Not upheld, no recommendations

Summary

C complained about the care and treatment that their late parent (A) received from the board. A was admitted to hospital after a fall at home. A’s condition declined whilst in hospital. C complained that during A’s admission there were clinical errors, inappropriate treatment and insufficient diagnosis work. In C’s view, this contributed to and hastened A’s death. C stated that clinicians had fixated on alcohol as the primary cause of A’s condition. A post-mortem later confirmed this not to be the case and that A had Lewy Body dementia (a brain disorder that can lead to problems with thinking, movement, behaviour, and mood) or similar when they died. C also asserted that A’s two brain bleeds sustained in the fall were not adequately monitored or treated. C highlighted concerns that there was no intervention and no repeat computed tomography (CT) scan carried out to check the condition/size of the two brain bleeds. This was despite a decline in A’s neurological condition.

In addition to this, C complained that the board’s communication with A’s family fell below a reasonable standard. C stated that, in their view, A’s two brain bleeds were more significant than clinicians had led the family to believe at the time of admission. They also highlighted an unwitnessed fall on the ward that was not reported to the family.

We took independent advice from a neurologist adviser. We found that the treatment provided by the board was reasonable. Given A’s circumstances and presentation, we did not consider the focus on alcohol-related cognitive failure to be unreasonable or that it materially affected the treatment provided. We also found that the decision not to carry out an additional CT scan to be reasonable. However, we highlighted concerns about some of the board’s justification for not carrying out an additional CT scan. We also received a limited amount of advice from an independent nursing adviser about some additional concerns raised by C. We found that in the context of the difficult circumstances of A’s condition, the nursing care provided was reasonable. Overall, we concluded that the board provided a reasonable standard of treatment during A’s admission. Therefore, we did not uphold this aspect of the complaint.

Summary

C complained on behalf of their adult child (A) about the standard of care and treatment that they had received in relation to their mental health from their GP practice. In particular, C complained that the surgery did not provide the support recommended for A following an Adult Autism Disorder (ASD) assessment. C also complained that the surgery had prescribed medication for A without any follow-up despite knowing that they had expressed thoughts of suicide. Additionally, C complained that the surgery had failed to explain the nature and process of a mental health telephone review A had been referred for and that the surgery had failed to let them know when this had been cancelled by the receiving service.

The surgery explained that referrals had been made to mental health services on behalf of A, however, the decision to accept or decline them was made by the receiving service and not the GP surgery. Regarding the cancelled appointment, the surgery said that they had not received advanced notice and were, therefore, unable to let C know that it would not go ahead.

We took independent advice from a GP adviser. We found that the ASD assessment report did not contain any recommendations or actions for the surgery to arrange on behalf of A, that A had been regularly reviewed during the period of the complaint and referrals had been appropriately made to other services. We also found that the surgery could not influence whether a referral was accepted or declined. In relation to the cancelled telephone assessment, we found that there was no evidence to suggest the surgery received advance notice of it being cancelled. Therefore, we did not uphold the complaint.

Summary

C complained that the board had unreasonably failed to follow the care plan put in place to support them with their mental health. In particular, C complained that the board had failed to arrange their admission to hospital during an episode of crisis.

The board’s response to C’s complaint advised that they had been appropriately assessed at the time, with it being the view of the mental health service that further support in the community would help to reduce the need for an inpatient admission. The board also advised that, in keeping with the care plan, C’s request for admission had been discussed with a consultant psychiatrist, with the decision not to arrange admission on this occasion being based on clinical opinion.

We took independent advice from a consultant psychiatrist. We found that C’s care plan included provision for a five day admission to hospital when required, however, the need for this would be discussed with a consultant at the time. When C reported feeling low in mood to the mental health service during their episode of crisis, they had responded reasonably, noting that C had been supported by increased phone and face to face contacts. On receiving C’s requests to be admitted to hospital, this had been assessed by the consultant psychiatrist in keeping with the care plan. Overall, we considered that the board had reasonably followed C’s care plan. We did not uphold this complaint.

Summary

C complained about a mis-diagnosis of their parent (A) at hospital. C noted that A was diagnosed with pancreatitis (inflammation of the pancreas) during their first admission. A CT scan was taken to confirm this diagnosis. During a later second admission, blood tests and an ultrasound were taken but no CT scan was taken and pancreatitis was again confirmed. A then attended a different hospital while away. A CT scan was taken and A was diagnosed with late stage pancreatic cancer and died shortly after. C complained that the pancreatic cancer had not been diagnosed at the original hospital. The board explained that the original scans confirmed pancreatitis and showed an abnormality which increased the risk of it recurring. During A's second admission, blood tests confirmed acute pancreatitis and there were no clinical signs to indicate that a further CT scan should be arranged.

We took independent advice from a gastroenterology (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) adviser. We found that the care and treatment was appropriate throughout the period and that there was no reason to suspect pancreatic cancer. In their second admission, A’s presentation was consistent with an attack of mild acute pancreatitis and immediate further CT scanning was not indicated at this time. As such the complaint was not upheld.

Summary

C complained that their cancer diagnosis was unreasonably delayed. They had previously suffered from cancer which had been successfully treated. C believed there was an inappropriate focus on the wrong part of their throat as a consequence, and that this combined with inadequate review of the CT imaging of their oesophagus had resulted in a delayed diagnosis, much more significant surgery and had allowed the cancer to spread to other parts of their body. C believed the extent of the cancer when diagnosed, meant it must have been visible earlier in the diagnostic process.

We took advice from a consultant ear, nose and throat surgeon. We found that C was correctly examined and there was no evidence of failings in their care. It was not possible to determine whether earlier diagnosis would have resulted in a different outcome for C. We did not uphold the complaint.

