptures are identified.


Unhappy with waiting time in A&E and lack of communication from staff (W)

Department to review process to ensure that all patients are assessed within appropriate timeframe if 'See and Treat' Service is busy,


Told loss of hearing - no loss suffered (W)

If the audiologist questions the accuracy of a hearing test, they will seek advice from ENT consultant in future before taking an impression of the ear for a hearing aid.


January – March 2013

Issue Action Taken Sharing Learning Miscommunication regarding source of infection in wound (H)

Staff reminded of importance of good communication and clarification for patient if required.

Discussed locally

20

Miscommunication regarding proposed clinical treatment plan (H)

Staff reminded of good and effective communication and to ensure that the patient fully understands the proposed care plan.

Discussed locally

Patient returned to nursing home in pyjamas on cold day (H)

Staff reminded of the importance of ensuring patient suitably dressed for journey at time of discharge.

Discussed locally

Poor nursing care for elderly patient (H)

OPAC nurse seconded to ward to promote and enhance care for elderly patients.


Patient not dressed appropriately on discharge (H)

Staff reminded of the importance of ensuring patient suitably dressed for journey at time of discharge.

Discussed locally

Appointment not cancelled for deceased patient (H)

Staff reminded of the importance of ensuring all future appointments are cancelled when patient passes away,

Discussed locally

Secretary gave patient first available return appointment instead of new appointment (H)

Secretary discussed error with Directorate Support Manager and will ensure that this does not happen again. Will clarify in future with patient.

Discussed locally

Delay in communicating result to patient and family (H)

Ward staff reminded of the importance of good timely communication at all times.

Discussed locally

No communication to family regarding patient transfer to Udston Hospital (H)

Staff reminded of the importance of making family aware of patient transfer timeously.

Discussed locally

Failure to diagnose fracture at initial visit and delay in recall (H)

New process put in place to prevent future delays in recall.


Failure to provide transport for patient who required to return to hospital as a matter of urgency (H)

Staff reminded of the importance of patient safety when asking them to attend the hospital urgently.

Discussed locally

Unhappy with attitude of consultant (H)

Letter sent to patient to apologise.


Breakdown in relationship between patient and consultant (H)

Patient care transferred to alternative consultant.


Treatment prescribed by consultant not commenced by physiotherapist due to poor communication (H)

Measures taken to prevent similar situation from arising again.


Relative kept waiting in waiting area for 2 hours because doctor not aware present in department (H)

Measures taken to improve communication between medical and nursing staff.


Unhappy that Nutritionist did not visit as indicated at the time of admission & various issues in respect of medication (M)

Senior Nurse to discuss this issue with nursing staff.

Discussed locally

Unhappy with various aspects of treatment and care (e.g waiting time A&E, physiotherapy, pain management, medication) (M)

Senior Nurse and SCN to conduct debrief meeting with nursing staff. SCN also to discuss these key issues at ward safety briefs thereafter.

Discussed locally

Unhappy with personal care (M) Senior Nurse to undertake a formal debrief with nursing staff to discuss the issues raised and review the lessons that can be learned.

Discussed locally

Unhappy with patient fall (M) Senior Nurse to meet with nursing staff to Discussed locally

21

discuss the issues raised and to review the lessons that can be learned.

Length of stay for patient requiring sleep studies (M)

Pathway for sleep apnoea patients being reviewed with NHS GG&C


Issues with complex discharge (M)

ASSET discharge process revised and case discussed with ASSET team; role of co-ordinator created


Condition of toilets at main entrance (M)

Checking frequency increased to hourly between 12noon and 7pm


Ankle injury not diagnosed (M) Further training of MINTS nurses has taken place in recognising dislocations of bones in foot


Patient unhappy with interaction with staff (M)

SCN has spoken with staff concerned and reminded them of their professional responsibilities

Discussed locally

Unhappy with infection control issues of nurse whilst treating daughter (W)

Staff Nurse sent on asepsis and hand hygiene training


Unhappy with both nursing and medical care that father received prior to his death (W)

Debriefing to be held with staff. Discussed locally

Questions over wife's care before she passed away (W)

Senior Nurse to meet with nursing staff to ask them to reflect on communication skills.

Discussed locally

Unhappy with sonographer’s attitude (W)

Staff reminded of the professional and caring manner we would expect from them at all times.

Discussed locally

Referred to Nuffield for hernia repair and consultant unable to access his CT scan results (W)

Surgical division to review process for sending patients to Nuffield to ensure patients’ medical records/results are available.

To be shared across Directorate

Family concerned that patient fell on two occasions in ward resulting in two fractured hips (W)

Debriefing session to be held with nursing staff

Discussed locally

Unhappy with treatment and attitude of nursing staff (W)

Nursing staff asked to look at ways of improving their interaction with patients and their relatives

Discussed locally

Unhappy with care and treatment (W)

Nursing staff reminded of the guidelines for dealing with a patient fall. Staff reminded of the importance of communication with patients and their relatives and documentation.

Discussed locally

Professionalism of doctor (W) Issues raised in letter discussed with doctor and he was asked to consider cultural differences


Unhappy with discharge (W) Staff reminded of the importance of ensuring that they request appropriate clothing for patient to be discharged.

