23rd March 2012

Dear Mr Kinloch
Following correspondence received by the Trust from the Parliamentary Ombudsman, I am sorry that you feel that previous correspondence from the Trust and meeting with Sister Fearn (Ward 16) and Mrs Gardner (Patient Advice and Liaison) has not answered all your concerns satisfactorily.

I have reviewed all the previous correspondence from members of the Stroke team and discussed your concerns further with Dr Chadha and Sister Fearn.

For ease of reference, ! have highlighted in bold text each of the main issues I identified in your letter of complaint, which I have considered during the course of my enquiries. This is followed by my response.

Was the Medical Management of Mr Kinloch's condition appropriate?

On review of your medical notes, I can see you developed early signs of a stroke on the weekend of the week ending 6 April 2010. Your GP reviewed you on the 7 th April 2010 and referred you to the Medical Assessment Unit, as he was suspicious that the symptoms you described from the weekend fitted those of the acute onset of a stroke. In relation to the FAST campaign, it encourages people to act quickly when they initially start with the early signs of a stroke. The reason for early recognition is that a treatment called thrombolysis can be given to reduce the impact of stroke. However, this treatment must be initiated within 3 hours of the symptoms commencing. Thrombolysis is a treatment administered to patients who have experienced an ischaemic stroke (where the blood supply to part of the brain is reduced by a clot) and the damage is often referred to as an infarct (damage to the tissue caused by blood clots obstructing the arteries which supply blood to the brain).. The window period for administering Thrombolysis treatment is three hours from the onset of the stroke symptoms.

Unfortunately, in your case I can see that your initial symptoms had started over the weekend and you did not attend the Hospital for review until the 7th April 2010 following referral from your GP. The thrombolysis treatment that is available must be started within 3 hours of symptom onset, if the patient meets the thrombolysis criteria. Patients who attend after that 3 hour period are unable to receive the discussed treatment

On admission, a CT scan was requested which I understand was carried out on the 7th April 2010 which did not indicate any intracerebral abnormality and therefore a MRI and MRA (a scan carried out with a special dye to make the blood supply standout on the scan) were requested. This was carried out on the 8th April 2010 and indicated an area of damage in the left cerebella hemisphere (are of the brain) which would account for the symptoms that you had over the weekend and on the day you saw your GP. The cerebellum is the part of the brain that relates to balance, muscle tone, and movement of muscles. The scan also indicated atheroma (Atheroma - degeneration of the walls of the arteries due to formation of fatty plaques. This limits blood circulation and increases the risk of blood clot formation. The principal causes of Atheroma include a diet rich in fatty foods, sugar, cigarette smoking, obesity) of the left carotid artery. There was also atheroma in the right carotid artery. Any blockages or restriction to blood flow such as these increase the risk of blood clot formation resulting in a stroke.

I understand that when Dr Chadha reviewed you on the Medical Assessment Unit on the 8th April 2010 he revised your medication accordingly and organised further investigations, which included a scan of the carotid artery. Dr Chadha requested transfer to the Stroke Unit once a bed was available. Although we do have a dedicated Stroke Unit at Doncaster Royal Infirmary, where the aim is to transfer all patients with newly diagnosed or suspected stroke, on occasions the demand on the service is more than the beds available. On these occasions, patients may remain on the Medical Assessment Unit until a speciality bed is available, however the Stroke Unit do on these occasions outreach to the patient. This means that patients are still reviewed by the Stroke Clinicians, Specialist Nurse and appropriate therapists. I can see from reviewing your notes that you were reviewed again on the 9th April 2010 by the Stroke Nurse Specialist, Medical Registrar, Dr Chadha and the Neurophysiotherapistand that you were transferred to the Stroke Ward at around 22:25 that evening. Dr Chadha advices that when he reviewed you at approximately 13:00 he felt your stroke was still evolving but that nothing differently could be done to halt the stroke, as you were already receiving optimum treatment.

I understand that your clinical observations remained stable on the 10th April 2010, however on the 11thApril 2010 you had developed a new right sided weakness. The Stroke Nurse Specialist discussed this weakness with Dr Chadha, who advised that you be commenced on medication to reduce the risk of blood clots in the legs, as your mobility would be further diminished by the worsening stroke. This medication is an injectable drug called clexane which is administered to thin the blood reducing the further risk of blood clots developing

Dr Chadha advices that you continued to show symptoms of dizziness, nausea, unsteadiness and anxiety which are all expected features of the stroke and the part of the brain affected. The treatment you were on as your stroke evolved is the recommended treatment. The Thrombolysis treatment cannot be given with an evolving stroke or in patients who have had a recent stroke, as there is a high risk of haemorrhage (bleeding) and more extensive damage to the brain.