Summary

C complained on behalf of a family member (A) who was diagnosed with breast cancer and died less than two years later. C complained that during a consultation the consultant oncologist (specialist in the treatment of cancer) treating A had given the impression that despite having a condition that was treatable but not curable, A was likely to live for many more years. C noted that they had been present when this had been explained, and that it was evident that A had made important life decisions based on what C considered, in light of subsequent events, to be have been highly misleading communication. C also noted a lack of documentation relating to the initial consultation.

In response, the board stated that the oncologist treating A was clear that it had been explained that they had metastatic, stage four cancer. The consultant was also certain that they had not stated that the treatment would definitely work in an on-going sense and life-expectancy would be unchanged. The board apologised if this has been the impression formed by A.

We took independent advice from an oncologist. We found that the board’s position that it was not the oncologist’s custom to discuss life expectancy at the first meeting in order not to overwhelm a patient, and that such predictions can be very difficult to make was reasonable. Additionally, we noted that a letter had been sent to A’s GP following the initial consultation. We found it was not unreasonable for a letter to be in lieu of additional notes in a paperless system, and that it is not a requirement for a copy to also be sent to the patient. We also noted that this was one of a number of records and communications with A’s GP that were somewhat generic in nature, noting that while a further letter referenced discussions of palliative options, which implied a discussion about the seriousness of A’s condition, this letter could have been more specific in relation to what exactly was discussed.

Overall, we found that while communication and documentation could have been better and more detailed, it was reasonable. For this reason, we did not uphold C’s complaint. However, we did provide feedback for the board outlining the adviser’s criticisms of the documentation in relation to communication.

Summary

C, an MSP, complained on behalf of their constituent (B) about the standard of care B’s late spouse (A) received from their GP practice. A attended an appointment with a GP and received antibiotics and steroids for a possible chest infection. A’s health deteriorated a short time later and they suffered a cardiac arrest at their home. B complained that the practice failed to recognise that A was suffering from a serious cardiac condition.

The practice said that a full examination and history had been taken from A. The GP concluded that the symptoms were from the chest wall rather than originating from the heart, with a suggestion of chest infection and narrowing of the airways. A received steroids and an antibiotic in treatment of a chest infection, and given advice on what to do if their condition worsened. On learning of A’s death, a Significant Event Analysis was carried out by the GP, which identified learning points in relation to arranging ECGs (a test that records the electrical activity of the heart, including the rate and rhythm), and strengthening the advice given to a patient about phoning again should their condition worsen.

We took independent advice from a GP. We found that it was reasonable for the GP to treat A on suspicion of a respiratory infection having taken a history and clinical examination. While A’s oxygen saturation levels were low, this can also be found in cases of acute or chronic lung disease, such as infection. A also displayed symptoms that were not typical of classic heart attack pain. We found that A’s blood pressure and heart rate were both normal which did not suggest a heart attack. We considered that the GP made a careful assessment and reached a reasonable working diagnosis at the time based on the information available and their clinical judgement. Therefore, we did not uphold C’s complaint.

Summary

C complained about arterial surgery. The board accepted that there were issues related to the surgery and communication with C before the procedure.

We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, overall, the clinical treatment provided to C was reasonable. We did not uphold the complaint.

Summary

C, a support and advice worker, complained on behalf of their client (A). A is a kinship carer to two grandchildren (child B and child D). When child B was born, they stayed with their parent and A at the same address. The following year, child B’s parent left the house and child B remained in A’s care. There was social work involvement during this period, with a section 25 being signed and a noted intention to assess further and refer to the Children’s Reporter. Within a few months, A was granted a residency order conferring parental rights and responsibilities and the council closed the case.

Child D was born and lived with their parent for four years, until they were placed with A under a Compulsory Supervision Order. A received kinship care allowance for child D and also applied for kinship care allowance for child B. This was initially refused, but after A made a complaint to the SPSO, the application was reconsidered. The council backdated the kinship care allowance in respect of child B.

C complained that kinship care allowance was not backdated far enough for child B. The council responded that they had never considered child B to be a “looked after” child and therefore eligible for kinship care allowance. As such there was no reason to backdate further.

We took independent advice from a social work adviser. We found that due to lack of evidence and dispute between parties it was not possible to definitively determine the status of child B in earlier years. On application, the council paid kinship care allowance and backdated to the point at which child D had been placed with A under a Compulsory Supervision Order. We determined that the council had acted reasonably in this matter. We did not uphold the complaint.

Summary

C complained about the care and treatment that they received from the board prior to and during the birth of their child (A). C complained that the midwives were dismissive of their pain levels during labour, failed to properly assess their condition, was wrongly sent home to allow labour to progress, and that staff denied their requests for an epidural. C also complained about the poor communication from the clinical team when they were in theatre for a caesarean section.

The board said that they considered the decision to send C home was made in line with current guidelines but apologised if the reasons for the decision were not communicated at the time. The board explained that C’s request for an epidural was not actioned as labour was progressing rapidly and consideration was being given as to whether an emergency caesarean section was required.

We took independent advice from a midwifery specialist. We found that the midwifery care provided to C was reasonable. We noted that the board apologised for some shortcomings in the care provided and that this was a reasonable response. Overall, we were satisfied that the decisions taken by the midwives were based on a reasonable assessment of C’s presenting condition. In respect of the medical care provided during the birth, we acknowledged that there may have been a lack of clarity around the consent process, however, overall, we did not find any significant shortcomings in the clinical care and treatment provided to C. We did not uphold C’s complaints.