Not upheld, recommendations

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) during his admission to Ninewells Hospital. In particular, Mrs C had concerns that the effects of the medication Mr A was prescribed for delirium were not monitored, and that after a fall whilst in hospital he was given a further dose of this medication. She also complained that he had not been reasonably checked and monitored throughout the night. By the time nursing staff came to check his observations the next morning, Mr A had died.

During our investigation we took independent medical and nursing advice. We found that the effects of the delirium medication were well monitored and that tests were carried out to ensure that there were no rare side effects. Therefore we did not uphold this aspect of Mrs C's complaint. The medical adviser suggested, however, that given Mrs C's concerns, the clinical team could have considered trialling a different medication. They also suggested that while overall the monitoring was reasonable, it would have been good practice to perform a test to check that Mr A's blood pressure did not fall significantly on standing. We made recommendations to address these points.

We found that after Mr A fell on the ward, he was not given any further dose of medication, but was checked thoroughly by medical staff and then reasonably monitored by nursing staff. Therefore we did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• draw the adviser's comments regarding the consideration of trialling alternative medications for confusion if families voice concern, and of documenting these considerations, to the attention of the relevant staff; and
• draw the comments of the adviser regarding the monitoring of blood pressure to the attention of the relevant staff.

Summary

Mr C was diagnosed with kidney cancer and underwent an operation at Ninewells Hospital to remove one of his kidneys. Mr C felt that, had staff acted appropriately in response to his emails, his cancer may have been diagnosed sooner and he may not have had to undergo the procedure.

Mr C said that he had reported a decline in his health in an email to the neurology department. He said that had staff reviewed him in the neurology clinic following this, his kidney cancer may have been diagnosed sooner. We took independent advice from a consultant neurologist. They did not consider that the content of Mr C's email indicated that he needed to be reviewed in the neurology clinic or that he needed clinical attention at this time. In view of this, we did not uphold this complaint. Although the adviser was satisfied that staff had not failed to provide treatment to Mr C, they noted that staff had not responded to Mr C's email to advise him that he did not require clinical review. They were critical of this and suggested steps the board might consider taking.

Mr C also raised concerns about the board's actions following a further email, in which he reported further symptoms. The adviser found that, in response to this email, the board had advised Mr C to see his GP, which we considered to be reasonable. We noted that Mr C was subsequently reviewed in the neurology clinic and a blood test performed. The adviser found that the results of the test indicated that Mr C had elevated levels of one of his liver enzymes and that the board had written to Mr C's GP regarding this, which the adviser considered to be appropriate. We therefore did not uphold this aspect of Mr C's complaint.

We found that Mr C's GP had arranged an ultrasound test of Mr C's abdomen to explore whether the increased liver enzyme levels were significant to the condition of Mr C's liver. The adviser noted that this ultrasound scan identified a lesion on Mr C's kidney, which was confirmed as cancerous. We did not consider that the care provided to Mr C by staff in the neurology department had caused a delay in diagnosing his kidney cancer. We found that the cancer was not related to the abnormal blood test or Mr C's neurological condition, rather it was an incidental finding based on an ultrasound scan.

Mr C expressed concern at the delay between the diagnosis of the cancer and the date he received treatment. We sought independent advice from a consultant urologist. They noted that the board had missed the timescales for cancer treatment by two days in this case. However, given that the delay was short, we did not consider that this was an unreasonable failing in care. We did not uphold this complaint.

Mr C also complained that the board had not investigated his complaint impartially, as the clinician who investigated Mr C's complaint was the educational supervisor of the clinician he had complained about. We noted that the guidance on complaints handling did not state any requirement in relation to this matter, and in the circumstances of the case we considered that the board had not failed to investigate impartially. While we did not uphold this complaint, we found that the board had taken a significant length of time to respond to Mr C's complaint. While we noted that various complexities of the case contributed to this, on balance we considered that the delay was disproportionate. We also found that the board had not addressed an important aspect of Mr C's complaint in their response. We were critical of this and made a recommendation.

Recommendations

We recommended that the board:

• feed back the comments of the adviser to staff in the neurology department to ensure that staff appropriately respond to patient correspondence;
• consider whether it would be appropriate to introduce guidelines regarding email communication in light of the adviser's comments; and
• feed back to staff the importance of ensuring that complaint responses address the concerns raised.

Summary

Mrs C complained about various aspects of the nursing care she received during an admission to the Royal Alexandra Hospital. This included her concerns about the assistance she received with her personal care, the attitude of staff and the management of her pain.

We took independent nursing advice. The adviser found no evidence to support Mrs C's concerns and considered that the overall nursing care she received appeared reasonable. Therefore we did not uphold Mrs C's complaint.

