"Record keeping needs work."

About: Angliss Hospital / Emergency Department

(as the patient),

I was taken by ambulance and admitted to the Angliss Hospital Emergency Department after I had a fall which resulted in an injury to my back. The ambulance people were great. I was in a lot of pain and they gave me a “green stick” to inhale which took the edge off my pain. I needed to go to the toilet in the ED and a nurse tried to get me to stand so she could put me in a wheelchair to go to the toilet. I experienced excruciating pain as soon as she tried to put my foot to the ground. I felt faint and had to sit down again. Another nurse told me that I was not to stand until I had seen the physio and doctor. I used a bed pan and it caused a lot of pain as I had to bear my weight to sit up. There seemed to be some confusion about what I could and could not do.

I was sent to have an X-ray and CT scan and moved to short stay. I was told that I had a fracture in my spine and that I needed an MRI because they needed to check if there was any tendon damage. They would take me to Box Hill that afternoon to have the MRI. They just had to wait for a response from the neurosurgeon (at St Vincent's hospital) who had been paged but was in surgery and had not phoned back yet. I had been given some pain relief, but I had not eaten since 6am. I was told I needed to fast in case I needed surgery. Around 1 o'clock I was feeling faint again and realised that I had not eaten since 6am. I was given a cup of tea and a sandwich as I clearly was not going to Box Hill and not having surgery.

In the very early hours of the following morning I was transferred to a ward, given more pain relief and was feeling very nauseous. I had seen so many nurses and doctors in the short time that I was quite confused about who knew what about me. My story for the handover at this time was just my name and that I had had a fall. I was told that before I could get an MRI I needed to see a physio and have a back brace fitted. The physiotherapist came around in the morning and told me she would fit the brace that afternoon. My son came to visit at lunchtime and he was told by the reception staff that I had been discharged. No physiotherapist came in the afternoon. Mid-afternoon I asked where the physio was and they phoned but there was no answer. I found out later that because I had been listed as discharged the physio cancelled the scheduled visit to me.

The nurse said that because of the public holiday that I would not get to see a physio for another few days. Because I had been “discharged” I had no dinner. They said that it was a mistake in the system and the nurse offered me a piece of toast and custard. They did bring me a plate of shredded lettuce, grated carrot, half a tomato and onion and jelly later in the evening. I was given more pain relief and vomited. I had not had a wash or cleaned my teeth, despite asking about this, since the morning I arrived in the ED and this was now the following night.

I was unhappy that I had not had the MRI, hadn’t seen the Physio and now had to wait days before I could get the brace. I asked to see the Charge Nurse who came and she did arrange for me to have soapy water to wash and was able to clean my teeth. I still could not get out of bed and moving was extremely painful. The Charge Nurse said there was not any physio available but tomorrow morning she would get the physio attached to the Emergency Department to fit the brace. She also told me that the nurses get nervous when dealing with spinal injuries which did not reassure me and made me worry more. I also had not opened my bowels since the morning of my accident and felt very uncomfortable. I was told that the medications could make me constipated but nothing was offered to relieve this.

On my third morning at the hospital I was fitted with a brace and they made sure I could walk okay. I was given a frame for a month and discharged. I was given the Patient Discharge information sheet but not asked about it. It did not have any post discharge arrangements, no Medical Certificate, X-rays or CT scan, no medical discharge summary given to me or faxed to my GP, no discharge education or written material provided, no appointment for an MRI and no appointment with the neurosurgeon. I didn’t know what activity I could do and I felt there was no forward plan. I was told that I needed to phone St Vincent’s Hospital to make an appointment with the neurosurgeon but no-one had the neurosurgeon’s name and St Vincent’s would not make an appointment without a name. I was told that the MRI appointment would be sent out to me and I assumed it would be at Box Hill but I was not told this.

I was given prescriptions for medication, but apart from knowing that I could take one of the medication's morning and evening, I didn’t know how much of the other I could take and whether I could take the two together, as well as Panadol and Ibuprofen. I made an appointment with my GP for the next working day. My GP had received no information. The Emergency Department records had been uploaded but nothing else had. My GP requested the X-rays, scans and medical discharge summary to be faxed to the practice. It was unclear about whether I had to make the appointments for St Vincent’s and the MRI or if the Angliss did.

I spent the two days prior to seeing my GP in a lot of pain, working out how I could get to the toilet and get the brace on by myself. My partner worked and there was no-one else home. I could take the brace off to sleep at night but if I needed to go to the toilet in the night I had to get the brace on by myself to get out of bed. This was a nightmare!

A week after my accident I phoned the ward to request:

1. Medical certificate, which I was told would be sent that day.

2. Who the neurosurgeon was and did I need to make the appointment at St Vincent's and also asked about the MRI. I was told they would get back to me once they had found out.

3. A medical discharge summary, which they said they would find and send it to the GP and a copy to me.

4. What movements I could do without hurting myself or causing more damage and I was told to phone the physio department to find out what I could do.

5. Copies of X-rays and scans to be sent to me. I was transferred to X-rays and told the X-rays would be sent that day. (They were and arrived the next day.)

Later that morning I phoned the ward and spoke to the same person who said that they had been busy and needed to go elsewhere to get my file and hadn’t had time. I was told they would do this next and phone me back soon. Later I phoned the Physiotherapy Department to check what movements I could do as suggested. I was told they couldn’t access my files because they had not been uploaded. I was then transferred back to the ward to ask who the physio was that I had seen initially, but the person I needed to speak to had gone to lunch. I was then told that a message would be given to this person and that I needed the information from my files and they would ask this person to phone me back. I phoned back later in the afternoon and was told that this person had gone home and they suggested I try again the following day.