Discussed locally

Unhappy with midwifery care (W) Member of staff reminded of importance of accurate documentation and has been advised that she must attend a documentation study day within next couple of months.


22

Senior Midwife to review student’s practice and competency carrying out a daily baby check. Audit of our rooming in standard/skin to skin contact on a weekly basis to ensure staff adhering to policy.

Unhappy with clinical treatment (W)

Debriefing session to be held with midwifery staff

Discussed locally

Concerns re father's care and treatment (W)

Staff reminded of the importance of effective communication and documentation

Discussed locally

Unhappy with treatment in both maternity and theatre recovery (W)

Staff reminded of the importance of keeping patients and relatives updated on management. Nursing staff reminded of the importance of ensuring women receive their medication on time. Staff reminded of the need for confidentiality when discussing patients’ management

Discussed locally

Unhappy with treatment and attitude (W)

Debriefing session to be held with staff Discussed locally

Unhappy with treatment and care (W)

Debriefing session to be held with nursing staff

Discussed locally

Unhappy with aftercare after surgery (W)

Process for making follow-up appointments for inpatients to be reviewed as patient given conflicting information

To be shared across Directorate

Unhappy with infection control issues of nurse whilst treating daughter (W)

Staff Nurse sent on asepsis and hand hygiene training


Unhappy with both nursing and medical care that father received prior to his death (W)

Debriefing to be held with staff. Discussed locally

Questions over wife's care before she passed away (W)

Senior Nurse to meet with nursing staff to ask them to reflect on communication skills.

Discussed locally

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Appendix VI

DE-BRIEF MEETINGS HELD DURING APRIL 2012 – MARCH 2013 APRIL – JUNE 2012 Hairmyres Hospital (7): 1 Directorate: Surgical Issues raised: • Patient kept waiting on trolley with no communication

• Pain score not recorded • Blood on bedside table • Medication error perceived • Shared toilet dirty • Lack of privacy • No dressing supplied for district nurse visit

Actions taken: • Staff reminded of importance of ensuring that they communicate effectively and timeously with patients and their relatives at all times

• Admission form changed to ensure pain score recorded for all patients • Staff reminded of the importance of ensuring that all tables and beds are cleaned

prior to a patient’s admission • Staff reminded of importance of communicating effectively at all times. This had

been a misunderstanding not an error • Cleaning checklist updated and signed by ISS, patient had not raised concerns.

Staff reminded of the importance of ensuring toilets checked regularly • Staff reminded of importance of ensuring patient privacy maintained at all times • Staff reminded of importance of ensuring patient has sufficient dressings for

district nurse visit 2 Directorate: Orthopaedic Issues raised: • Delay with medication Actions taken: • Recognise increase in medical admissions impacting on orthopaedic ward.

Reviewing at management level. • Discussed at safety brief • Shortage of staff due to unforeseen circumstances • Team building exercise

3 Directorate: Surgical Issues raised: • Communication poor

• Waiting time in unit before procedure • No refreshment offered

Actions Taken • Charge Nurse spoke to member of staff to ensure similar situation does not arise again and that staff member reflects on her practice.

• Staggered appointment times considered but not appropriate. Designated member of staff for inpatient admission to assist patient and keep updated re process

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4 Directorate: Medical Issues raised: • Communication breakdown

• Attitude and behaviour • Family not allowed to visit out with visiting time • Patient on commode for 2 hours • No water jugs available

Actions Taken • Staff reminded of importance of good communication with patients and relatives • Staff reminded of importance of acting professionally at all times • Staff reminded that family can visit outside of visiting time following discussion

with Senior Charge Nurse or nurse in charge of ward • Not the case re commode, patient wished curtains kept pulled round bed during

visiting hours • Staff reminded of importance of ensuring water available for patient

5 Directorate: Medical Issues raised: • Communication breakdown

• Attitude and behaviour • Timeous contact with family when patient deteriorated • Family not allowed to see patient before being transferred to mortuary • No evidence to show family contacted

Actions Taken • Staff reminded of importance of good communication with patients and their relatives

• Staff reminded of the importance of ensuring they act professionally at all times • Staff reminded of importance of contacting family timeously when a patient

deteriorates. Judgement call re whether to phone family or not, but would be better to call and give relatives the option to attend the ward

• Staff reminded of importance of good communication with relatives when patient passes away

• Staff should record details of contact made with family in order to evidence on telephone records

6 Directorate: Medical Issues raised: • Volume of urine not recorded

• Dignity not maintained • Poor communication

Actions Taken • Staff reminded of importance of recording void in urine for all patients. Review procedure for when catheter removed. If void not witnessed scan should be carried out

• Staff reminded of importance of checking patients ready for visiting time before visitors are allowed access

• Staff reminded of importance of walk round at visiting time and updating visitors on clinical treatment plan and medication where appropriate

25

7 Directorate: Medical Issues raised: • Family felt staff were ignorant when visitors came into ward

• Poor communication. Patient was admitted into inappropriate ward and was not made to feel welcome

• Eye drops not administered by nursing staff every hour • Patient lost confidence in staff • Lack of care and compassion

Actions Taken • Member of staff now welcoming patients relative/visitor into ward. Nursing staff reminded of importance of ensuring they are approachable during visiting time

