"Poor care of my elderly relative"

About: Inverclyde Royal Hospital / Respiratory Medicine

(as a relative),

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

Response from Lorna Gray, Patient Experience, Public Involvement Project Manager, NHS Greater Glasgow and Clyde

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)

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

Response from Craig White, Divisional Clinical Lead, Directorate of Health Quality and Strategy, Scottish Government

picture of Craig White

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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Response from Lorna Gray, Patient Experience, Public Involvement Project Manager, NHS Greater Glasgow and Clyde

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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