Not upheld, recommendations

Summary

Miss C's mother (Mrs A) was admitted to Glasgow Royal Infirmary with an exacerbation of her chronic obstructive pulmonary disease (COPD – a disease of the lungs in which the airways become narrowed). Miss C complained about the care and treatment her mother received from the board whilst in hospital and the arrangements for her subsequent transport home. She was concerned that her mother was weaned off oxygen too early. She was also concerned that the board should not have considered her mother for a normal flight home when she had been admitted to hospital with a severe COPD attack and chest infection. Miss C said that her mother should have been transported home by air ambulance.

We obtained independent advice on the case from a consultant respiratory and general physician. The adviser said there was no evidence to suggest that Mrs A was weaned off oxygen too early. They explained that Mrs A needed oxygen from day one to day five of her admission but that from day six to day eight her oxygen levels were stable and at a satisfactory level and no additional oxygen was required.

In terms of Mrs A's discharge and transport home, the adviser said that as Mrs A had been assessed appropriately by the board, her condition was deemed to be stable and she had recovered from her recent COPD exacerbation. We found that, on balance, it was reasonable for her to have been discharged and flown home on a short, low altitude, commercial flight without provision of additional oxygen.

Although we concluded that Mrs A received reasonable medical care during her in-patient stay and that her discharge arrangements were appropriate, we were concerned about the standard of the handwriting in Mrs A's medical records, the standard of the photocopy supplied to this office, the board's handling of Miss C's complaint and the board's late submission of their comments on this case to our office. We therefore made some recommendations to address these issues.

Recommendations

We recommended that the board:

• feed back the failings identified in our decision on Miss C's complaint to the staff involved;
• ensure that in future readings are clearly recorded in patient records; and
• provide Miss C with a written apology for the failings identified.

Summary

Mr A was referred to hospital by an out-of-hours GP after feeling increasingly unwell. On admission to Vale of Leven Hospital, Mr A was diagnosed as suffering from sepsis (a blood infection) and received treatment for this. Mr A's condition deteriorated over the following days and he was transferred to Royal Alexandra Hospital. Mr A's wife (Mrs C) complained that staff at Vale of Leven Hospital did not identify sepsis quickly enough and that Mr A was not transferred to Royal Alexandra Hospital soon enough.

We took independent advice from a consultant in respiratory medicine. The adviser confirmed that sepsis was identified immediately and noted that Mr A was treated appropriately, in line with the board's sepsis protocol. While the adviser noted that medical records should have shown greater detail about plans to transfer Mr A, they were satisfied that there was no inappropriate delay in transferring him. However, the adviser noted that the board should consider introducing a more robust set of criteria for the transfer of seriously ill patients.

After Mr A was transferred to Royal Alexandra Hospital, he was treated in the high dependency unit, where he died. Mrs C expressed concern that her husband did not receive treatment in the intensive therapy unit (ITU) and was not referred for dialysis. The adviser considered that Mr A received appropriate treatment and noted that the medical staff involved in Mr A's care decided that he was not suitable for escalation to ITU or referral for dialysis because of his multiple health conditions and deteriorating health.

While we did not uphold Mrs C's complaints, we made a recommendation to take into account the adviser's comments about the transfer between hospitals. We also noted that the board had acknowledged communication failings and had advised Mrs C that a new standard process template would be introduced for staff to record communication with families of patients. We accordingly made a further recommendation to confirm that this learning had been implemented.

Recommendations

We recommended that the board:

• feed back to relevant staff the adviser's comments regarding record-keeping and introducing more robust criteria for transferring seriously ill patients; and
• provide us with a copy of the new process template.

Summary

Ms C complained about the communication between her grandfather (Mr A), who had prostate cancer, and the medical practice. Mr A was cared for by the practice at home, on a GP-led ward and while he was in a nursing home. Mr A died ten days after his admission to the nursing home. Ms C complained that the practice had failed to communicate appropriately with Mr A in relation to his cancer diagnosis and treatment options, despite the practice having access to this information.

We took independent advice from a GP adviser. They noted that Mr A was being seen by a consultant urologist (a clinician who treats disorders of the urinary tract) and that it was the urologist's responsibility to discuss Mr A's cancer diagnosis and treatment options with him, not the GP's. We therefore did not uphold Ms C's complaint.

The adviser noted that there was a delay in referring Mr A for an ultrasound scan and that the national referral guidelines for suspected cancer had not been followed. We therefore made a recommendation in relation to this.

Recommendations

We recommended that the practice:

• ensure the relevant GP familiarises themselves with the national guidelines for cancer referral and considers identifying this as a learning point for their annual appraisal.