• Staff reminded of importance of ensuring patient aware why they are in the particular ward and what they should expect during their stay. Staff also reminded of importance of being professional at all times

• Nursing staff reminded of consequences of not administering eye drops timeously. Now agreed that the ophthalmology liaison nurse will assist

• Complaint discussed with ward staff in order that they can reflect on their practice and ensure that this situation does not arise again

• Staff reminded of care and compassion policy and importance of adhering to this Monklands Hospital (9): 1 Directorate: WCD Issues raised: • Communication

• Patient notes – breach of confidentiality • Medication • Mealtimes

Actions Taken • SCN to speak to nursing staff regarding their communication skills • SCN to reiterate importance of putting patient’s personal folder in appropriate

holder to avoid breach of patient confidentiality • SCN to reiterate procedure with nursing staff • SCN to remind staff of importance of ensuring food trays are cleared immediately

after meal times 2 Directorate: EMS Issues raised: • Issues re discharge of vulnerable patients Actions Taken • Senior Nurse advised that it was important that staff in the Department were

aware of their responsibilities with regard to the care of vulnerable patients during their time in the department and at the point of discharge.

3 Directorate: SCC Issues raised: • Wound management

• Standard of food Actions Taken • Issues regarding communication of management of wounds discussed

• Patient had not raised concerns at time of admission to allow catering staff to attend ward but had been referred to dietician by ward staff

4 Directorate: EMS Issues raised: • Lack of nursing care Actions Taken • Senior Nurse discussed concerns raised and acknowledged significant progress

had been made in the ward since the time of complaint

26

5 Directorate: EMS Issues raised: • Lack of nursing care Actions Taken • Senior Nurse discussed concerns raised and acknowledged significant progress

had been made in the ward since the time of complaint 6 Directorate: EMS Issues raised: • Lack of nursing care Actions Taken • Senior Nurse discussed concerns raised and acknowledged significant progress

had been made in the ward since the time of complaint 7 Directorate: SCC Issues raised: • Staff were unhelpful

• Cleanliness of ward • Issues regarding patient’s dietary intake

Actions Taken • Senior Nurse reminded staff of the importance of ensuring patients receive optimal care at all times

• SCN to remind staff of the correct procedure to follow when areas of concern are highlighted in relation to ward cleanliness

• SCN advised that the “Getting to know you booklet” was completed and acted upon accordingly in relation to feeding issues. Senior Nurse asked that the SCN nominate two staff members to attend Dementia Awareness training.

• Senior Nurse asked that SCN share results of patient experience indicators with all nursing staff, and to act on any issues that may have arisen.

8 Directorate: EMS Issues raised: • Patient left alone in clinical area whilst relative remained in waiting area

• Nursing staff did not request help from colleague to carry out a 2-person task Actions Taken • Senior Nurse advised it was not acceptable that vulnerable patients were left alone

when a relative was in the waiting area and could accompany the patient. She asked that nursing staff ensure that they are mindful at all times of the needs of patients and their relatives.

• Senior Nurse advised that patient should have been changed with the assistance of two nurses rather than the assistance of a family member

• Senior Nurse acknowledged that clear improvements had been made since the time of the complaint in line with OPAC which was ongoing in the department

9 Directorate: SCC Issues raised: • Concerns regarding pressure area care and personal hygiene Actions Taken • Senior Nurse commended staff on their documentation regarding the patient’s

pressure area care. SCN accepted staff should have informed patient’s main carer regarding the changes to their skin prior to discharge from the ward

• SCN advised patient was given a daily bed bath and this had been documented. • Senior Nurse acknowledged that improvements had been made with regard to

nursing documentation

27

Wishaw General ( 5): 1 Directorate: Women’s Services Issues raised: • Wrong date of induction of labour provided to patient

• Poor documentation • Patient delivered her baby at home and upon arrival at hospital staff did not

acknowledge her traumatic experience • Delay in patient being given skin to skin contact with her baby

Actions taken: • Staff to ensure that correct dates are provided for induction of labour • Staff reminded of the need to document all communication with patients and their

relatives • Staff to ensure support is provided and offer a meeting to discuss • Staff to be reminded of the breastfeeding policy

2 Directorate: Surgical Issues raised: • Concerns about delay in IV fluids being given

• Confusion about patient being fasted Actions taken: • Staff reminded of the importance of completing fluid balance charts

• Senior Charge Nurse to speak to medical colleagues regarding improved communication with nursing staff

3 Directorate: Women’s Services Issues raised: • Unhappy with number of calls made to Triage service before admission was

arranged Actions taken: • Staff reminded of the importance of providing clear communication to women

and when to ask women to attend hospital for assessment. • Staff reminded of the need for good documentation in relation to care given

allowing evidence-based responses 4 Directorate: Women’s Services Issues raised: • Communication in relation to care and advice • Poor documentation in relation to care and advice Actions taken: • Staff reminded of the need for good documentation in relation to care given

allowing evidence-based responses 5 Directorate: Women’s Services Issues raised: • Patient readmitted to labour ward following miscarriage

• Patient attended scan department and highlighted that she was allergic to latex. No latex-free cover available for probe so Sonographer used latex-free glove

Actions taken: • Management to review appropriate placement for care of women suffering pregnancy loss

• Ensure latex-free equipment is available within the Scan department JULY - SEPTEMBER 2012 Hairmyres Hospital (5):

28

1 Directorate: Emergency Medicine Issues raised: • Communication with family.

• Handover arrangements. • Catheter volume not measured.