However, while reasonable efforts appeared to have been made to manage Mrs C's pain, it was noted that she had been refusing pain medication and the nursing adviser considered that staff might have done more to explore the reasons for this with Mrs C. In addition, we considered that some of the language used in the nursing records could be viewed as lacking compassion. We made a recommendation in this regard.

Mrs C also complained about her medical care as she considered that she received inadequate sedation before an attempt to carry out a lumbar puncture (a procedure where a needle is inserted into the lower part of the spine). This initial attempt was abandoned due to Mrs C's distress and the procedure was carried out successfully the following day. We took independent advice from a consultant physician, who considered that the procedure was carried out appropriately and that reasonable steps were taken to try to control Mrs C's pain. They advised that it would be unusual and not in line with routine practice to offer sedation to patients for such a procedure. We did not uphold this complaint.

Recommendations

We recommended that the board:

• ensure that the staff involved are made aware of, and reflect on, the nursing adviser's comments.

Summary

Miss C complained about the care and treatment provided to her mother (Mrs A) at Glasgow Royal Infirmary. Mrs A had a complex medical history and was admitted to hospital for a blood transfusion. Her condition deteriorated and she remained in hospital, where she died six weeks later.

Miss C believed there was an unreasonable delay in establishing the source of an infection contracted by Mrs A and in the treatment of it, and that the cause of death was related to the infection and not to diabetes or heart disease.

We took independent advice from a specialist in kidney diseases. We found that appropriate investigations were carried out within a reasonable time and treatment decisions (particularly in relation to the prescription of antibiotics) were reasonable, including a decision not to resuscitate. We noted that Mrs A was very unwell on admission and the subsequent infection at the site of an intravenous cannula (a tube inserted into a vein, often to deliver medication) was in addition to a background of significant chronic medical conditions. We found that medical staff failed to communicate this and its implications in a reasonable way to Mrs A's family and made a recommendation to address this. We found no failings in the medical treatment provided to Mrs A and therefore did not uphold Miss C's complaint. However, while the infection at the site of the cannula was a recognised complication of the procedure Mrs A underwent, we made a recommendation in relation to policy regarding the insertion and care of intravenous cannulas.

Recommendations

We recommended that the board:

• provide us with an action plan to address the failings in communication highlighted in this investigation and ensure no recurrence;
• provide evidence that appropriate governance arrangements are in place to minimise the risks of an infection at the site of intravenous cannulas; and
• apologise for the failures this investigation identified.

Summary

Mrs C complained about the treatment provided to her at Glasgow Royal Infirmary when she sustained a left distal radius fracture (fracture of a bone in the forearm, close to the wrist). Mrs C said that the splint provided for her injury was too big, and that the delay in this being rectified resulted in her having to have an operation to correct the fracture when it displaced. She also felt that her medical history had not been taken into account when treatment was being provided for her arm injury.

During our investigation, we obtained independent advice from two clinicians, an A&E consultant and an orthopaedics consultant. We found that providing a splint for Mrs C's injury was reasonable, and there was evidence that suggested attempts were made in A&E to make sure it fitted as well as possible. We were advised that an injury such as Mrs C's should not be fully immobilised and that the splint being too big, whilst it may have been uncomfortable, would not have had an effect on the fracture position. We also found that Mrs C's medical history was noted in the clinical records and was reasonably taken into account. We did find that at Mrs C's follow-up appointment, as her fracture had minimally displaced, she should not have been discharged and we made a recommendation related to this. However, we found that this did not cause any significant injustice to Mrs C, and therefore we did not uphold Mrs C's complaint.

Recommendations

We recommended that the board:

• feed back the findings of this investigation to relevant staff, in particular the adviser's comments on the appropriateness of discharge when there is a change in fracture position.

Summary

Mrs C complained about the cataract surgery she underwent at Gartnavel General Hospital. Mrs C received cataract surgery from a trainee ophthalmologist, under the supervision of a consultant ophthalmologist. She said that her eye was painful after the operation, and appeared smaller than the other eye. Mrs C subsequently attended her optometrist, and the consultant ophthalmologist for a follow-up some weeks later. She received an ultrasound and subsequently received a further examination from a second consultant ophthalmologist.

Mrs C raised a number of concerns about the surgery. She also said she felt the operation was performed by a doctor with insufficient experience. The board said the cataract surgery had been performed appropriately. They considered Mrs C had an abrasion that had resolved, and that the drooping appearance of Mrs C's eye was due to the lid speculum (the instrument that allowed the surgeons to hold her eye open). They said both consultant ophthalmologists found no evidence of significant complications.