Summary

Ms C complained about the appropriateness of her late son (Mr A)'s discharge from a clinic at the Royal Edinburgh Hospital and also the adequacy of his follow-up care and treatment in the community. Mr A had a diagnosis of schizophrenia and also had alcohol and drug problems. He died of a drug overdose five weeks after discharge. Ms C complained in particular that community psychiatric nurses (CPNs) did not get help for Mr A, or alert her, when they visited him the day before his death and found him in an intoxicated state.

We took independent medical advice from a consultant psychiatrist and a mental health nurse. We were advised that Mr A was no longer suffering from the symptoms of his mental illness at the time of discharge. It was highlighted that his hospital detention could not have been prolonged solely on account of his drug taking behaviour. The advice we received indicated that the decision to discharge was reasonable and that it followed detailed risk assessment and appropriate multi-agency planning. We therefore did not uphold this complaint.

We were also advised that an intensive package of care was arranged, with multi-agency involvement, and we therefore did not uphold Ms C's complaint that adequate support was not in place for Mr A for his return to the community. However, we were advised that all relevant paperwork was not fully completed and distributed prior to discharge and so we made some recommendations to try to prevent a similar future omission.

In relation to the actions of the CPNs the day before Mr A's death, it was noted that it was not an unusual scenario for them to find him in an intoxicated state when they visited him. We were advised that there was no evidence to suggest that the level of risk was increased on this occasion or that it represented an emergency situation. As the CPNs did not perceive the circumstances to represent an emergency situation, they were required to respect Mr A's confidentiality. We therefore did not consider there to be an unreasonable failure to involve Ms C. We concluded that there was no unreasonable act or omission on the part of the CPNs that directly contributed to Mr A's death. However, with the benefit of hindsight, we noted that there were additional steps the CPNs might have considered taking and we made a recommendation about this.

Ms C also complained that mental health and addiction services staff did not work together to support Mr A the day before, and on the day of, his death. However, we were advised that addiction services had no acute role over these particular days and we did not uphold this complaint. In terms of their longer-term role, we were advised that they were appropriately involved in Mr A's care. However, as the addiction psychiatrist appeared not to have been invited to one particular meeting, we made a recommendation about this.

Finally, as we were unable to determine that the board's incident review report contained factual inaccuracies, we did not uphold Ms C's complaint in this regard. However, we considered that a report written by one of the CPNs could have been more clearly worded and we made a recommendation about this.

Recommendations

We recommended that the board:

• take steps to ensure that Care Programme Approach documentation is brought fully up to date prior to discharge and is circulated to all relevant parties;
• remind staff to ensure that standardised documentation, such as the Discharge Checklist, is completed fully and accurately;
• consider providing field management guidance to community staff who, in the course of their duties, are likely to encounter patients significantly under the influence of harmful drugs;
• remind staff to ensure that all relevant parties are invited to attend key multi-disciplinary meetings; and
• take steps to remind nursing staff that clinical reports should be factual and unambiguous in order to ensure that the meaning is clear and in line with Nursing and Midwifery Council record-keeping guidance.

Summary

Mrs C complained on behalf of her husband (Mr A) that the audiology department at the Victoria Hospital had unreasonably cancelled an appointment. Mrs C was also concerned that her husband did not have an appropriate hearing aid for his needs.

We took independent advice from a consultant clinical scientist in audiology. Regarding Mrs C's first complaint, the adviser was not critical of the board's cancellation of the appointment and noted that another, longer appointment had been arranged in its place. While we did not uphold Mrs C's complaint, we found evidence that Mr A and Mrs C had not been advised of the cancellation and so they had expected to attend two appointments. The adviser considered that the failure to advise them of the cancellation was not reasonable and therefore we made a recommendation.

Regarding Mrs C's second complaint, the adviser confirmed that Mr C had been given the appropriate hearing aid for his needs.

Recommendations

We recommended that the board:

• feed back the findings of this investigation to the staff in the audiology department; and
• apologise to Mr A for not informing him at the appropriate time that his appointment had been cancelled.

Summary

Mr C's neighbour applied for planning permission to build an extension on the gable end of their property closest to Mr C's property. Mr C received a neighbour notification letter from the council which invited him to submit comments about the application. In response to this, Mr C sent a letter of objection to the council which expressed a number of concerns about the proposed development. Mr C noted that the plans submitted with the application contained inconsistencies and stated that the development was not in accordance with the local development plan for the area. Mr C added that he felt that the development would increase the risk of flooding to his property and would also affect his privacy. The council, after receiving Mr C's letter in addition to relevant consultation responses, decided to grant planning permission to Mr C's neighbour's application.

Mr C was not satisfied that the council had appropriately considered his objections and said that they had not followed the relevant planning rules when considering the application. We took independent advice from a planning adviser. We found that the council had reasonably assessed the effect the development would have on Mr C in terms of the relevant policies and guidance, and had reasonably taken into account the material objections he raised. We therefore did not uphold Mr C's complaint. However, we noted that the council had upheld one aspect of Mr C's complaint and had agreed to review procedures as a result. We accordingly made one recommendation.

