Some upheld, recommendations

Summary

Mr C complained about his care and treatment while he was being treated by a consultant surgeon in Ninewells Hospital. He said that, although he had lost weight, lost his appetite and become increasingly thin and lethargic, the surgeon discharged him and referred him to the care of a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). Mr C said that it was only by chance that the seriousness of his condition was appreciated. He also complained that the board delayed in responding to his complaint about this.

We considered all the complaints correspondence and Mr C's relevant medical records as well as taking independent advice from one of our medical advisers. We found that a scan had showed that Mr C had a narrowing of his colon (part of the large intestine). A later review noted that he felt well, had no pain and his bowel habit was unchanged, and it was decided to keep him under review and to scan him again later. Some 14 months after this, he went to a surgical out-patients' clinic and as he was complaining of a swollen stomach and the inability to eat, a scan was arranged for the following month. This showed further thickening in his colon and in the small intestine, and doctors decided to review him again in six months. By that time, his symptoms had settled but he was lethargic and nauseous, and the surgical team felt that there was no surgical solution to the problem. They referred him to gastroenterology for advice and further management.

Mr C continued to lose weight and was prescribed intravenous nutrition (fed directly into a vein), but his condition continued to decline and another scan was organised. This showed evidence of chronic small bowel obstruction and he was referred back for surgery. Because of this, Mr C felt that the surgical team should not have discharged him to gastroenterology when they did. Our adviser, however, said that given Mr C's symptoms at the time this was not an unreasonable approach to take, and that the thickening of his colon could have been considered to be due to disease and not a bowel obstruction. We accepted this advice, and did not uphold Mr C's complaint.

We did, however, uphold his complaint about complaints handling. The board acknowledged that there was delay, and said this was because their complaints team were awaiting clinical information so that they could respond fully. They had already highlighted to the team as a learning point both this failure and the fact that the team should explain such delays when writing to the person who has complained. As they had already taken this action, we made only one recommendation.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to respond to his complaints within published timescales.

Summary

Mrs C's late mother (Mrs A) was admitted to the Western General Hospital as an emergency, and had an operation to release pressure in her bowel. She was told that her case would be discussed by a multi-disciplinary team (MDT) in a few days, and that they would advise on her future treatment. Before this could happen, Mrs A fell and broke her hip and was transferred to the Royal Infirmary of Edinburgh for an operation, where two days later she suffered a heart attack and died. Mrs C complained that the board did not keep her fully informed about her mother's condition and what was happening. She said she had understood that her mother's case was to be discussed at the MDT meeting at the Western and this had not happened, which caused both her and her mother upset and confusion. Mrs C was also unhappy because she said that her mother's risk of falling was not properly assessed and prevented by the Western General and that the board took too long to answer her complaints.

We took independent advice from two of our advisers, one a consultant surgeon and the other a nurse. We also considered all the relevant information, including all the complaints correspondence and Mrs A's clinical records, after which we did not uphold three of Mrs C's complaints. Our surgeon adviser said that, after Mrs A's fall, the priority was, correctly, to address her broken hip and make sure that she was recovering from it well before moving on to discuss her future treatment. We noted that although it was not unreasonable that discussions did not take place because of what happened, the board had said that in future the MDT would not cancel discussions without telling the patient and their families why. The records also showed that Mrs A had been assessed as not being at risk from falling, and although she did fall, this could not have been anticipated. Although Mrs C said that the board took too long to address her complaints, we found that they did respond within acceptable time limits. We upheld the complaint about communication, however, as it was clear that the board had not kept Mrs C as well informed as she should have been, particularly about her mother's fall.

Recommendations

We recommended that the board:

• apologise for their failure in this matter; and
• remind staff of the importance of keeping relatives and their families informed, in a timely manner, when an accident/injury occurs.