Actions taken: • Staff reminded of importance of being proactive daily at visiting times to ensure patients and their relatives are kept fully informed regarding patient care. Staff also reminded of importance of acknowledging relatives who approach the nursing station.

2 Directorate: Surgical And Critical Care Issues raised: • Incorrect information in casenotes

• Wrong medication given because of paperwork error. • Inappropriate diet. • General standard of care poor.

Actions taken: • Staff spoken to and counselled re error. • Discussed with staff and counselled re error.

3 Directorate: Surgical and Critical Care Issues raised: • Patient dignity not maintained.

• Family felt IV infusion should have been continued. • Interaction with family poor. • Difficulties breaking bad news • Anticipatory Care not discussed with relatives.

Actions Taken • Staff reminded of the importance of ensuring patient dignity at all times. Undignified that discussion took place in front of patient with no regard to the impact that this would have on the patient and family. In future relatives will be taken to private area/duty room.

• Care plan was appropriate as patient would not keep mask on or venflon in situ. Relative kept holding in place. In line with Liverpool Care pathway for palliative patients, not appropriate to insert IV infusion or oxygen as appeared to cause more distress.

• On reviewing nursing records, well documented appropriate care carried out. Nursing staff reminded of importance of relaying relevant information to relatives.

• Care and Compassion policy reiterated to all staff. • Liverpool Care pathway should have been discussed in detail with family. Staff

reminded of importance. Also needs to be discussed at safety brief and ward meeting.

Directorate: Emergency Medicine Issues raised: • Communication with family regarding discharge poor.

• Care package not reinstated prior to discharge. • Sitting inappropriate patients out of bed whilst waiting for discharge. • Staff not aware of patient’s capabilities.

Actions Taken • Staff reminded of importance of good communication with relatives at all times. • Staff reminded of importance of ensuring appropriate care package in place prior

to discharge and that this is communicated to the family. • Staff reminded of importance of ensuring patient is fit to sit out of bed whilst

awaiting discharge. • Staff reminded of importance of assessing patient’s vulnerability during hospital

stay.

29

5 Directorate: Surgical and Critical Care Issues raised: • Patient asked if she had been drinking

• Pain score not recorded • Inappropriate brace used • Patient not made to feel welcome in ward • Patient allergic to plate required for surgery no explanation given.

Actions Taken • General question asked and not intended to offend. Staff should explain this. • Pain relief not adequate and should have been acted upon sooner. Staff reminded

of importance. • Staff will explain in greater detail in future. • Staff reminded of the importance of good communication and orientation of

patients when they arrive in the ward. • Staff reminded of importance of explaining reason for delay in surgery.

Monklands Hospital (1): 1 Directorate: EMS Issues raised: • Breakdown in communication

• Lack of care and compassion Actions Taken • Debrief held with all ward staff

• ADN asked staff to reflect and agree as a group about their expected standard for patients and their relatives and how they can achieve this

Wishaw General (2): 1 Directorate: Medicine Issues raised: • Concerns raised by family not taken on board/Issues with communication in

general Actions taken: • Staff to be reminded of the importance of documenting relatives concerns

• Senior Nurse to carry out spot audits of documentation 2 Directorate: Medicine Issues raised: • Family did not appear to appreciate how ill the patient was

• Family concerned about oral hygiene • Family concerned about another patient feeling vulnerable

Actions taken: • Staff to be reminded of the importance of providing adequate communication • Staff reminded of the importance of documenting oral hygiene carried out • Staff to escalate any requests for extra support to help with patients who are

confused/wandering OCTOBER - DECEMBER 2012 Hairmyres Hospital (7): 1 Directorate: Emergency Medicine Issues raised: • Senior Charge Nurse did not communicate with family on return from leave

because Deputy Charge Nurse had done so in absence. Acknowledged would have been prudent to revisit the family to confirm all was well after leave.

• Patient transferred late in evening when daughter had been advised that mother would be left in ward until discharge.

30

Actions taken: • Senior Charge Nurse to reflect on practice. • Patient had been transferred whilst daughter was being advised that she would be

kept in ward. Patient was given the opportunity to return to original ward but was content to remain in new ward. Staff reminded family should have been updated given concerns.

2 Directorate: Emergency Medicine Issues raised: • Poor communication with family

• Patient felt nursing staff did not respond to needs. • Transport issues to MDGH • Patient and husband not reassured by staff.

Actions taken: • Staff reminded of importance of intentionally speaking to relatives during visiting and trying to ensure that they speak to every relative. ADN would expect CSW to provide information on fundamental care carried out and to pass on any issues that they were unable to answer to senior staff. Staff to reflect on meet and greet and how we make sure relatives are getting timeous information. CSW to share details of complaint with colleagues.

• Intentional rounding ongoing and documentation in patient records regarding communication with relatives. Needs to be carried out at least every two hours. Reassuring for patient during long stay.