I am sorry to hear that you did not feel that your evolving stroke was managed appropriately, however wish to assure you that this was not the case. Dr Chadha recalls having several discussions with you about your condition and the treatment administered, however I apologise if the treatments that could not be administered were not discussed with you in sufficient detail at that time.

Why did the nurse on Ward 16 tell me there were no Doctors to see me over the weekend and I would have to wait until Monday?

I understand that following transfer to ward 16 your neuro observations were recorded four hourly, these observations included monitoring of pupil size, response to voice and ability to move limbs. This allows monitoring of the affects of a stroke. Other observations including your blood pressure were also monitored on a regular basis as indicated. On the morning of the 11th April 2010, one of the Stroke Nurse Specialists reviewed you on the ward and noted that you had reported further weakness on the 10th April 2010, which was intermittent and noted that your observations remained stable. This then prompted a review by the on call medical Dr and a telephone consultation with Dr Chadha, who advised the commencement of clexane, further blood tests and possibility of the need to do a further MRI scan, following review by Dr Chadha the next day. The clexane and the blood tests were initiated straight away.

Sister Fearn offers her apologies if you felt that the nurses were not responsive to your concerns about your worsening symptoms which were part of the stroke evolving. Rather than informing you that no Stroke Doctors were available they should have explained the nature of your symptoms and how strokes do evolve. Please be assured that there are Doctors available 24 hours a day over the weekend period to review any patient who the nursing staff feel requires a medical review on the Stroke Unit. The Stroke Nurse Specialists also cover the weekend period and will liaise with the On Call Medical team or one of the Stroke Consultants at home if they feel a patient requires further review, before the Specialist team ward round on a Monday morning.

I understand that the second MRA planned for the 14th April 2010 scan was delayed until the 6thApril 2010, due to transport issues across to the MRI unit at Bassetlaw Hospital. However, this did not affect the treatment you were already receiving; the MRI was to confirm the extent of the evolving stroke and to rule out any non-stroke related problems. I can understand how anxious you must have felt waiting for a further scan and apologise that a delay did occur in relation to the second MRA scan.

Why does the Stroke service only run Monday to Friday 9 - 5pm?

The stroke service at Doncaster Royal Infirmary is a 24-bedded unit, which provides patients with 24 hour nursing care. The Stroke Medical team which includes two Doncaster based Consultants who work Monday to Friday. However, access to the Stroke Clinicians at weekends and out of hours was available at that time for advice. The service is also supported by three Stroke Nurse Specialists Monday to Sunday and support from the On Call Medical team out of hours and over the weekend period. The Trust has more recently led a pilot service called telemedicine whereby Stroke Consultants from across South Yorkshire including our team provide an out of hour's consultation service to support the diagnosis and treatment of patients presenting with early onset stroke symptoms. The system allows a consultation to take place from a designated treatment area that is tele linked to the on call Consultants place of residence. The on call Consultant reviews the patient and any investigations including scans and blood tests, whilst the on site Medical Registrar and Stroke Nurse perform the required physical examination. Patients who then fit the criteria for Thrombolysis are commenced on the appropriate treatment and monitored accordingly. This new pilot service improves access to Specialist Stroke Clinicians out of hours and the timely access to the thrombolysis treatment if the patient meets the required criteria.

Why was ! abandoned on the Ward when I was first admitted to the Hospital?

Once again I am sorry to hear that you felt abandoned when you initially admitted to the Medical Assessment unit as this clearly was not the intention to make you feel this way. The Medical team had clearly commenced a management plan which included CT scan and blood tests and the nursing team carried out the required vital signs observations and I understand you were transferred around 4pm from the assessment bay into the main MALI ward area and a CT scan was undertaken. From the nursing documentation, I can see that your observations were carried out at regular intervals and as your stroke symptoms progressed, your neuro observations were carried out accordingly.

