Complaint about Heatherwood and Wexham Park Hospitals NHS Trust (now Heatherwood and Wexham Park Hospitals NHS Foundation Trust), Berkshire East Teaching Primary Care Trust (now Berkshire East Primary Care Trust) and the Healthcare Commission
Jump to
Complaint about the care and treatment of an older person and about subsequent complaint handling
Background to the complaint
In March 2003 Mrs U, then aged 83, collapsed and was admitted to Wexham Park Hospital (Wexham Park), managed by Heatherwood and Wexham Park Hospitals NHS Trust (the Trust). She saw Dr G, who suspected a cardiac condition. He arranged for a 24-hour ECG (electrocardiogram) and an echocardiogram. Mrs U was discharged, although her niece (Mrs T) said she was weak and had dizzy spells. A few days later Mrs U was admitted to Heatherwood Hospital (Heatherwood), also managed by the Trust. A head scan found no abnormalities. Mrs U was discharged, but collapsed on 17 April, fracturing her ankle. She was readmitted to Wexham Park, where Dr G diagnosed possible drop attacks (short blackouts that result in falls) and prescribed Epilim Chrono, an anticonvulsant medication.
Mrs U had ankle surgery at Wexham Park on 20 April 2003 and her leg was put in a cast. She was transferred first to Heatherwood and then, on 3 May, to Upton Hospital (Upton), managed by Berkshire East Teaching Primary Care Trust (the PCT) for rehabilitation. Mrs U was due to have an out-patient appointment with Dr G on 20 May, but a week earlier Upton had cancelled the appointment (and did not schedule a further appointment) because she was an in-patient with them and was therefore under the care of a consultant on the ward. (At the time, Mrs T was told that the appointment had not been cancelled and that Mrs U had not been offered another appointment because she had failed to attend the clinic on 20 May.)
In June 2003 Mrs U was transferred back to Wexham Park, having developed a vascular ulcer on her ankle. Her cast was removed and the wound was found to be infected. Mrs U was treated with intravenous antibiotics. A swab for MRSA was negative. She went back to Upton on 10 June. A further 24-hour ECG was carried out on 1 July, whilst Mrs U was still largely confined to bed. A swab for MRSA then proved positive and Mrs U was readmitted to Wexham Park. She was later transferred back to Upton, and discharged in mid-July. By Mrs T’s account, Mrs U’s dizzy spells and weakness continued. She was suffering from hair loss and a bad taste in her mouth; possibly side-effects of her medication. Mrs U went for an EEG (electroencephalogram) at Charing Cross Hospital in August, the results of which are unknown. However, Mrs U’s GP contacted Mrs T on receiving the results, having diagnosed a heart problem. An ECG taken in September showed Mrs U had a complete heart block (no connection between the atrial and ventricular beats of the heart). The Royal Brompton Hospital fitted her with a pacemaker and she remained on Epilim Chrono until some time in October.
Complaint to the Trust and to the PCT
Mrs T complained to the Trust in September 2003 about delay in diagnosing Mrs U’s heart condition, the prescription of Epilim Chrono and the lack of review of the medication. She was dissatisfied with the Trust’s response and made additional complaints about delay in placing Mrs U’s EEG results on her records, the care of the ankle wound, the development of MRSA, and the arrangements for the May 2003 out-patient appointment. A local resolution meeting took place in June 2004, after which the Trust told Mrs T that some of her complaints had not been answered at the meeting, because they involved Upton. The Trust asked the PCT in July 2004 for a response to the issues that related to Upton, and sent a final response in October.
Complaint to the Healthcare Commission
Mrs T then complained to the Healthcare Commission (the Commission). Because Mrs U’s medical records were confirmed as lost by the Trust, the Commission could only view the limited records from Mrs U’s GP and the Royal Brompton Hospital. Its subsequent report to Mrs T addressed all of her complaints, apart from the appropriateness of carrying out a 24-hour ECG test when Mrs U was immobile. The Commission upheld a number of Mrs T’s complaints and recommended that the Trust review their policies and systems for booking follow-up orthopaedic appointments and tracking clinical records.
What we investigated
Mrs T complained to the Ombudsman in January 2007 that she had not received adequate explanations about Mrs U’s care and treatment from the Trust, the PCT and the Commission. She was also concerned that the Commission could not make findings in some areas because of the loss of Mrs U’s medical records. Mrs T wanted to know what had gone wrong with Mrs U’s care and treatment and wanted the Trust ‘taken to task’ for the delays in investigating her complaint and for losing the medical records.