Summary

Mrs C has complex health and mobility issues and has seen a number of hospital consultants over several years. After she saw a consultant orthopaedic surgeon she said she was not given enough information about her diagnosis, and the consultation was rushed. The surgeon arranged a scan, but Mrs C was unable to go through with it and a different scan was carried out instead. Mrs C said that when she raised concerns about the proposed treatment the surgeon did not then discuss alternatives, and she was unhappy with the way the surgeon described events on the day of the scan when writing to her GP about it. Mrs C then attended another consultant's clinic, but he was not there to see her. Mrs C complained to the board about both consultants. The board responded in writing and met with her, but she came to us as she was not happy with the way they handled her complaints. She said that she did not receive an amended agreed copy of the minutes of the meeting, although she provided detailed comments and followed this up with several phone calls and emails. She was also unhappy about the board's response to her complaint about the surgeon, and said that they had not explained how the missed appointment with the second consultant had come about.

We found that the board did not tell Mrs C what had happened about the updated minutes of the meeting, and that, while they responded to her complaint about the surgeon's communication and attitude during consultations, they had not properly addressed the issue of the use of inappropriate language when writing to her GP. We were satisfied that they provided a reasonable explanation and response about the missed appointment with the second consultant.

Recommendations

We recommended that the board:

• clarify in writing to Mrs C the status of the amendments in relation to the meeting note;
• bring the failures in their complaints handling identified in our investigation to the attention of relevant staff; and
• apologise to Mrs C for the failures our investigation identified.

Summary

Mr C complained about the board's treatment of his wife (Mrs C) when she was admitted to the Royal Infirmary of Edinburgh. Mrs C, who had a history of severe renal (kidney) failure, had hip replacement surgery and was kept in for five days. During that time she experienced constipation and although she asked staff for laxatives, these were not provided before she was discharged home. Mrs C continued to suffer from constipation there. She developed a sore, swollen stomach and began vomiting black liquid. Concerned about her condition, Mr C phoned NHS 24 and requested a home visit from an out-of-hours GP. The GP examined Mrs C and prescribed two enemas and laxatives. He advised Mr C to monitor her overnight and to call Mrs C's own GP in the morning if she did not improve. As she did not improve, Mr C called the GP, who examined her and immediately referred her to hospital, where she was diagnosed with a perforated bowel and had emergency surgery. Mr C complained that this could have been avoided had his wife been given laxatives in the hospital and had the out-of-hours GP recognised the seriousness of her condition.

We upheld the complaint about Mrs C's hospital treatment, as we found that that staff clearly failed to provide her with laxatives during her admission, despite her requests. We accepted independent medical advice that patients with renal failure are particularly sensitive to medications and their side effects, noting that Mrs C was on pain medication containing codeine, which is known to cause constipation. Staff should have been aware of the increased risk of constipation and should have closely monitored her for this. Although tools were available to prompt them to ask patients about their bowel movements, staff did not use these and Mrs C was discharged without a proper assessment of her bowel activity. We did not, however, uphold the complaint about the out-of-hour GP's examination of Mrs C, as we found that medical records showed that her symptoms at the time did not suggest a perforated bowel. As such, the treatment provided and the advice offered was entirely reasonable under the circumstances.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for failing to implement the safeguards that they had in place to identify and manage constipation during Mrs C's admission; and
• conduct a review to assess whether their post-operative care pathway and patient information are sufficiently rigorous, particularly for patients with renal failure.

Summary

Ms C's late father (Mr A) had a complex medical history including heart disease. He had a chest x-ray, which showed a mass on the lung but was wrongly reported as normal. After further tests and body imaging Mr A was diagnosed with advanced lung cancer. Ms C said Mr A was told that his tumour was inoperable, and it was decided to treat him with chemotherapy and radiotherapy. Mr A developed kidney disease after the first cycle of chemotherapy, which was stopped, and he was then treated with radiotherapy. However, he became more unwell and was diagnosed with radiation pneumonitis (lung damage arising from radiotherapy). A scan the next month showed lung changes that were reported as relating to emphysema (lung disease that causes shortness of breath). Shortly afterwards, however, an underlying lung condition was detected. Mr A continued to deteriorate and he was admitted to the Western General Hospital where, despite treatment, he died.