We took independent advice from a consultant ophthalmologist. We found the evidence suggested the board provided appropriate cataract surgery. We considered the board's explanations of the problems Mrs C had encountered after surgery were reasonable and accurate, and did not evidence any failings on the part of the board. We also found the surgical trainee had an appropriate level of experience to perform the operation. While we did not uphold Mrs C's complaints, we made a recommendation relating to informing patients that operations may be performed by a trainee.

Recommendations

We recommended that the board:

• consider changes to their standard consent form to note that operations may be performed by a trainee.

Summary

Mr C complained about care he and his wife (Mrs C) received from their medical practice. This related to the prescribing of medication to Mr C and a repeat blood test, the investigation and treatment of symptoms suffered by Mrs C and invitations sent regarding appointments.

We sought independent medical advice on the complaint. The adviser had no concerns about the medical care provided by the practice and we did not uphold Mr C's complaints.

However, during the investigation concerns were raised about the practice's complaints handling and a particular doctor's approach to complaints. For that reason we made a number of recommendations to address these concerns.

Recommendations

We recommended that the practice:

• provide this office with a copy of the practice's complaints handling procedure demonstrating compliance with the Patient Rights Act and government guidance 'Can I Help You?';
• reassure this office that the practice has a robust system for recording and storing complaints documentation; and
• discuss the findings of this investigation with the doctor's appraiser.

Summary

Mr C complained that the Scottish Prison Service (SPS) unreasonably failed to manage his property in line with relevant policy and procedure. Mr C said that over a few months, he had condemned (voluntarily given up) items of his property, handed it out to visitors, or donated it to the prison library. Mr C said he had followed all the correct processes but that the items had not been removed from his property card and therefore he was not allowed to receive any more items.

Following our enquiry to SPS, we found that the procedure for items being condemned or handed out to visitors is that the prisoner must fill out a mandate detailing the items they wish to have removed from their property and what they want to happen to these items, before handing both the mandate and property to a member of staff, who will take it to reception to be actioned. SPS explained that given the large volume of property transactions it was not possible to take every prisoner to reception to sign their property cards when items were removed, and so the mandate acted as a signature. In addition, SPS said that whilst Mr C said he had donated items to the prison library, there was no evidence that he gave these items to a member of staff to be removed from his property card.

We could not see any evidence that Mr C had condemned, handed out, or donated the property he claimed to have and we considered the policies in terms of property to have been reasonably followed. We did, however, recognise that there was opportunity for property or mandates to be lost after being handed to staff members to be actioned. Therefore, we made a recommendation that SPS consider whether the prison's policy was detailed enough.

Recommendations

We recommended that SPS:

• consider whether the prison's existing policy is detailed enough when covering the period between the mandate being signed by the prisoner and the mandate and property being taken to reception.

Summary

Mrs C complained about the care and treatment she received at the Royal Infirmary of Edinburgh when she has a hysterectomy (surgical removal of the womb). Mrs C was concerned that the surgery should not have gone ahead given that she had been suffering from a cold and cough a couple of weeks earlier. Mrs C became significantly unwell after surgery and further tests identified that she had internal bleeding and a blood clot. Emergency surgery was carried out and she also developed a chest infection.

We took independent medical advice and found that there was evidence to show that Mrs C was fit for surgery with no evidence of active infection or respiratory problems. We considered that the hysterectomy was performed appropriately and that the problems she experienced after surgery were recognised complications of the surgery, rather than failings in care. Whilst we did not uphold the complaint, we were critical that there was a lack of clear documentation to demonstrate that Mrs C was fully appraised of all the relevant risks and complications associated with hysterectomy. Therefore, we made two recommendations to the board in order to address the matter.

Recommendations

We recommended that the board:

• ensure that the staff involved in Mrs C's consent process reflect on these findings to ensure that all recognised risks of hysterectomy are fully discussed with patients and documented on the consent form prior to surgery; and
• consider providing patients with written information where appropriate in relation to hysterectomy.

Summary

Mr C complained about the care and treatment provided to his wife (Mrs A) when she was admitted to the Western General Hospital for radiotherapy to treat a spinal condition. Mr C said that nursing staff failed to provide reasonable care in relation to the taking of blood samples, pressure ulcers and use of a pressure-relieving mattress, and said that the failings caused Mrs A pain and distress.

We took independent advice from a nursing adviser. We found that the standard of nursing care in relation to blood sampling and pressure ulcer care was reasonable, but that there were shortcomings in relation to record-keeping and the explanation about the mattress and we made recommendations in relation to this. However, on balance we were satisfied that the standard of nursing care and treatment on the whole was reasonable and we did not uphold Mrs C's complaint.

Recommendations

We recommended that the board:

• take steps to ensure the record-keeping shortcomings are addressed including that they are raised with relevant staff; and
• inform this office of the safeguards in place to ensure that mattresses requiring inflation do not deflate inadvertently.