Recommendations

We recommended that the council:

• provide us with evidence that a review of procedures in the relevant team has taken place.

Summary

Miss C complained that the dental care and treatment she received in relation to the removal of a wisdom tooth was unreasonable. We took independent advice from a dental surgeon. The advice we received was that the procedure was carried out appropriately and in line with relevant guidelines, and that the treatment provided to Miss C was reasonable and appropriate. However, we were concerned that there was no evidence in Miss C's dental records to confirm that she was given sufficient information prior to the extraction to allow her to give informed consent. Although we did not uphold Miss C's complaint, we did make a recommendation to the board with regard to the consent process and providing information to patients prior to surgery.

Recommendations

We recommended that the board:

• introduce a process for written consent for this type of procedure to be obtained evidencing the discussion of risks; and
• consider producing an appropriate local patient information leaflet for this type of procedure.

Summary

Mr C was experiencing pain in his left knee and was referred to Raigmore Hospital by his GP. Mr C was seen by specialists at a number of appointments over the following two years as his symptoms worsened and began to affect other areas including his back. Mr C complained that the staff caring for him at the board had failed to pick up on his spinal problems or investigate appropriately.

After taking independent advice on this case from a consultant orthopaedic surgeon, we did not uphold Mr C's complaint. The advice we received was that Mr C had appropriate treatment for his symptoms and that thorough clinical investigations had been carried out.

However, we found that after one of his appointments, no clinic letter had been issued (a letter that would be sent from a hospital specialist to the patient's GP). The adviser did not consider that this had any impact on the care provided in Mr C's case, but as this could potentially be significant in other cases, we did make a recommendation to the board about this.

Recommendations

We recommended that the board:

• take steps to ensure that clinic letters are appropriately issued following out-patient appointments.

Summary

Mrs C complained to us that her daughter (Miss A) had been detained unreasonably under an emergency detention certificate (a 72-hour emergency section) after displaying symptoms of a mental disorder. We are normally unable to consider complaints about detention under the Mental Health Act, as there is a right of appeal to a mental health tribunal. However, there is no right of appeal against an emergency detention certificate and we were able to consider this aspect of Mrs C's complaint. We took independent advice on Mrs C's complaint from a psychiatric adviser. We found that Miss A had met the criteria for detention and it was reasonable that she was detained under an emergency detention certificate. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that nursing staff at Parkhead Hospital had restrained Miss A unreasonably around the time she was detained. We found that the restraint used by staff had been reasonable and was consistent with normal practice at that time.

Miss A had been discharged and the emergency detention certificate had been revoked when she saw a consultant on the day after she had been detained. Mrs C complained that appropriate medical staff were unavailable until the day after Miss A was detained. She said that if an appropriate doctor had been available at the time Miss A was admitted, she would not have had to be detained in hospital overnight. We found that is that it is common, accepted practice that there was no consultant on the ward when Miss A had been admitted to hospital out-of-hours. We also found that it was reasonable that Miss A's detention was reviewed and revoked within 24 hours. We did not uphold this aspect of Mrs C's complaint. That said, we found that the board had failed to issue an adequate response to Miss A's complaint to them and we made a recommendation in relation to this.

Recommendations

We recommended that the board:

• issue a written apology to Miss A for the failure to respond to the matters raised in her complaint.

Summary

Mrs C complained about the level of pain she experienced during a colonoscopy procedure (an examination of the bowel with a camera on a flexible tube) at Forth Valley Royal Hospital. Mrs C's pain was very bad and the procedure had to be stopped. Mrs C felt that the level of pain that she experienced was caused by failure to give her appropriate sedative and pain medication prior to the procedure. Mrs C highlighted that she had previously undergone the same procedure at another hospital with no ill effects.

After taking independent advice from a consultant colorectal surgeon, we did not uphold Mrs C's complaint. The adviser reviewed the medication that Mrs C received prior to the procedure and confirmed that this was appropriate. The adviser noted that Mrs C had previously had a similar procedure at another hospital and advised that whilst the reasons why this type of investigation can be successful for the same patient on one day but not another are not clear but that is sometimes the case. It was also noted that Mrs C had undergone major abdominal surgery in the past and the adviser explained that adhesions (scar tissue that can make tissues or organs inside the body stick together) can cause pain during colonoscopy procedures.

Although Mrs C's complaint was not upheld, the adviser pointed out that some of the patient information and other guidance did not appear to be current or was due for review, and also that the consent form for the procedure had not been countersigned. We made a number of recommendations to address these issues.

Recommendations

We recommended that the board:

• review their internal guidance and patient information leaflets in relation to colonoscopy procedures to ensure they are current;
• confirm the adviser's comments will be considered during the next review of the pre-procedure patient information leaflet and consent form; and
• take steps to ensure that all endoscopy consent forms are appropriately countersigned.