Because of the loss of Mrs U’s medical records, we decided to investigate the substance of Mrs T’s complaints against the Trust and the PCT, as well as the Commission’s handling of her complaint. We investigated ten issues of concern to Mrs T which were that:
- the Trust delayed diagnosing Mrs U’s cardiac problem;
- the Trust inappropriately prescribed an anticonvulsant, which was not monitored or stopped when Mrs U was diagnosed with cardiac problems;
- the Trust delayed placing Mrs U’s EEG results on her medical notes;
- the Trust and PCT failed to cancel Mrs U’s May 2003 appointment;
- Trust and PCT staff failed to examine Mrs U’s broken ankle at regular intervals;
- a 24-hour ECG was carried out on Mrs U when she was immobile;
- Mrs U’s ankle wound became infected with MRSA;
- the Trust lost the medical records during the Commission’s investigation;
- the Trust’s investigation of Mrs T’s complaint was unhelpful and slow; and
- the Commission’s investigation and explanations were unsatisfactory.
The only clinical evidence available was contained in letters from the Trust and PCT to Mrs U’s GP, and the records relating to her treatment at the Royal Brompton Hospital. Limited clinical information was contained in the Trust’s letters to Mrs T. We took clinical advice from a Consultant Physician and a Senior Nurse, both with expertise in the care of older people. The guidance we took account of included the National Service Framework for Older People (March 2001), and the NHS Modernisation Agency’s Essence of Care (revised in April 2003).
What our investigation found
There was no evidence before late August 2003 that Mrs U had any significant cardiac problems, that her early treatment and investigations were inappropriate, or that she had a cardiac problem from the outset that was undiagnosed. The Epilim Chrono should have been stopped when her heart condition was identified. The Trust said that the prescription was reviewed at that point but, if so, that did not explain why the prescription continued for a month. A delay in placing Mrs U’s EEG results on her medical records may have contravened the NHS code of practice on records management, but we could not say more without seeing the records. In any event, a delay would not have been clinically significant.
There was evidence that Upton had cancelled Mrs U’s May 2003 appointment, and that she had not been removed from the clinic list. The Trust explained that they would not have made a further appointment automatically because Mrs U remained under the care of Upton, which would have indicated the timescale for a follow-up review upon discharge. A review appointment was said to have been arranged for 15 September at the request of the ward staff, but we could not confirm that. The failure to arrange a follow-up appointment for the plaster cast to be checked was a significant failing. As Mrs U was transferred to Upton shortly after surgery, responsibility for carrying out the appointment lay with both the PCT and the Trust. We could not be certain what checks were carried out and when, but the cast was not removed until over a month after surgery. These facts, taken with Mrs T’s account that Mrs U had complained of pain and a smell coming from her cast, strongly indicated that the checks were inadequate.
It was not inappropriate to carry out the ECG test when Mrs U’s movement was restricted, as the results would show the same heart rhythm and rate. Without the records we could not comment definitively on the testing for and management of the MRSA infection, but the screening and isolation procedures appeared reasonable. The loss of Mrs U’s medical records was a serious failing which had significant consequences for the investigation of Mrs T’s complaints by both the Commission and the Ombudsman. The Trust’s responses were slow and often contained little information, with few apologies or explanations for the delays. Mrs T was not told by the Trust until late in the proceedings that Upton was managed by the PCT.
The Commission’s investigation was reasonable. It was slow to conclude, but that was partly because of matters beyond its control. The delays, in themselves, did not amount to maladministration. The Commission failed to address Mrs T’s question about the 24-hour ECG test, which was unhelpful; our investigation has remedied that injustice.
What injustice flowed from the service failings and maladministration identified? The failure to examine Mrs U’s ankle appropriately led to her developing an ulcer; the failure to monitor her prescription following the diagnosis of her heart condition meant that she may have taken the drug for longer than necessary; and the loss of the clinical records deprived Mrs T of comprehensive answers to many of her complaints. The Trust’s poor complaint handling meant that she did not receive a satisfactory resolution locally and had to involve the Commission and then the Ombudsman, causing additional inconvenience and delay.
We concluded our investigation in November 2007, and upheld Mrs T’s complaints against the Trust and the PCT. We did not uphold her complaint against the Commission.
Outcome
As a result of our recommendations, the Trust:
- re-examined the monitoring of Mrs U’s medication and gave Mrs T an explanation;
- reviewed the handling of Mrs T’s complaint and informed her about how the lessons learnt from this case were used in their review of their complaint handling process; and
- apologised in writing to Mrs T for the failings in their complaint handling.
In addition, the PCT provided Mrs T with an account of the lessons learnt from the failure to examine Mrs U’s ankle wound in an appropriate and timely manner.
Principles for Remedy
The Principles for Remedy were not referred to in our report but this case summary serves to illustrate the following Principles:
- ‘Putting things right’ (considering fully and seriously all forms of remedy, such as an apology and explanations).
- ‘Being customer focused’ (understanding and managing people’s expectations and needs).
- ‘Seeking continuous improvement’ (using lessons learnt from complaints to ensure that maladministration or poor service is not repeated).
