"Poor care of my elderly relative"

About: Inverclyde Royal Hospital / Respiratory Medicine Inverclyde Royal Hospital Respiratory Medicine PA16 0XN

Posted by ElizabethNHS (as a relative), 8 years ago

93 year old frail relative was admitted to Inverclyde Royal Hospital in Feb 15 with a chest infection. Our relative also suffered from other health conditions. After an acute phase in the main hospital our relative was transferred to the Larkfield Unit for rehabilitation. The care our relative received there was very poor, After an inpatient stay of approx six weeks unfortunately our relative passed away. This was not altogether unexpected. We did voice our concerns to nursing staff when issues occurred at the time. One of the doctors in charge we felt really was not interested in speaking/helping us, however we were very concerned with so many aspects of the care that we requested a copy of the case notes.
Without going into detail we had major issues with personal care (no bath/shower given to patient for the full 5 weeks of his inpatient stay),
oral hygiene was neglected -teeth were obviously not cleaned on a regular basis.
After referring to the case notes we also noted pressure sore chart completed incorrectly.
nutrition- first seen by dietitian 14 days after being admitted to the unit- weight loss during the inpatient stay was greater than 10% in a short space of time. Our relative was not eating/drinking enough. We feel that staff, were aware but Did not escalate the problem, however recorded it in the notes regularly with no action.
A Dieteticn review recommended a prescription of high energy drinks- this instruction was ignored for three weeks despite being recorded in the clinical notes and nursing notes and was only rectified when the dietician realised the mistake .As a family we were unaware of this major error at the time. This error in our opinion definitely hastened death. Despite major weight loss and poor oral intake nobody bothered to implement the instruction to commence drinks and they were not prescribed. We believe this would have given an extra 500calories per day.
Fluid balance charts / food charts were completed to such a low standard it was embarrassing. No evidence of any senior nurse "signing off" these “ complete” charts.
Medicine administration-often as relatives we found tablets on the bedside table not ingested, however they had been signed as given by the nursing staff. Patient was also severely dehydrated however a diuretic continued to be offered and no review of my relatives medication appeared to take place. Also, digoxin levels were not taken..
Observation charts- near end of life - mews scored as 4 (which means four hourly obs-) was checked at 17.20 . next checked 34 hours later! ! ) unacceptable.
Death certificate- delay of 36 hours to obtain said document, and then no cause of death was entered. This caused more distress and delay when registering the death.
This summary is very brief, and we had many more issues.
Our first letter of complaint was submitted to Greater Glasgow and Clyde and acknowledged in early June 15( before we had reference to the case notes). The reply (mid August 15) (delayed and in breach of the guidelines) acknowledged some of the poor standards of care. After receiving and reading the notes I was appalled by the extremely poor level of documentation spanning the complete length of his inpatient stay.
I was so concerned I really believe that it constituted basic institutional neglect that we submitted a further letter of complaint which lead to a face to face meeting with a panel of representatives from the hospital in October where they agreed that poor care was delivered. The written minutes from this meeting have still not been made available to us at the time of writing today.”
Lessons must be learned from this.

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Responses

Lorna Fairlie

Patient Experience, Public Involvement Project Manager,

NHS Greater Glasgow and Clyde

I work in a small team in NHS Greater Glasgow and Clyde which seeks to involve patients and carers in the work of the NHS. The biggest part of my role is in managing feedback projects across the Board area, one of which is Patient Opinion. It is my job to give our patients and carers the opportunity to give us feedback, and to make sure that this is passed to the right people to help us improve the services we provide.

Submitted on 17/12/2015 at 16:58

Published on Care Opinion on 18/12/2015 at 09:29

Dear ElizabethNHS,
First of all, I’d like to say how sorry I am to read this. I know that this will have been, and continues to be, an extremely difficult time for your family. Your story has been shared with the Director of Nursing for NHS Greater Glasgow and Clyde, Mags Mcguire, amongst others. We will ensure that the delays you have experienced so far are addressed and that the notes of the meeting you refer to are with you as soon as possible.
The General Manager for Older Peoples services and Director of Clyde Acute Services, would also like to acknowledge your post and the wide ranging concerns you have raised regarding the care provided whilst your relative was in the Larkfield Unit, Inverclyde Royal Hospital.
You have raised a range of concerns relating to clinical care and communication and a meeting was arranged in October 2015 to discuss these in more detail with members of the clinical team. We know that the note of this meeting has been delayed and I must apologise for the further distress that this delay has caused.
The clinical team has agreed to undertake a further review of your relative’s care to review clinical care and treatment and supporting documentation, as well as to ensure that lessons are learned and improvements made to patient care and in involving carers. By doing so, we want to provide the very best care for all of our patients and ensure that no other family experiences what you have.
The clinical team will be in contact with you to discuss the written outcome from this clinical review and feedback the findings and actions that will be adopted within the service to make improvements in any area identified.
We will be in touch directly as soon as possible – in the meantime my thoughts are with you and your family.
Best Wishes,
Lorna

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Update posted by ElizabethNHS (a relative) 8 years ago

Dear Lorna,
yet again as a family we have been let down by the NHS. This time by the complaints process. Your response above - quote-
"We will ensure that the delays you have experienced so far are addressed and that the notes of the meeting you refer to are with you as soon as possible." promises everything. Empty promises. We are still waiting on the response from the face to face meeting which took place at the end of October. It is now 1st February 2016. As a family can you begin to imagine how that makes us feel?
When mistakes happen and a complaint is lodged, as an organisation you should be striving to deal with the complaint as efficiently and effectively as possible. Mistakes happen, how you deal with them matter greatly.Yet again, NHSGGC have failed. This again is unforgivable. As a family we are extremely angry at ther continued incompetence. and we think that NHSGGC are hoping we will just give up. How wrong you are. Everything written in the original letter of complaint is true.
Please respond
ElizabethNHS