Ms C complained that the hospital did not detect her father's underlying lung condition quickly enough. She said that, had it been spotted earlier, Mr A could have had surgery instead of radiotherapy, which she believed would have led to a more positive outcome. She was concerned about a consultant's communication with her family about her father's treatment options, and said that the board failed to treat his heart condition. She was also unhappy with the way they handled her complaint.

We took independent advice from two of our medical advisers, who specialise in oncology (treatment of patients who have cancer) and radiology (the analysis of images of the body). They said that it was reasonable that Mr A's underlying lung condition was not detected earlier and, while knowing about it might have made radiotherapy a more risky option, surgery was also a high risk option with no guarantee of a cure. The oncologist said that the management of Mr A's conditions was appropriate based on information available at the time of treatment (including for his heart condition). We appreciated that, for the family, learning about Mr A's underlying lung condition was extremely distressing and clearly caused them a great deal of uncertainty about the potential outcome. However, our adviser said that it was very unlikely that Mr A's life expectancy would have been different had treatment changed. Our radiology adviser criticised the radiologist's interpretation of the x-ray, although they also said that the failure to identify the mass would not have affected the outcome. Although a number of aspects of Mr A's care and treatment were reasonable, we upheld the complaint as there was an unreasonable delay in identifying the mass, which was a significant failure and led to a delay in diagnosis.

We did not uphold Ms C's complaint that the consultant did not discuss surgery or heart treatment. The advice we accepted was that communication was reasonable and there was evidence that treatments were fully discussed. This was on the basis of the information available to board staff at the time and, as already noted, it was reasonable that they did not pick up Mr A's underlying lung condition earlier. Our oncology adviser also said that there was evidence that the consultant had explained the issues and obtained Mr A's consent for treatment.

On the complaints handling, we were satisfied that the board fully addressed the complaint and that the time they took to respond was reasonable as there were delays in obtaining consent from the family. However, it was clear after further contact from Ms C that she wanted clarification and a further response to the issues raised, and the board should have taken earlier steps to provide this.

Recommendations

We recommended that the board:

• raise the failures identified with relevant staff; and
• apologise to Ms C for the failures identified.

Summary

Mr C was admitted to Monklands Hospital with suspected kidney damage. He was already suffering from end stage alcoholic liver disease. Mr C was initially cared for in the Emergency Receiving Unit (ERU), where he fell twice. He was then transferred to a ward. Mr C's condition continued to deteriorate. Four days after he was admitted he was reviewed by a consultant, and staff contacted his wife (Mrs C) and asked her to come to the hospital urgently as he was considered to have a very poor prognosis. Mr C died that day.

Mrs C complained that her husband did not receive appropriate medical or nursing care when admitted to hospital, and that he was not properly assessed as a fall risk whilst in the ERU. She also said that when he was transferred from the ERU to a ward there was no proper handover and nurses had lost a crucifix he wore. This was returned to her after he died, but had been irreparably damaged. Mrs C said that medical staff were slow to assess her husband's problems and failed to provide him with the appropriate treatment, as they had not considered him for a liver transplant. She was also unhappy with the board's response to her complaint, which listed Mr C's entire medical history and emphasised the role alcohol had played in his ill health, which she felt was insensitive.

We took independent advice from a medical adviser and a nursing adviser. The medical adviser said that although the medical treatment provided to Mr C was appropriate, communication by medical staff fell below a reasonable standard. He said that they had not discussed with Mrs C the decision to designate her husband as 'Do Not Attempt to Resuscitate' (DNAR - a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). They had also not explained either his poor prognosis or the decision not to refer him for a liver transplant, contrary to General Medical Council guidance. The adviser said that the decision not to refer Mr C for a transplant was, however, in itself reasonable in the circumstances.

The nursing adviser said the standard of basic nursing care was reasonable, but the record-keeping of staff in ERU fell below an acceptable standard. They had not completed the falls assessment in a timely fashion and had not responded quickly enough to Mr C's first fall. It was not possible to be certain his second fall could have been prevented, but nursing staff had not taken the appropriate action, which was unacceptable. The adviser also said staff had not shown empathy or compassion to Mrs C while her husband was dying, and end of life care was a key part of the nursing and midwifery code.