The patient flow process on MAD has been revised in the past 18 months, which ensures patients are assessed in a more timely manner and admitted to one of the three nursing teams as soon as possible. This allows the admitting nurse to have more detailed discussion with patients about the medical and nursing plan of care, answer question or queries in a more proactive manner and liaise with relatives as needed. Being admitted to Hospital is a very daunting and stressful time and by ensuring nurses interact early with patients and relatives early ensures effective communication and can reduce the anxiety that goes with an emergency admission.

Why was the nurse on ward 16 so unhelpful when my wife made enquiries about my condition?

Sr Fearn has discussed your concerns at length with the Staff Nurse on duty when you were transferred to Ward 16 and I understand has offered her apologies to both you and your wife for the way in which the member of staff interacted with your wife.This is certainly not the way in which Sister Fearn or myself expect any of our Registered Nurses to interact with patients or relatives and agree that the unhelpful attitude of the staff nurse was unacceptable.

The staff nurse concerned has reflected on the way she did speak to your wife and acknowledges that she came across in an abrupt and unhelpful manner, which although she was busy was unacceptable. She wishes to offer her apologies for any distress this may have caused your wife. On relfection, the staff nurse is aware that what she should have done was to offer to go and review your notes and then have a discussion with your wife about the medical plans in place, rather than reacting in a defensive, unhelpful manner. Sister Fearn has already following your meeting, had a discussion with all her staff about effective communication with patients and relatives, particularly on transfer from another ward or on admission when anxieties are increased. Sister Fearn wishes to assure you that following your meeting she engaged with her team and shared your concerns to ensure they realised how behaviours may be interpreted by patients and relatives. Sister Fearn does and will continue to challenge and address inappropriate attitude within her team.

Why was there a delay of 9 days in getting a MRA scan?

From reviewing your Clinical Notes, I can see that you had a CT scan of your head carried out on the afternoon of your admission on the 7th April 2010. The following day on the 8th April 2010 you had further imaging undertaken which included a MRI scan and a MRA scan (MRA - images that are enhanced by radiological dye - copy enclosed). A further scan was planned for the 14th April 2010 at Bassetlaw Hospital (copy enclosed). I understand there was a delay in you having the MRA scan on the 14th April 2010 until the 16th April 2010. This was due to a fault within the MRI suite on the Doncaster site, and was further compounded by transport difficulties, however I understand this delay did not affect your treatment as the most appropriate treatment was already in place for your condition. I do acknowledge that this untimely delay did understandably increase your anxiety and I understand Dr Chadha apologised for the delay at the time.

I am sorry to hear that your felt that Dr Chadha had not considered your dignity when he discussed your scan reports with you and his junior clinicians. Dr Chadha certainly did not intend to cause you any embarrassment or upset and was merely trying to show you with use of the scan images the part of the brain affected by the stroke. Dr Chadha does always endeavour to discuss scan results with his patients as it helps most patients to begin to understandthe affects of a stroke and apologises if the way in which he did so offended you in any way.

Once again, I am sorry that you feel that your medical condition was not treated as appropriately as you feel it should have been. On referral to the Medical Assessment Unit the early symptoms of a stroke and been progressing over the weekend and therefore you were unable to have the Thrombolysis treatment that can be given within 3 hours of onset of symptoms to try and reduce the impact on the brain. A CT scan was carried out and you were commenced on the appropriate medication to reduce the risk of further blood clot formation in the arteries. Further scans were carried out on the 8th April 2010, which included a MRA & MRI scan. These scans showed tissue damage to the brain and atheroma. Your symptoms did worsen which is not unusual in patients who present with a stroke as the damage caused by the stroke continues to evolve, however at this time you were already on the most appropriate treatment and Multi Disciplinary Team care was in place. As the effects of the stroke continued, you were commenced on further medication that reduce the risk of blood clot formation and a review MRA scan.

The second MRA scan showed as Dr Chadha had expected further tissue damage to the left side of the brain and some extending to the right side. Dr Chadha advices that the treatment you received for this evolving stroke was appropriate and that you were unable to receive thrombolysis treatment as longer than 3 hours had elapsed since the onset of your symptoms. The short term and long-term affects of a stroke are life changing and I can fully understand your frustration at the long-term affect this condition has had on you and your family. Dr Chadha is more than happy to meet with you and your family to discuss any of your concerns relating to the medical management of your stroke if you would feel this would be beneficial.

I would like to thank you again for bringing your issues to our attention. I hope my letter has addressed the concerns you raised to your satisfaction.