Not upheld, no recommendations

Summary

C complained about the care and treatment their late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, the patient in the bay beside A was confirmed positive for COVID-19. A received a test for COVID-19 and was discharged home. A was then made aware that they had COVID-19. A's condition deteriorated and they died.

C complained about the placement of A within an amber zone, rather than a green zone at the hospital. C was also concerned that A was placed in a bay beside the other patient, who subsequently tested positive for COVID-19.

We sought independent advice from a consultant oncologist (a specialist in the diagnosis and treatment of cancer). We noted that the COVID-19 guidance in place at the time required NHS Boards to have COVID/Non-COVID areas and provided examples of pathways for how NHS Boards might separate patients. The guidance was not prescriptive and each NHS Board had to decide how to apply the guidance to the different hospital environments within their area. We found that the board’s internal pathways were consistent with the pathways set out in the guidance. Given that A did not meet the criteria for a low risk/green zone within the hospital, we found it was reasonable to place A in an amber zone based on the information known at the time. We therefore did not uphold this aspect of the complaint.

We recognised how distressing it must have been for C to learn that their parent had contracted COVID-19 while in hospital. To assess this aspect of C's complaint we obtained the relevant clinical records for the other patient and shared these with the independent adviser. We found that the symptoms the other patient was exhibiting were not thought to be due to COVID-19 and we did not identify any failure regarding the placement of A beside this patient. We therefore did not uphold this aspect of the complaint.

Summary

C, an advocate for A, complained about the way A was treated by the board for their chronic psychotic illness. A experienced a relapse when administration of their medication was changed from a depot injection (a slow release method) to an oral route. A subsequently required two in-patient admissions. C complained the second admission only occurred due to a failure by the board to manage A's medication properly, and to being discharged from their first admission when they were still experiencing psychotic symptoms.

We took independent clinical advice from a consultant psychiatrist on the board’s management of A's medication and the circumstances of their discharge from hospital during their first in-patient admission. In reference to the board managing A's transition back onto their medication by depot injection, we found that this had been managed appropriately, and in agreement with A. However, we noted that the documentation of this could have been better. While we did not uphold this aspect of the complaint, we gave feedback to the board in respect of record-keeping.

Regarding the timing of A's discharge from hospital, we found that this had been reasonable and person-centred in approach, noting there was no reference in the medical records to A experiencing psychotic symptoms at the time of their discharge. As such, we did not uphold this aspect of the complaint.

Summary

C, an advocate for A, complained about the actions of the board's paediatrics department in relation to child protection concerns raised about A's child (B). C complained that the board did not reasonably communicate with A about the concerns raised and that they took an unreasonable length of time to arrange a child protection conference. C also complained that the board failed to fully involve the family GP in the child protection process and to explain the rationale for proposing to reassess B's autism spectrum disorder (ASD) diagnosis.

To investigate C's concerns, we reviewed the relevant clinical records and sought independent advice from a consultant community paediatrician. Our investigation found that the steps taken to invite A to a meeting to discuss the concerns about B and to share a summary of the professionals meeting held were reasonable. We also concluded that from the time the concerns were noted to holding a child protection conference, it was reasonable to consult with other professionals, gather information and attempt to speak with A. As such, we did not consider there was an unreasonable delay in holding the child protection case conference.

We also found evidence that the family GP was invited to a professionals meeting by email, however, due to administrative errors outwith the board’s control, the email was not received by the GP. With regards to the reassessment of B's ASD diagnosis, we concluded this was explained both in writing and at a meeting. We therefore did not uphold C's complaints.

Summary

C complained about the treatment they received at the Queen Elizabeth University Hospital. C said that they had been admitted with problems concerning a foot ulcer and that on both occasions they were discharged home after one night in hospital. C felt that they should have been admitted for a longer period to ensure that their condition improved and that they were able to take any medication which was required. The board felt that C was fit for discharge on both occasions and that there was no clinical requirement that C should remain in hospital and it was appropriate to discharge C home with support from the district nurses.

We took independent advice from an adviser and found that staff at the hospital had carried out appropriate investigations and that it was appropriate to discharge C home with support from the district nurses to change the foot dressings. We did not uphold the complaint.

Summary

C attended Queen Elizabeth University Hospital (QEUH) on a number of occasions prior to being diagnosed with cauda equina syndrome (CES, a narrowing of the spinal column where all of the nerves in the lower back suddenly become severely compressed). C required two emergency surgical procedures and has been significantly impacted by the condition. C complained that there were missed opportunities to diagnose CES, and about the clinical assessments carried out at QEUH.

C's complaint concerned assessments in A&E and in gynaecology (specialists in the female reproductive system). We took independent advice from a consultant in emergency medicine and a consultant gynaecologist. We found that C was assessed appropriately during each admission to A&E. We found that C was displaying no red flag symptoms and that appropriate follow-ups were arranged. We also found that C was not exhibiting symptoms which would indicate CES, nor was C displaying symptoms which would have triggered immediate imaging. We were satisfied that C was assessed appropriately and that it was reasonable to arrange follow-up gynaecology assessment later that day. We did not uphold these aspects of the complaint.

We also found that C was appropriately assessed when they attended the emergency gynaecology appointment. There was no clinical evidence to suggest C needed emergent care. The doctor noted no symptoms of CES and consulted with the consultant on call before discharging C with appropriate advice. We found this was reasonable. We did not uphold this aspect of C's complaint.