I phoned the following morning and spoke with the person I needed to speak to who told me that the medical summary would be sent to me and the GP, the St Vincent’s referral and MRI referral (at Box Hill) had be sent by the Angliss and I did not need to do this. They did not have a time frame and no forward plan except to wait for the X-ray Department to contact me about the MRI.

I still hadn’t heard anything from Box Hill by the following week and had been told that I would get confirmation straight away so I phoned Angliss again and was put through to Outpatients. I was then told they would try to find out but my records had still not been put on the system. They then suggested I phone the ward to speak to the person I had previously spoken to and gave me the direct number. They also gave me the direct number to phone Box Hill about my MRI. I phoned the ward to speak to the same person I had previously spoken to, but they were not available and it was suggested that I phone back the next morning. I phoned Box Hill MRI and they said that they had not received any request for my appointment. This person gave me the direct fax number for this to be faxed to.

When I phoned the ward to find out what progress had been made, I was told that the request for the neurosurgeon had been made but they had no name of the neurosurgeon. I told this person (the same person I'd spoken each time) that no request for an appointment had been received at the Box Hill MRI Department and this person said that they would do that 'today'. I had not received the medical summary and this person said that it was complete now and they would send it 'today'. I had received the Medical Certificate for work but it had not been filled in and was rejected by my work because it did not say that I was not fit for work or had any of the details filled in so I requested that a new Medical Certificate be sent.

This person said to me that I wasn’t having much luck and asked me did I trip over a black cat? I found this very upsetting and offensive.

I told this person that I did not have any confidence that what they said they would do would actually happen. They said “Yes I can see what you mean. ” I asked to speak to the supervisor and they said the supervisor wasn’t available, but did I want to speak to the person in complaints. I decided to write this letter instead.

Box Hill phoned me within half an hour of receiving the referral with the appointment details. I feel this could have been done over 2 weeks ago. I phoned St Vincent's and they did receive my request for an appointment, but have not phoned back to confirm or to let me know when there is an appointment. I asked for an approximate time frame and was told that they were processing June 2012 now. I asked did that mean it would be 4 years for an appointment and she said it may not be that long, I just had to wait.

I feel that I have been left in limbo now for weeks and the only plan is to keep medicated and in a brace until an MRI is done. Then what? I still have not received a medical discharge summary, a new Medical Certificate ( which my work place is requesting), any confirmation from St Vincent's about an appointment with the neurosurgeon, the name of the neurosurgeon, advice about what movements I am able to do and no forward plan for treatment apart from the MRI.

Responses

Response from Alan Lilly, Chief Executive, Eastern Health

picture of Alan Lilly

Dear Left in Limbo

First of all, please let me say how sorry I am to read your story and to see the extensive list of where things have not gone according to plan or have not been followed-up appropriately for you. I sense your frustration and disappointment in the story and I can see that there are a number of questions to be answered for you (and for me too). I am particularly disappointed to read that you asked to speak to the Supervisor and whilst he or she was not available, you were asked instead if you wished to make a complaint.

Based on what you have written, I am concerned that we have fallen short in a number of areas and I am keen to be able to rectify this for you.

In the first instance, I will send this story to the Chief in charge of Clinical Services at Angliss Hospital, Mr Ben Kelly and ask him to follow-up the matters you have raised some of which can be managed in a generic sense. However, I also think that there are some specific matters which we need to follow-up further for you and if you feel comfortable in doing so, please email me privately at alan.lilly@easternhealth.org.au and I would be happy to arrange a discussion to follow-up each of the specific matters you have raised and to provide you with the reassurance you need.

At Eastern Health, we are committed to using Patient Opinion to help us recognise where we do things well and also, where we need to improve. Your feedback has provided much for us to focus on and I thank you for taking the time to do that.

I do hope that you will make contact with me further as I would very much like to follow-up those specific matters for you but in the meantime, I will be in touch with Mr Kelly. Additionally, you may like to leave a response on this website via Patient Opinion.

Once again, I am sorry that you have experienced our health service in this way and I hope that you can see that we are committed to easing your burden. Thank you for taking the time to share your feedback.

Kind regards, Alan Lilly

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Response from Alan Lilly, Chief Executive, Eastern Health We have made a change

picture of Alan Lilly

Dear Left in Limbo

Following up on my commitment above, I am pleased to report that Mr Kelly has met with his team and collectively, they have agreed on a number of improvements which they are putting in place following you sharing your story on Patient Opinion:

Fasting – this will be reassessed at more frequent intervals. Nurses will consult the Nurse in Charge to investigate probability of transfer/theatre lists; Understanding of the treatment plan – each shift, the primary nurse will ensure the plan is communicated and the patient has a clear understanding of the plan and the rationale. They will also be mindful of using appropriate terminology when discussing the treatment plan with the patient to ensure they have a good understanding and feel included in management plans. Clinical patient handover – clinician to clinician. A clear plan is documented in the medical notes regarding what the patient can/cannot do. (eg can mobilise after brace fitted); Analgesia regime - Staff will ensure an adequate patient understanding of analgesia and what to expect with regard to the pain; Discharge plan – Staff will ensure the patient understands and has a written discharge plan outlining what referrals have been sent. (this currently occurs in ED)

The team also discussed and confirmed guidelines with respect to when and how expert advice is sought for presentations requiring additional clinical advice. Both consultants and nurses have been involved in these discussions and as a result, they do anticipate an improved experience for patients presenting with a similar complaint in the future.

So, thank you again for sharing your experience, It has certainly generated a lot of discussion and commitment from staff to prevent a recurrence of this nature.

Our offer remains open to review and follow-up specific details if you would like to write to me directly at the above address. In the meantime, I hope your health is otherwise continuing to improve.

kind regards, Alan Lilly

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