Angry Patient OSCE - Relative Complaint about Care

Case Overview

• Age/Sex: 67-year-old female
• Occupation: Retired school secretary
• Setting: Inpatient medical ward (admitted 2 days ago for cellulitis of left leg)
• Chief complaint: "I'm not being looked after properly" (daughter is vocally complaining about care)

Patient Script

Who I Am

I'm a 67-year-old retired school secretary; my daughter is here with me and she's been very upset.

What Brings Me In

I want someone to listen — I feel like the nurses aren't looking after me properly and no one answers when I press the buzzer.

My Story

I was admitted 2 days ago because of an infection in my left leg. Since then I've felt that staff are slow to come when I call and that I didn't get my insulin on Tuesday morning like I usually do. Yesterday morning I pressed the buzzer for help to go to the bathroom and waited about 20 minutes — I was embarrassed and then my daughter came and said something to the nurse. I also had a bit of pain in my leg that felt worse last night and I don't think they gave me my painkillers on time. My daughter keeps saying the staff are rude and that I was left without help. I'm tired and annoyed, and I just want someone to take this seriously.

(If asked: I don't have chest pain now — I had a little tightness a week ago which settled, and I had a urine infection last year.)

My Medical Background

• Past medical history: Type 2 diabetes mellitus (diagnosed 15 years ago), hypertension, osteoarthritis (knees), prior urinary tract infection last year
• Medications: Metformin 500 mg twice daily, basal insulin at bedtime (chart available), lisinopril 10 mg daily, paracetamol PRN, topical emollient for knees
• Allergies: None known
• Social: Lives with daughter who visits daily; previously independent with most activities but needs help with heavy housework; ex-smoker (stopped 10 years ago); drinks 1–2 glasses wine/week
• Family: Daughter present and involved in care; no other nearby relatives

What I Think & Worry About

• I think the staff are ignoring me and not doing their job properly.
• I'm worried I might be left without my insulin or medicines and that I could get worse.
• I'm worried my daughter will keep getting upset and make things difficult for me.

If You Ask Me About Other Symptoms...

• Pain: My left leg is sore where the cellulitis is — I say it feels worse at night but it's tolerable.
• Mobility: I can walk a short distance with help; I fell once 6 months ago at home but was fine (red herring).
• Bladder/Bowels: I had a urinary infection last year, no current burning or blood, passing urine normally.
• Mood/Sleep: I am tired, haven't slept well since being in hospital; feel frustrated and a bit tearful.
• Cognition/Hearing: I am usually sharp; I can hear OK with my hearing aids (I asked the nurse to bring them but can't always find them).
• Chest: I had a mild chest tightness one week ago which went away (red herring).

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Clinical Summary

Examination

• General: Alert, cooperative but tearful; accompanied by adult daughter
• Vitals: Temperature 36.8°C, BP 142/78 mmHg, HR 88 bpm, RR 16/min, SpO2 97% on room air
• Cardioresp: Heart sounds normal, lungs clear
• Abdomen: Soft, non-tender
• Left lower leg: Erythema and warmth over medial aspect consistent with cellulitis; no fluctuance; small area of superficial desquamation
• Neurological: Oriented to person, place, time; brief cognitive screen (Abbreviated MMSE) 26/30 — intact orientation and recall; peripheral sensory exam: diminished vibration in toes consistent with diabetic neuropathy
• Skin: No new bruises, no pressure ulcers

Investigations

• Random capillary blood glucose: 10.2 mmol/L (slightly above target)
• HbA1c (recent): 7.8% (62 mmol/mol) (moderately controlled diabetes)
• U&E: Na 138 mmol/L, K 4.2 mmol/L, creatinine 120 µmol/L, eGFR 48 mL/min/1.73m2 (chronic kidney disease stage 3)
• CBC: WCC 9.5 x10^9/L, Hb 12.2 g/dL, platelets 250 x10^9/L
• CRP: 12 mg/L (mild elevation consistent with cellulitis)
• Urinalysis: negative for nitrites/leucocytes
• Medication administration record (MAR): basal insulin doses documented as administered on admission day and last night (contradicts patient's belief about missed insulin)
• Nursing notes: several call bells documented with response times ranging from 5–25 minutes; analgesia PRN documented as given at staff discretion

Diagnosis

Primary diagnosis:

• Complaint about care / perceived neglect and communication breakdown
  • Evidence: Patient and daughter report delays in response to call bell, concerns about missed insulin and analgesia; patient tearful and distressed; MAR and nursing notes show medication given and variable response times, suggesting a perception issue and possible genuine delays in response rather than missed clinical treatment.

Differential diagnoses:

• Under-treated pain contributing to distress — leg cellulitis with reported worse pain at night; analgesia PRN may not meet needs if not proactively offered.
• Delirium or acute cognitive change — less likely given orientation x3, coherent history, and near-normal brief cognitive screen.
• Depression or anxiety reaction to hospitalisation — possible contributor given tearfulness and poor sleep.
• Elder neglect/abuse — must be considered given daughter's allegations; currently no physical signs of abuse, but requires safeguarding enquiry if concerns persist.
• Medication error (missed insulin) — MAR documents insulin given, so less likely but worth verifying with staff and capillary glucose monitoring.

Management

• Immediate: Sit with patient and daughter; listen actively and acknowledge their concerns; apologise for distress (acknowledgement, not admission of liability).
• Review and clarify facts: review MAR and nursing notes with patient and daughter; show documented insulin administrations and timing of analgesia; check last analgesic given and pain score now.
• Assess unmet needs: check and ensure hearing aids/glasses are available; offer toileting/assistance proactively; ensure pain control is adequate (consider scheduled analgesia if PRN inadequate).
• Safety: confirm there are no signs of physical abuse or neglect; if daughter or patient reports ongoing unsafe care, escalate to ward manager and consider safeguarding referral.
• Communication plan: arrange a family meeting with named nurse/consultant to discuss plan of care, expected response times, and agree a named point of contact; agree how call bell concerns will be addressed (e.g., nurse to check within X minutes and document).
• Follow-up investigations: continue capillary glucose monitoring; repeat review of vitals and cellulitis response; consider referral to diabetes specialist nurse if glycaemic control or insulin technique questioned.
• Documentation: record the complaint in the notes and complete incident/complaint form per hospital policy; document actions taken and agreed plan.

Key Learning Points

• Always start by listening and acknowledging the patient's concerns — perception of poor care can cause significant distress even when clinical care is adequate.
• Check objective data (MAR, observations, medication records) but also assess and address unmet needs (pain control, communication aids, toileting) that drive dissatisfaction.
• In any family-raised concern, consider safeguarding and escalate appropriately if there are signs of neglect or abuse; ensure clear communication and a documented plan to restore trust.