Summary

Ccomplained that their late parent (A) called the practice and was given a prescription without being seen in person. C also complained that an appointment or home visit wasn’t arranged when C called three days later and reported that A's condition had worsened.

We obtained independent advice from a general practitioner adviser. We found that the actions taken by the practice at the time of the initial call were reasonable and considered it reasonable for A not to have been seen in person at that time. We also considered that reasonable action was taken when C called three days later, based on what was documented in the records. However, it was acknowledged that there were differing accounts of what had been discussed, and that the symptoms C said they communicated would reasonably have prompted A to be seen in person. Based on the evidence available and the advice obtained, which we accepted, we concluded that A received reasonable medical care and we did not uphold this complaint.

However, we noted that the level of documentation could have been improved. This includes recording when safety netting advice is given (when patients are advised to return if their symptoms don’t improve, advice which the practice said was given to A during the first call but was not documented); reasons why a patient is not spoken to directly (as was the case when C called); and reasons to see or not to see a patient in person, particularly for a repeat caller. We fed this back to the practice for their reflection and learning, along with feedback on their handling of the complaint.

Summary

C complained about the care and treatment provided to their parent (A) when they were a patient at Glasgow Royal Infirmary. C raised concerns that they had to alert staff to the fact that A had become unresponsive. C complained that A was stepped down from critical care to a medicine for the elderly ward when A was still unwell and suffering from delirium. C also complained about changes made to A's death certificate, which had been amended by a consultant, following the initial certificate prepared by a junior doctor. The death certificate was updated to fully reflect A's underlying condition, including the possibility of an underlying cancer diagnosis. However, it was subsequently amended again to remove the reference to cancer in light of C's upset over this.

We obtained independent medical advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A's condition was monitored appropriately and reasonable action was taken in a timely manner when it was noted they had deteriorated. We were satisfied that the board had already acknowledged and apologised for not keeping C updated while they dealt with A's care. Therefore, we did not uphold this complaint.

In relation to the second complaint, we considered action was appropriate as A was no longer in need of critical care, and confirmed delirium would not have been a reason to delay the transfer. We, therefore, did not uphold this complaint.

With regard to the complaint about changes to A's death certificate, we were satisfied that the board had provided an appropriate explanation and apology, and had demonstrated learning. We had no concerns about the accuracy of the death certificate. However, we noted that it would have been good practice to offer a post-mortem examination in light of the clinical uncertainty, and C's concerns, surrounding a possible underlying cancer. While we fed this back to the board, on balance, we did not uphold this complaint.

Summary

C's baby (A) was born with a rare genetic disorder and died four days after their birth. C complained about the board’'s failure to identify A's condition during prenatal scans. C complained that despite A's face not being visualised in two abnormality scans, a further scan was not arranged.

We took independent advice from a consultant obstetrician and gynaecologist (a specialist in pregnancy, childbirth and the female reproductive system). We found that the board had appropriately followed national and departmental guidance in relation to the scans. We found it reasonable that A's condition was not detected during C's pregnancy. Although imaging of A's face was not possible during the second scan, we found there was no requirement to carry out a further anomaly scan or take any further action in relation to this. We therefore did not uphold this complaint.

Summary

C complained about a delay in diagnosis of cancer due to insufficient investigations undertaken by a number of GP's at the practice. C was later diagnosed with stage 4 lung cancer. C said the signs of cancer were missed, which was likely due to seeing different GP's at each consultation. In addition to this, C had a history of kidney cancer and considered their history was not adequately taken into account. C attended the practice on several occasions, reporting a number of concerns. C said that considering their history of cancer, the early signs of lung cancer were evident. It was only following a CT scan for C's kidney cancer that the oncology team found evidence of stage 4 lung cancer.

The practice agreed that some of C's symptoms during this time could explain developing cancer. However, they also considered that the symptoms reported could be caused by a wide range of diagnoses. The practice evidenced that multiple x-rays were taken along with blood tests and vital sign checks, and there was nothing to indicate that cancer was developing. Due to these findings, the practice say that they had no medical reason to request a CT scan or refer C to a specialist team. We took independent advice from a GP adviser and reviewed the relevant medical records. We found that C did not present with any symptoms suggestive of lung cancer but a variety of unrelated problems, some of which were long standing. It was noted there was a lack of red flag symptoms of lung cancer, and as such, there was no requirement for a CT scan or to be referred to a specialist team during this period.

In light of this, we found that the overall care and treatment provided to C was reasonable. We therefore did not uphold this complaint.

Summary

C complained to the board about the treatment provided to their late relative (A) who died of a ruptured bowel. A had been in University Hospital Ayr two weeks previously with symptoms of severe pain. Staff had carried out tests and a scan, and discharged A home without follow-up. C believed that the board should have carried out more intensive investigations, which may have discovered A was still having bowel problems and provided additional treatment. The board believed that appropriate treatment had been provided.

We took independent advice from a consultant in acute medicine (a specialist in the immediate and early management of adult patients with a wide range of medical conditions who present in hospital as emergencies) and a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that staff at the hospital provided a reasonable standard of treatment based on A's reported symptoms. We also found that it was not unreasonable to discharge A home with antibiotics based on the diagnosis of pyelonephritis (kidney infection) following a CT scan. Although a subsequent CT scan carried out on readmission showed evidence of infarct (a small localised area of dead tissue resulting from failure of blood supply) which might have been evident on the original scan, it was not unreasonable to have diagnosed pyelonephritis following the original scan. We therefore did not uphold the complaint.