• Transport for patient to other site not ordered timeously therefore SAS unable to provide appropriate transport. Taxi ordered but was unsuitable and dropped patient some distance from department. Staff Nurse to develop transport booking policy for ward to prevent similar situation from arising again.

• Reflect on how the patient and her husband felt. Reassurances should have been given and issues escalated appropriately. Reflect on how to approach difficult situations and escalate where necessary.

3 Directorate: Surgical and Critical Care Issues raised: • Dirty cotton wool ball left on locker

• Details of visiting hours not on NHS Lanarkshire website • No communication regarding patient transport to family • Visiting out with normal hours denied • Gown not changed for 48 hours • Discharge process poor

Actions Taken • All staff reminded of the importance of clearing and cleaning the locker in advance of new patient admission.

• Website information chased with IM&T • Staff reminded of the importance of keeping the family informed of any ward

moves. ADN will email all wards to reminded of importance. • Plans need to be communicated fully to patient and family. Intentional rounding

now introduced and working well in both wards. Patient gown should have been changed and staff reminded of the importance of assisting patients to change where necessary.

• Discharge process to be reviewed to ensure robust system addressing all aspects of discharge planning.

4 Directorate: Surgical and Critical Care Issues raised: • Poor communication between family and ward staff Actions Taken • Staff reminded of importance of good communication and documentation to

evidence discussions. Need to ensure that staff are identifying appropriate patients for discharge. Communication between staff regarding change of plan

31

needs to be documented. Handover information needs to be accurate. 5 Directorate: Surgical and Critical Care Issues raised: • Communication poor

• Patient not moved to side room immediately • Patient exposed at visiting time • Refreshments not made available for visitors

Actions Taken • Difference of opinion. Documentation had been good in the ward and therefore issues in complaint were easier to address. Staff to be commended on good documentation. Patient had underlying condition and there was gap between letter and ward information. Communication not as robust as family needed. Patient’s mother anxious and set in way of caring for daughter. Expected same in ward. Highlighted the importance of addressing these issues at an early stage during patient stay. Staff on duty felt they had given the patient and daughter sufficient information but were unable to satisfy needs. SCN took over patient care and communication with patient and mother. Staff need to explain expectations that cannot be met. Less experienced staff need to highlight issues to SCN where concerned.

• Response was appropriate when patient was moved as soon as a side room was available. Information had been given to patient and family at that time.

• Family entered room and patient was exposed. No sign put up to identify not to enter the room. Sign to be used in ward when relatives not to enter room.

• Facilities should be highlighted to relatives who visit for extended periods. Refreshments currently offered if relative staying with patient for prolonged periods.

6 Directorate: Emergency Medicine Issues raised: • Poor communication with family regarding medication and seizure activity Actions Taken • Staff reminded of the importance of good communication with patient and family

at all times to provide reassurance that staff are taking on board concerns. 7 Directorate: Emergency Medicine Issues raised: • Family felt ward staff did not approach family/patient during final days.

• Patient left exposed at visiting time • Lack of nursing care • Inappropriate comments

Actions taken: • Important staff make a judgment on how often family need support. Staff reminded of importance of communicating with family and agreeing plan. Family need reassurance that assistance is always available. Staff reminded of good communication at all times.

• Staff agreed not acceptable to be left exposed. All staff reminded of importance of ensuring patient prepared for visiting time.

• Staff reminded of importance of being proactive at visiting times, ensuring that patients and their visitors are kept fully informed when appropriate. Acknowledged difficult to control when open visiting for terminally ill patient.

• Staff reminded of the importance of good communication at all times. Monklands Hospital (10): 1 Directorate: EMS Issues raised: • Issues regarding discharge of patient

• Communication and nursing care

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Actions Taken • All patients being discharged should remain in the department until a family member or patient transport is available to take them home.

• Senior Nurse advised that nursing staff must speak to patients in a respectful way at all times. Staff were also reminded of their responsibility to ensure good practice was delivered at all times within their area and they should highlight any concerns via the appropriate channels.

2 Directorate: SCC Issues raised: • Pain control

• Discharge medications Actions taken: • Nursing staff reminded that a medical review should be requested if a patient

continues to complain of pain. • Senior Nurse commended ward staff on their practice of removing the interim

discharge letter and forwarding it on to the patient’s GP if drugs were not collected by patients or their families following their discharge from the ward. CN advised that it was also the practice of the ward to issue the patient with a nursing discharge summary and in most cases the typed operation note was sent to the patient’s GP.

3 Directorate: EMS Issues raised: • No family present with patient

• Communication Actions Taken • It was reinforced to staff that if a patient has family members accompanying

them, they are allowed to remain with the patient, if appropriate. • Staff were reminded of the need to ensure that they communicated effectively

with patients, relatives and their carers at all times to minimise any concerns or anxieties.

4 Directorate: EMS Issues raised: • Monitoring of patients

• Urine retention • Delay in transfer of patient’s case notes and communication to receiving hospital

Actions Taken • SCN discussed with staff the importance of observing patients appropriately. • SCN discussed with staff the need for good communication with relatives when

providing updates. • SCN discussed with staff the importance of completing the “Getting to Know

Me” document and the importance of providing detailed patient information to the patient’s receiving hospital with all staff.

