Elderly stroke victim left without food and water for 20 hour spell
By JOHN ROBERTSON
An elderly stroke victim confined to a wheelchair and unable to speak went without food or water for 20 hours after delays in getting treatment for her in the Gilbert Bain Hospital.
An ambulance was only despatched to take Eileen Renwick from the Edward Thomason House care home hours after it was ordered by a doctor, and was then unable to take her in her motorised wheelchair. She had to be laid on a stretcher instead. By the time she had been treated by a surgeon and returned home she was becoming dehydrated.
Two weeks later, after Mrs Renwick had been back to the hospital again, her husband Stan was told she would be kept in overnight and went off to get her clothes. But during his absence she was discharged by taxi and taken to the wrong address, causing her considerable distress because she could not speak.
The catalogue of errors did not end there – when Shetland NHS Board later arranged for her to go to hospital in Aberdeen for an operation she was booked to go on her own on a normal scheduled flight until her husband complained and she went by air ambulance instead with him to help her.
This week the Scottish Public Services Ombudsman forced the board and the Scottish Ambulance Service to apologise to the woman’s husband for their shortcomings and have agreed to implement a series of improvements to prevent a repeat of the episode.
Public exposure of the poor treatment of a patient by the board and the ambulance service will further damage their reputation in the wake of other high-profile failings which have come to light.
Yesterday Shetland NHS chief executive Sandra Laurenson declined to say whether any members of staff had been disciplined as a result of the board’s internal investigation into what went wrong, saying only that “a number of specific actions” had been undertaken.
An apology was made to Mr Renwick some time ago but she said she would be writing another letter in the next few days.
The ombudsman’s 14-page report into the affair states that Mr Renwick had made five specific complaints to the ombudsman, all of which have been upheld and are now accepted by the board and ambulance service as failings.
His wife suffered a severe stroke in 2004 which left her paralysed and unable to speak or swallow. In June 2006 the tube through which she had to be fed became blocked during the night at her care centre. The next morning two district nurses could not clear it and a doctor at the health centre was contacted. He asked a health centre receptionist to order a routine ambulance to take Mrs Renwick to Accident and Emergency at the Gilbert Bain.
The ambulance service’s medical dispatch centre in Scotland did not alert the ambulance until nearly four hours later, even though the ambulance was idle for 40 minutes at the time it was requested and could have gone immediately.
The ombudsman reported: “For some reason the dispatcher has held on to the job and then other, higher priority jobs, had come in. Staff had been made aware of the need to allocate jobs quickly following this incident.”
All GPs in Shetland have now been told that if a patient has a feeding tube blockage which is not sorted out after eight hours, as was the case with Mrs Renwick, they should upgrade their ambulance request to “serious” rather than routine.
When the ambulance was alerted it arrived to pick up Mrs Renwick within 50 minutes but could not take her motorised wheelchair and there was a further short delay while she was put on a stretcher. By the time she arrived at hospital she had gone over 17 hours without food or liquids. She had to wait another hour and a half before she was seen by the surgeon and longer before she got home. A professional medical adviser to the ombudsman said there was no reason why Mrs Renwick should not have been given liquids in some other way, perhaps even by a drip and there was time for that to have been done while she waited for the surgeon. “The fact that it was not considered suggests a poor assessment by staff at the time of … admission to Accident and Emergency.”
Miss Laurenson told the ombudsman that staff in the unit had since been reminded of the importance of assessing and recording when patients last had food or fluids, particularly those unable to communicate for themselves, like Mrs Renwick.
When she was ready to go home there was no transport available because the non-emergency patient transport van had stopped work at 5pm. Her husband had to find and pay for a specially adapted taxi to take the old-fashioned wheelchair that the hospital had lent for Mrs Renwick to get home.
As a result of the complaint the board has extended the hours of patient transport and can call on the emergency ambulance or a standby service outside those hours. Mr Renwick was offered a refund for the taxi fare but said he just wanted the board to sort the system out. When Mrs Renwick was admitted again two weeks later after another tube blockage she was sent home in a taxi to the wrong care home. The Shetland NHS has not been able to find out how that happened but has tightened up its procedures and put a new travel arrangements system in place.
The ombudsman said: “It must have been frightening for an elderly person, unable to move or speak, to be taken to the wrong place.”
A month and a half later Mrs Renwick had to go south to hospital to have her feeding tube replaced. She was expected to make her own way to the airport and travel on a normal flight without an escort. Her husband had to intervene and get a GP to sort the fiasco out.
Miss Laurenson told the ombudsman the staff at the care centre had failed to give the patient travel service all the details about Mrs Renwick that they should have done to enable appropriate travel to be arranged. A new system has since been put in place which requires the patient travel service to ask about care needs when taking a booking for a patient from a care centre and for care centre staff to give full details.
The complaint has taken two-and-a-half years for the ombudsman to investigate and report on. The delays were for a variety of reasons and the ombudsman has apologised to the family, the board and the ambulance service.
Miss Laurenson said the board took complaints very seriously and if anybody got a service which was not up to standard they would take steps to resolve it. “This happened in 2006 and we have put in place the majority of the actions to resolve it, some of which were recognised in the report, including working with the Scottish Ambulance Service. On a personal level I am really very sorry if the service does not meet people’s needs at any time.”
Her board has not asked for a report on the specific case and if it did she would produce one. There will be a report on the ambulance issue at the board’s meeting next month.
A spokesman for the ambulance service said it had apologised to the family and had implemented the ombudsman’s recommendations for improvements.
Last month the lack of a second ambulance led to an injured teenage driver having to wait two hours after his car crashed off the road and down an embankment at Levenwick. Last year a hospital porter turned up in his car at Sandwick to take Alan Woodworth to the Gilbert Bain an hour after his wife had twice call 999 to say he was having a heart attack. The ambulance service, although a separate board, is part of the NHS.