We upheld most of Mrs C's complaints, as our investigation found that the nursing and medical care provided to Mr C fell below an acceptable standard. We did not uphold the complaint that he was not considered for a transplant.

Recommendations

We recommended that the board:

• apologise in writing for the failings identified in our investigation;
• ensure patients are provided with up to date information on their suitability for liver transplant referral;
• remind all nursing staff responsible for Mr C's care of the importance of communication with family members during end of life care;
• remind nursing staff in the ERU of the importance of ensuring records are accurate and contemporaneous;
• remind nursing staff in the ERU of the importance of the timely assessment and implementation of falls reviews;
• review their procedures for assessment and care planning for patients at risk of falls;
• review the handover process for ERU staff to ensure that it is being carried out appropriately;
• remind the medical staff responsible for Mr C's treatment that where a patient has been designated DNAR for medical reasons, the earliest opportunity should be sought to discuss this with the patient and their family; and
• remind the medical staff responsible for Mr C's treatment of the importance of discussing a patient's prognosis with them and their family at the earliest opportunity.

Summary

Mrs C complained on behalf of her son (Mr A) that his medical practice failed to provide him with appropriate care before and during appointments when he attended the practice with concerns about his physical and mental health. She also complained that the practice had, following the appointments, unreasonably removed her and her son from their list of patients.

We reviewed the clinical records and obtained independent advice from our medical adviser. Having considered the medical records, he said that the care given to Mr A was reasonable, so we did not uphold this element of the complaint. We noted that, after the second appointment, the police had to be called because of Mr A's violent and threatening behaviour and Mrs C's abusive behaviour, and that it was following this that both were removed from the practice list.

Having reviewed the case we established that the practice had followed the correct procedure in terms of removing Mr A from their list because of his violent behaviour, and we did not uphold this aspect of the complaint. However, Mrs C had not been violent and they did not give her a written warning, allowing her the opportunity to modify her behaviour. Before removing a patient whose behaviour is non-violent, but unacceptable, the practice are required to warn them about this, and so we upheld this aspect.

Recommendations

We recommended that the practice:

• review their removal policy to ensure that it reflects the terms of the NHS General Medical Services Contracts (Scotland) regulations and associated guidance, particularly in respect of giving patients relevant prior warning if they are at risk of removal; and
• apologise to Mrs C for not following the proper procedure when removing her from their list of patients.

Summary

Ms C attended the medical practice a number of times with various symptoms including constipation, low abdominal pain, recurrent urinary symptoms and diarrhoea. She was also treated in hospital for kidney inflammation. Ms C was eventually diagnosed with pelvic inflammatory disease (PID) and said she was told that she was infertile as a result of the delay in diagnosing and treating this. She complained that the practice did not provide her with adequate care and treatment by failing to investigate her repeated symptoms and diagnose PID.

We took independent advice on this case from one of our medical advisers. The advice, which we accepted, was that the care and treatment Ms C received was not unreasonable. The adviser said that PID is a difficult condition to diagnose, with symptoms that may also be indicative of other more common diseases, or that may not appear at all. There was nothing typical or suggestive of a diagnosis of PID in Ms C's consultation records, and the adviser agreed with the practice that Ms C did not present with a clear cut case of PID. While we did not uphold this aspect of Ms C's complaint we recommended that the practice reflect on issues raised by the adviser in relation to their record-keeping and symptom review in relation to PID.

Ms C also complained that the practice delayed in responding to her complaint. We found there was delay in their investigation of Ms C's complaint and a failure to keep her updated about the investigation.