5 Directorate: SCC Issues raised: • Communication regarding transfer of patient to ward Actions Taken • CN explained that staff in the ward were very particular and mindful about the

terminology they used to patients and their relatives and they always ensured their communication was appropriate.

6 Directorate: SCC Issues raised: • Observing patients

• Patient was a “boarder” Actions taken: • Senior Nurse advised since the complaint had been received new nursing

documentation and intentional rounding had been introduced, which would have addressed some of the concerns raised in the complaint.

• Senior Nurse advised that it was important that lessons were learned and she

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emphasised the need to ensure that terminology, such as ‘boarders’ was not used to describe patients in the ward.

7 Directorate: EMS Issues raised: • Nursing care

• Mis-communication regarding x-ray results Actions taken: • Senior Nurse advised that the introduction of the new nursing documentation and

intentional rounding should be helpful in minimising similar issues as those highlighted in the letter of complaint in the future.

• Senior Nurse stressed the importance of ensuring that any information given to patients, relatives and their carers was accurate at all times.

8 Directorate: EMS Issues raised: • Communication regarding pressure area care

• Communication • Medication left at patient’s bedside

Actions taken: • Senior Nurse advised that nursing staff were the patient’s advocate and they should ensure that any issues are fully communicated to medical staff on the ward round.

• Senior Nurse asked that staff were reminded of the need to be courteous to patients at all times.

• Senior Nurse advised that the Drug Administration Policy must be followed at all times and it was the responsibility of nursing staff to ensure that all medications are taken by the patient.

9 Directorate: EMS Issues raised: • Family members not allowed to accompany patient

• Pain relief Actions taken: • SCN advised that notices were now displayed in the department waiting room

advising that two relatives per patient were allowed in the clinical area. • Notices are displayed in the department waiting area advising if patients need

pain relief whilst waiting to be seen they should contact a member of staff. 10 Directorate: SCC Issues raised: • Nursing care

• Pain control • Patient fall

Actions taken: • Senior Nurse advised since the complaint had been received new nursing documentation and intentional rounding had been introduced, which would have addressed some of the concerns raised in the complaint. Senior Nurse asked that CSWs were also encouraged to complete any patient interventions in the nursing documentation.

• It was explained that the patient would often leave the ward to go to the front entrance. The patient was advised that morphine could not be given if they were not going to remain in the ward as staff were unable to observe them.

• Senior Nurse emphasised the need to ensure that a Falls Risk Assessment was completed and if a patient did fall in the ward the family must be contacted. CN confirmed this issue had been raised with staff and the flow chart ‘Protocol of care after an inpatient fall’ was in the off duty folder for all staff to see and familiarise themselves with.

Wishaw General (4):

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1 Directorate: Older People’s Services Issues raised: • Concerns that chair was blocking mother’s access to toilet

• No table available for patient • Process for requesting appointment with consultant

Actions taken: • Laminated sign to be placed on door to remind visitors to return chairs • Staff reminded that this is equipment patients cannot do without and therefore

any issues require to be escalated to senior nurse • Staff encouraged to contact the secretary and arrange appointment

2 Directorate: Medical Issues raised: • Patient fell in ward

• Lack of communication from nursing staff re patients management Actions taken: • Falls risk to be completed/updated

• Staff reminded to complete Datix incident form • Staff to improve communication with relatives

3 Directorate: Older People’s Services Issues raised: • Concerns about patients urostomy bag leaking

• Concerns about the way in which patient was lifted Actions taken: • Staff to ensure clear communication is provided to patients and their relatives

• Staff to ensure manual handling guidelines followed 4 Directorate: Medical Issues raised: • Lack of communication from nursing staff regarding patient’s management

• Lack of pain management Actions taken: • Staff reminded of the importance of documenting communication between them

and relatives/medical staff • Senior Charge Nurse to carry out a spot check of medical records

JANUARY - MARCH 2013 Hairmyres Hospital (5): 1 Directorate: Emergency Medicine Issues raised: • Repeat admissions with similar symptoms: family did not feel that staff looked at

whole journey, just individual admissions. Relatives’ perception/expectations of what could be done for patient at time of admission incorrect.

• Communication with family regarding purpose of receiving unit poor. • Patient moved late at night. • Poor communication in general

Actions taken: • Complaint to be discussed at next GP meeting to ensure that patient is aware of why they are being admitted.

• Staff reminded to complete SBAR fully noting that family have been contacted. • No clear guidance on whether or not to phone relatives late at night. Agreed

receiving ward should call the following morning. SBAR should be clearly documented.

• Complaint to be discussed at next ward meeting.

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2 Directorate: General Surgery Issues raised: • Patient felt pain medication was not administered when it was requested.

• Patient named male nurse as not giving analgesia timeously. • Lack of information provided on discharge document regarding district nurse

referral. Actions taken: • All staff reminded of importance of responding to request for pain relief from

patient timeously. • SCN to discuss with male nurse regarding discussing pain with patient, assessing

need for medication and should always follow up if pain relief has been effective. • SCN to remind staff of importance of completing discharge documentation

accurately at all times. 3 Directorate: Emergency Medicine Issues raised: • Responsibility of physiotherapy to provide arms splints but responsibility of ward

staff to ensure used. Physiotherapy should check being used correctly. Breakdown in communication regarding this.