Craig White

Divisional Clinical Lead, Directorate of Healthcare Quality and Improvement,

Scottish Government

Leadership team supporting improvements in quality across health & care services

Submitted on 02/02/2016 at 14:19

Published on Care Opinion at 14:23

Dear ElizabethNHS
I was very sorry to read of your poor experiences of communication, in particular relating to the implementation of the NHSScotland Complaints process.
I have asked the policy team in Scottish Government to pass on your feedback to the Complaints Standards Authority - because colleagues from there have been working with staff from across NHSScotland to identify areas for change and improvement in the way in which NHSScotland responds to complaints.
I also made some enquiries this morning when I read your posting on Patient Opinion and understand that others have raised this same concern within some other NHS Board areas.
I know that this does not help with the lack of communication and involvement with the review into the concerns you raised, although wanted you to know that I agree with you that this is an area that needs to be looked at, and that I have asked NHS Greater Glasgow and Clyde to prioritise a response to you.
One of the helpful features of Patient Opinion is that alerts are generated when anyone responds to postings, so I will look out for the response and hope that there can be an emphasis on improving the communication - as well as involving you more meaningfully in the review, learning and changes needed to make sure that other people don't have the same experience - with care or with the complaints procedure.
Yours respectfully,
Professor Craig A White
Divisional Clinical Lead, Scottish Government

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Lorna Fairlie

Patient Experience, Public Involvement Project Manager,

NHS Greater Glasgow and Clyde

I work in a small team in NHS Greater Glasgow and Clyde which seeks to involve patients and carers in the work of the NHS. The biggest part of my role is in managing feedback projects across the Board area, one of which is Patient Opinion. It is my job to give our patients and carers the opportunity to give us feedback, and to make sure that this is passed to the right people to help us improve the services we provide.

Submitted on 03/02/2016 at 16:22

Published on Care Opinion on 04/02/2016 at 08:48

Dear ElizabethNHS
I am so sorry for the continued delay you have had and the additional stress that this has undoubtedly caused to you and your family. We know that something has gone very wrong in our communication with you and are urgently looking into this; not only to resolve this for you as is our priority, but to ensure that we do much better for others in future.
I am working to be able to give you much more specific information on what has happened here, but I felt it was important to acknowledge your post and all that it contains as soon as I could. I understand how let down you and your family will be feeling and will ensure this is addressed.
We will back in touch shortly,
Marie Farrell,
Director, Clyde Sector
NHS Greater Glasgow and Clyde

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Update posted by ElizabethNHS (a relative) 5 years ago

I wrote this story in 2015 regarding the very poor care of my relative. With all the responses above, and eventually with the final written report sent to my family, I got some comfort in the knowledge that new processes would be implemented and additional training would be rolled out to staff and hopefully no other patient would suffer like my relative. Imagine my absolute disgust when I read the report issued on the Healthcare Improvement Scotland ( Sept 18) website on the unnanounced inspection carried out within the hospital in July 18 - the inspectors were so concerned at the poor documentation they returned for another unnanounced inspection one month later. Their findings mirrored almost exactly my concerns in 2015. Read the report yourself- quite shocking.

Jacki Smart

General Manager, Clyde Sector,

NHS Greater Glasgow and Clyde

Submitted on 19/11/2018 at 12:15

Published on Care Opinion at 14:10

Dear Elizabeth NHS
Thank you for your updated comments. Health Improvement Scotland (HIS) visited Inverclyde Royal Hospital in July of this year to carry out an older peoples visit. This is something they do on a regular basis for all NHS hospitals in Scotland. Although there were positive comments and observations around patient dignity, patient and staff interaction and patient satisfaction, the team did find areas of patient care mainly around robust documentation and some risk assessments which they highlighted to the Chief Nurse. The main area of concern which required immediate attention was around the timely and accurate completion of our Malnutrition Universal Screening Tool (MUST). This is the tool we use to assess a patients level of nutrition on admission and any support they may require with that. They found that some of our wards were failing at times to complete the required information within 24 hours which is our goal and also that some of the scores were inaccurate and or poorly completed. Both Christina McKay Chief Nurse for Clyde and HIS colleagues agreed this was unacceptable and the Chief Nurse put in place a number of actions to rectify this situation immediately which HIS were satisfied with.
HIS did return the following month to carry out a second visit and commented that we had made improvements between the first and second visits with regards to the fact that the majority of our patients had a MUST assessment completed within 24hours of admission, that there was a significant improvement in the recording of patients actual weights or obtaining alternative measurements and that there was no significant discrepancies in the recording of patients weights.
To say that the nursing and management teams were disappointed with our initial failures with our quality of MUST assessments and documentation is an understatement. I can only imagine how upsetting it would have been to read about this and how it obviously reflected and reminded you of parts of your elderly relatives care. We have continued to work with the ward teams to ensure that the level of improvement with our assessments is continue with weekly reviews of MUST assessments by Senior Charge Nurses and any concerns highlighted to our Lead Nurses and Chief Nurse for immediate attention. This level of scrutiny has now been spread to all hospital within NHSGG+C to ensure consistent good practice.

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