Home > Publications > Selected Cases > Selected Investigations Completed AugustNovember 2002 > Foreword
This volume contains reports of 63 investigations completed between 1 August and 30 November 2002. The short reports include several significant cases, which are reported in some detail; other cases appear as short summaries. This time none of the investigation reports is published in full. Three important cases (E.814/00-01, E.208/99-00 and E.1626/02) are included in this volume in summary form for the sake of completeness. The full texts were published in my report on NHS funding for long term care on 20 February (HC 399).
Many of the cases I see provide graphic illustrations of the ways in which poor communication contributes to, or causes, problems which may result in sub-standard care and treatment being given to a patient. This collection of cases is no exception. The lack of communication between medical and nursing staff and with patients and their carers, or delays in providing the results of investigations to the relevant medical team all feature in these investigations.
One investigation into a complaint that an elderly confused patient was in effect “lost” by the medical team after his admission over the weekend (>E.1511/01-02) revealed major failures in communication. In spite of his son’s many telephone calls asking for his concerns to be passed to the medical team, and repeated requests from nursing staff, the patient was not seen by a doctor until he suffered a seizure three days later.
Another investigation (E673/01-02) revealed a disregard for a patient’s post-operative communication needs when, unable to speak or use a call button, he was placed at some distance from the nursing station. In addition, the nursing records did not include information on the patient’s special needs and how they might affect his recovery. A further failure in communications occurred when his condition deteriorated and staff failed to contact his parents immediately. This added to the family’s distress.
One investigation (E.2110/00-01) involved both failures in communication and the related issue of lack of informed consent. The patient signed a consent form relating to the minor surgery which she expected to undergo. In the event a much more extensive procedure was carried out. I found that every member of staff who had seen the patient between her clinic appointment and the subsequent operation inferred, wrongly, that she had understood and consented to the more major procedure. Another case (E.1986/00-01) turned on the importance of ensuring that a patient was fully aware of the risks associated with repeated operations to try to alleviate a worsening problem. None of the doctors involved had given the patient sufficient information to enable her to make an informed choice about her treatment. In this case I recommended that the trust audit their performance on obtaining informed consent against the standards set by the NHS and the General Medical Council.
The lessons to be learned from these investigations are simple ones: taking the time to try to make sure that patients and their families understand all the information available to them, sharing information between professionals, and making contemporaneous records are all fundamental to the care of patients. Communication matters. Otherwise an enormous amount of time can be spent dealing with the consequences of failure.
Ann Abraham
Health Service Commissioner for England
March 2003
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