• Family frustrated that physiotherapy not actively encouraging patient to mobilise. • Family felt they had to feed patient. • Family brought in pictures to show improvement in patient when transferred to

NHS Lothian in comparison to Hairmyres Hospital. • Pressure sores not documented. • Lack of basic hygiene. • Lack of clinical care.

Actions taken: • Physiotherapy have introduced handover for each patient to clarify changes to care or treatment.

• Patient declined assistance, closed eyes and turned away. Terrified of hoist. Should have been better communication with family to highlight and gain assistance from family if possible. Highlighted to all staff.

• Patient was sick when being helped to eat and was not fit to sit up when eating. Recognise family meeting should have been set up at early stage. Staff reminded of importance of good communication and escalation if required.

• No clothes brought to ward despite family being asked. • SCN met with staff, no assessment on admission. Documentation patchy and no

plan of care. Pressure mattress in place but not documented. Staff reminded of importance of initial assessment and good documentation.

• SCN hours of work changed to allow presence at 4/7 visiting times. Strive to achieve rounds during visiting.

• Food in patient’s mouth, patient wouldn’t open mouth. Mealtimes protected now and all patients checked before visiting.

• Nursing dependency now discussed at bed meeting to ensure additional staff supplied if required.

• Complaint discussed at ward meeting in order that staff can reflect on their practice.

4 Directorate: Surgical Directorate Issues raised: • Patient handled roughly

• Patient put to bed with no pyjama trousers on. • Poor documentation regarding conversation with Charge Nurse • Nurse call system not used. • Patient’s daughter unaware of laundry process. • Poor communication.

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Actions taken: • Hospital cover were called regarding patient being handled roughly. It would appear that the lady was concerned because there had been no communication when being put to bed and she felt that this was inappropriate. Hospital cover advised the lady that the reason for this was because it was late at night and other patients were sleeping and could not be disturbed. Apologies given an accepted.

• Acknowledged patient should not have been put to bed without pyjama trousers. SCN will discuss with nurse involved to ensure that this does not happen again.

• Nurse recalled speaking with patient’s daughter and was able to advise on discussion. However, acknowledged documentation poor. All staff reminded of importance of documenting discussions with patients and their relatives.

• Staff confirmed buzzer was available. • Staff reminded of importance of ensuring that relatives are aware of laundry

process if they live far away. • Staff reminded of the importance of good communication particularly where the

family have expressed anxiety to ensure that they are reassured. 5 Directorate: Emergency Medicine Issues raised: • Patient’s perception that communication was poor within Emergency

Department. Husband left waiting in waiting area. Staff did not return with answers to patient’s queries.

Actions taken: • Nursing staff reminded of the importance of good and effective communication at all times. Core staff supplemented to improve communication and patient flow.

Monklands Hospital (0): Wishaw General (7): 1 Directorate: Women’s Services Issues raised: • Patient unhappy with management/felt midwife did not acknowledge her birth

plan.

Actions taken: • Staff reminded of the need to consider patient’s birth plan/explain management. • If staff feel under pressure from women they need to involve maternity co-

ordinator 2 Directorate: Women’s Services Issues raised: • Lack of breastfeeding support

• Staff attitude • Visitors asked to leave

Actions taken: • Staff reminded of the need to provide women with the opportunity to express milk

• Staff to consider how communication can be interpreted 3 Directorate: Women’s Services Issues raised: • Unhappy with management – loss of baby outwith hospital after being sent home

• Felt discussion re funeral arrangements was too early Actions taken: • Staff reminded of the need to coordinate admission to hospital/request an

ambulance • Staff reminded of the importance of advising women to come to the side door at

maternity and providing an escort if woman distressed

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4 Directorate: Medical Issues raised: • Delay in patient receiving special mattress for pressure sores Actions taken: • Staff to ensure that orders are printed off and placed within the patient’s medical

records. 5 Directorate: Surgical Issues raised: • Patient unhappy with management of urinary retention

• Patient unhappy that bladder scan was not performed • Patient felt there was a shortage of staff

Actions taken: • Review NHS Lanarkshire spinal pathway • Check for spinal injury patient leaflet • Reinforce importance of documentation with nursing staff. • Audit of staffing levels in ward

6 Directorate: Surgical Issues raised: • Patient collapsed and died, relatives unhappy with communication

• Pain management • Patient incontinent of urine after requesting assistance to toilet • Relatives concerned about management of DVT

Actions taken: • Staff to be reminded of the importance of documenting findings/actions taken • Staff to be reminded of importance of responding to nurse call alert system

timeously and providing reassurance to patients • Senior Nurse to contact Scottish Patient Safety Programme regarding the risk

assessment/scoring system for DVTs 7 Directorate: Older People’s Services Issues raised: • Staff attitude

• Relatives concerned about patient’s food, fluid and nutrition • Lack of communication

Actions taken: • Staff reminded of the importance of professional manner at all times • Staff reminded of the importance of keeping relatives fully updated on patient’s

condition/management.

