Part 2 - Complaint about University Hospital Birmingham NHS Foundation Trust (the Trust) and the Healthcare Commission (the Commission)
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Complaint about the care and treatment of an elderly patient with Alzheimer’s disease and coeliac disease following an admission for planned surgery, and complaint about the Commission’s subsequent review
Background to the complaint
Mr L, aged 79, lived in a nursing home and had Alzheimer’s disease (he was not able to communicate) and coeliac disease (he required a gluten-free diet). In December 2005 Mr L was admitted to Selly Oak Hospital (the Hospital) for surgery to remove a squamous cell carcinoma lesion (a common type of skin cancer). The referral letter to the Hospital explained about Mr L’s medical conditions and that he needed assistance with eating and drinking. The operation, which was successful, took place on the day after Mr L’s admission. Eight days after the operation Mr L was discharged and returned to the nursing home by ambulance.
The complaint to the Trust and the Commission
Mrs L, Mr L’s wife, complained to the Trust in January 2006 about Mr L’s discharge arrangements, lack of adherence to his dietary requirements, the decision to send him for surgery when she was not present, and the administration and prescription of drugs on discharge (medication was prescribed in the wrong form and other medication could not be dispensed due to an error on the prescription). She said that an inexcusable lack of consideration by the Trust had caused Mr L great distress. In February 2006 the Trust offered a number of explanations and apologised for the inconvenience and distress caused and said that in the light of the complaint they had looked at discharge planning in general, with emphasis on older vulnerable adults who might have communication difficulties.
Mrs L complained again, met with the Trust in April 2006 and received a further written response in June 2006. The Trust acknowledged and apologised for several errors, including: the failure to order gluten-free meals; Mr L being unable to take anti-sickness medication as it was prescribed in the wrong form; and failure to dispense medication due to wrong information on a prescription.
In July 2006 Mrs L complained to the Commission which, in September 2006, asked the Trust to provide Mrs L with a response to outstanding issues, which they did in November 2006. Mrs L complained again to the Commission, but it decided to take no further action.
What we investigated
Mrs L complained to the Ombudsman, in February 2007, about the care and treatment provided to Mr L, in particular:
- that the Hospital did not pay sufficient attention to her husband’s mental state, allowing him to be taken into theatre for surgery and later discharged back to the nursing home without her being present;
- that Mr L was not provided with gluten-free meals during his time in the Hospital, despite the fact that the staff knew about his nutritional needs, and Mrs L was forced to bring food in for him herself; and
- that Mr L’s medication on discharge was wrong, in that he was not given anti-nausea drugs to prevent travel sickness and that his medication was not provided in a soluble form, despite his difficulties with swallowing.
Our investigation considered Mrs L’s complaints against the Trust as well as the Commission’s subsequent handling. We had access to all relevant documentation including Mr L’s medical records and the complaint correspondence. We also took clinical advice from an adviser with expertise in the nursing of the elderly.
We also took note of the relevant standards relating to clinical care and the treatment of older people. Of particular relevance were the National Service Framework for Older People (2001) and the NHS Modernisation Agency’s benchmarking tool ‘Essence of Care’.
What our investigation found
- Mr L was caused avoidable distress by the failure to ensure that his wife was present when he was taken for surgery and when he was discharged. There was a lack of awareness of his needs arising from his Alzheimer’s disease, because of the failure to adequately assess him upon arrival, the lack of a personalised care plan, and the failure to begin discharge planning at an early stage.
- The Hospital failed to provide a suitable diet for Mr L, despite being told in advance of his needs. It was unreasonable that Mrs L was placed in a position where she felt she had to bring food in from home for her husband, incurring expense and inconvenience. Hospital staff had then accepted this situation without trying to rectify the failing or provide assistance.
- There was unacceptable confusion over Mr L’s medication, which meant that he was given tablets despite his difficulties with swallowing, was prescribed the wrong medication on discharge, and then did not receive the medication because of an error.
- The Commission’s investigation of Mrs L’s complaint was poor. There was little evidence that an objective investigation was carried out and no clinical advice was passed on to Mrs L about the standard of care and treatment provided to her husband, or about the adequacy of the Trust’s proposed initiatives to address the problems.
The investigation concluded in September 2007 and we upheld Mrs L’s complaints against the Trust and the Commission.
Outcome
As a result of the Ombudsman’s recommendations, the Trust took a number of actions, including:
- the production of ‘All about me’ (a document aimed at improving communication with patients and those caring for patients with dementia, head injuries and learning difficulties);
- the development of a discharge care plan checklist to ensure safe and timely discharge from hospital with provision of relevant information to patients and families;
- a range of dementia training and the nomination of an ‘older people’s champion’ in each ward or department to review the service in that area;
- a review of the Trust’s guidelines about communicating with carers and relatives;
- a successful bid to re-establish the post of Trust Mental Health liaison nurse;
- annual benchmarking of the suitability of wards to care for older people with mental health needs;
- an offer to include Mrs L’s experience in the Trust’s training programme; and
- nutrition link nurses to highlight the nutritional needs of older people and special diets.
As a result of the Ombudsman’s recommendation the Commission wrote to Mrs L to apologise for the deficiencies identified in its review.