Recommendations

We recommended that the practice:

• reflect on our adviser's comments about the lack of detailed recording of negative findings, and discuss ways to improve this;
• reflect on the learning identified in our investigation about the presence of sterile pyuria (the presence of elevated numbers of white cells in urine which appears sterile using standard culture techniques), which can be linked to PID;
• issue a written apology to Ms C for the unreasonable delay in responding to her complaint; and
• review their complaints handling guidance and training to ensure that this includes: the obligation to promptly investigate and respond to complaints; the obligation to advise the complainant of any delay, together with an explanation for the delay and an estimated time-frame for response; and where an investigation exceeds 20 days, the obligation to advise the complainant that the SPSO may be willing to consider the complaint before their investigation is concluded.

Summary

Mrs C complained about the care and treatment that her late father (Mr A) received at University Hospital Ayr for prostate cancer and the palliative care (care to prevent or relieve suffering only) he had at home during the last weeks of his life. Mrs C said that her father's cancer was not properly monitored, and that this meant that doctors were not aware when it started to spread. She complained that had he been properly monitored this could have been treated, he would have lived longer, and would have suffered less pain. She also complained that the palliative care was inadequate and, because he was too unwell to be at home, this led to him being transferred to a hospice shortly before his death, against his wishes.

We took independent advice from two of our advisers - an oncology adviser (cancer specialist) and a nurse. The oncology adviser found that there were monitoring failures, with appointments cancelled and not reinstated. However, he said that Mr A was given appropriate treatment, and that the delay in some consultations did not affect the decisions doctors made about treatment. Our nursing adviser said that Biggart Hospital, where Mr A was an in-patient towards the end of his life, should have involved the district nurse in planning for his discharge while he was still in hospital. She also said that once the district nurse was involved, Mr A's palliative care was not sufficiently assessed and planned, and that the family's needs were not appropriately taken into account. She was critical that the family's concerns were not responded to when they were first raised, and continued to be overlooked, even when Mr A was becoming very unwell.

On the basis of the advice we received, we found that the board did not monitor Mr A's cancer appropriately. However, they had already identified this and had taken steps to ensure this did not happen again. We did not consider that this failing had any significant impact on Mr A's medical treatment. In relation to Mr A's palliative care, we found failings by both hospital and district nursing staff.

Recommendations

We recommended that the board:

• ensure that all patients receive clear information on how prostate cancer is monitored, what treatment options are available, and when they might be applicable;
• review arrangements for the discharge of terminally ill patients to ensure district nursing staff are fully involved in discharge planning;
• ensure all district nursing staff have up to date training in their role in the provision of palliative nursing care; and
• apologise to Mrs C and her family for the considerable distress experienced by her father and her family, due to the board's failure to provide appropriate palliative care in the final weeks of Mr A's life.

Summary

Mr C, who is a prisoner, bought a watch through the prison's approved purchase scheme. Before issuing the watch to him, the prison removed the protective case and told Mr C he was not allowed to have it in use. Mr C complained that the decision was unfair.

The prison explained that this type of packaging had been identified as something in which prisoners might conceal illicit items. Because of that, they had decided not to allow prisoners to have such items in use. We found that the prison rules confirm that governors are entitled to refuse to allow a prisoner to have any items in use which might be damaging to the security or good order of the prison. We were satisfied the prison were entitled to take the decision to no longer issue such packaging in these circumstances, and we did not uphold that part of Mr C's complaint.

Mr C also complained to us that the prison failed to complete his complaint form properly. He said the governor had not indicated whether he accepted the decision of the internal complaints committee (ICC) on Mr C's complaint. Mr C submitted an additional complaint directly to the governor about that, but was advised to discuss it with his hall manager. Our investigation found that the prison rules confirm that the governor must tell a prisoner whether they accept the ICC's decision. They can do so by simply ticking a box on the complaint form. In Mr C's case, that did not happen, and the prison acknowledged that this had been an oversight. We upheld this part of the complaint because the prison failed to complete the form properly. In addition, when Mr C made his additional complaint the prison missed that opportunity to resolve the matter and he had to bring it to us.

Recommendations

We recommended that the Scottish Prison Service:

• apologise to Mr C for failing to complete his complaint form properly; and
• remind the governor, or those acting on his behalf, of the requirement to indicate at part 6 of the complaint form whether the ICC's decision is endorsed or rejected.