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APPENDIX VII

OMBUDSMAN DECISION LETTERS CONTAINING UPHELD COMPLAINTS

AND / OR RECOPMMENDATIONS • The care and treatment the patient received during attendances at the A&E department of Hairmyres Hospital

in February and March 2010 was not reasonable (upheld); • The Board’s reaction to an ultrasound scan in late April 2010 was not reasonably urgent (not upheld); the

Board unreasonably carried out a hysterectomy without referring the patient to an oncologist or carrying out a biopsy (or both) (not upheld); and

• The Board’s response to the complaint about these matters was not reasonable (upheld). • The Board failed to provide an acceptable standard of nursing care to the complainant’s father in Wards 10 &

11 of Monklands Hospital (not upheld); • The Board failed to admit the complainant’s father to the Ward within an acceptable time period (upheld); and • The Board failed into account the information provided by the family in respect of the patient’s needs and

abilities when providing him with care (upheld). • In 2008, the patient was given inadequate care and treatment at Wishaw General Hospital (upheld); • A doctor had inappropriately written in the patient’s notes ‘do not resuscitate’ without the family knowing

(not upheld); and • In 2010 the patient was given inadequate care and treatment at Wishaw General Hospital (not upheld). • The Board did not provide reasonable care and treatment to the patient between 3 and 7 March 2011 (upheld);

and • The Board did not reasonably respond to the complainant’s contacts in late July, mid August and late

September requesting a meeting with senior managers to discuss complaint (a) (upheld). • Despite the patient being at known risk of developing pressure ulcers and the family alerting staff to their

concerns about the frequency of his position being changed, staff at Monklands Hospital unreasonably failed to monitor him appropriately and change his position frequently enough to prevent pressure ulcers developing (not upheld);

• There was an unreasonable delay of nine days in obtaining specialist equipment such as a special mattress for the patient (not upheld);

• When the patient was transferred to Coathill Hospital, there was a further unreasonable delay of two days in transferring the special mattress between the two hospitals (upheld); and

• The response from the Board to the complaints was inadequate, in that the family found the information therein to be ‘patronising’, ‘misleading’ and ‘disingenuous’ (not upheld)

• The taking of notes regarding the patient’s symptoms was inaccurate as he was described as being able to weight bear which was incorrect (upheld);

• The initial diagnosis was inadequate (upheld); • There was a failure at the initial consultation to appropriately refer the patient for an x-ray (upheld); and • There had been no feedback to the doctor concerned (upheld) • The Board failed to act in accordance with Scottish Government guidelines regarding the decision that the

patient did not meet the criteria for NHS continuing healthcare (upheld) • Aspects of patient’s care and treatment at Monklands Hospital between April and October 2011 were below

an acceptable standard (upheld) • The Board did not provide reasonable care and treatment to the patient from June to November 2011 (upheld) • The Board did not take reasonable actions to address a known issue with return appointments at the

gastroenterology clinic (upheld) • The Board did not respond to the complainant’s enquiries of 16 November 2011 within a reasonable time

(upheld)

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• The Board failed to investigate patient’s condition appropriately (upheld) • Discharged him inappropriately when he was unwell and confused (upheld) • Advised his family there would be a follow up appointment but failed to send one (not upheld) • Failure to provide appropriate treatment for perforated intestine (caused by diverticular disease) and

subsequent complications, within reasonable timescales (not upheld) • Failure to take reasonable steps to notify patient of the cancellation of appointments and failure to contact

patient to rearrange these appointments (upheld) • Failure to give reasonable and consistent explanations for the reasons for the cancellation of these

appointments (upheld) • Patient was not reasonably advised in advance of the purpose of an appointment (already upheld by Board) • The doctor unreasonably continued when told by the patient to stop (unable to reach supportable view) • The doctor unreasonably failed to advise the patient that there would be bleeding following the procedure

(unable to reach supportable view) • There was an unreasonable failure by the locum consultant to refer the patient to the specialist respiratory

consultant following his admission to Monklands Hospital in July 2009 (upheld) • During an OT assessment on 13 October 2010 the Senior OT conducted a personal care and dressing

assessment using water taken from the tap at the sink next to the patient’s bed. It was unreasonable to use this as this sink had been blocked for three days with stagnant water in the sink (not upheld)

• It was unreasonable that while he was on Ward 5 of Monklands Hospital the patient’s wife and her niece found three pages of notes from another, female, patient mixed in with the patient’s notes (upheld)

• Failed to properly advice the patient of the nature and scale of her operation (upheld) • Prematurely removed her from the HDU after her surgery (upheld) • Failed to provide her with adequate post operative care in hospital and aftercare at home (upheld) • Overall management of the patient’s prolapse, from the date that a complication arose in October 2011 until

her surgery in May 2012, was unreasonable (upheld) • The medical and nursing care and treatment in three admissions of March 2012 were unreasonable (upheld) • Failure to adequately consider the patient’s symptoms and this led to a delay in reaching a diagnosis of Non

Hodgkin’s lymphoma (not upheld) • Failure to ensure the patient was adequately hydrated (upheld) • Administration of patient’s death was unreasonable in that the Board:

o Issued death certificate prematurely o Delayed in deciding not to release body (not upheld)

• Communication was unreasonable in that the Board: o Delayed in informing appropriate persons that the body was not to be released o Provided an inadequate reason for not releasing the body o Failed to provide reasonable information about what would happen if the test results were positive o Failed to provide reasonable information about when the body would be released (upheld)

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