Some upheld, recommendations

Summary

C complained about the treatment provided to their late parent (A) by their GP practice. A had prostate cancer for a number of years which later spread to their liver.

C complained that the practice failed to reasonably monitor A's blood sugar levels (HbA1c) after prescribing medication. We took independent advice from a GP. We found that the decision to commence medication for A's raised HbA1c was reasonable and appeared to be made with the input of a specialist medical consultant. However, there was no record to indicate that the practice discussed the risks of hypoglycaemia (low blood sugar) with A or took steps to allow A to monitor their blood sugar levels. We considered that the responsibility of monitoring any risks from the medication fell to the practice. Therefore, we upheld this aspect of C's complaint.

C complained that the practice failed to reasonably respond to A's reduced haemoglobin (Hb) levels. We found that, while the actions taken after the blood test results reported two weeks prior to A's death were reasonable, there was an opportunity prior to that to act on A's falling Hb levels. We noted that given the trend of A's falling Hb levels and their overall clinical picture, there was a fair to good chance that A's condition would deteriorate prior to a scheduled admission for a blood transfusion. We considered that the decision not to admit A prior to the scheduled admission, was a doctor-led decision rather than one made in conjunction with A and their family's wishes. As such, we upheld this aspect of C's complaint.

Finally, C complained that the practice failed to reasonably manage A's pain and comfort. We found that the pain management was reasonable and that the practice provided a high standard of palliative care. The medications administered, the timing of them and the increases in dosage were in keeping with the recommended standards of care, and in keeping with A's needs. Therefore, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably manage A's blood sugar levels after prescribing medication and the delay in responding to A's falling Hb levels. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Decisions about admission for treatment should be made in conjunction with the patient's and family's wishes.
• The practice should discuss with patients the risk of hypoglycaemia, or the institution of finger prick monitoring when instigating medication affecting HbA1c. The patient should be counselled about the risk and this should be recorded.
• Trends towards falling Hb in a patient with cancer should be noted and acted on timeously.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the treatment provided to their parent (A) by the board. A had prostate cancer for a number of years. A's symptoms worsened in the period complained about and it transpired that the cancer had spread to A's liver. C considered that the care and treatment provided by the board in the period prior to A's death was unreasonable, with the board failing to reasonably respond to A's worsening condition.

We took independent advice from a consultant in palliative medicine (caregiving approach aimed at optimising quality of life and reducing suffering among people with serious, complex illness), a registered general nurse and community health specialist nurse practitioner.

C's first complaint was that the board failed to reasonably respond to A's reduced haemoglobin levels. We found that A's haemoglobin levels were appropriately managed with regular review and assessment of symptoms, and the prescribing and monitoring of 'safer' medication before planning a transfusion. We noted that there was appropriate escalation of the transfusion date once doctors became aware that the haemoglobin had fallen further. Based on A's condition at the time, the initial planned date of admission for transfusion was reasonable. As such, we did not uphold this aspect of C's complaint.

C complained that the board failed to reasonably manage A's pain. We found that the levels of pain medication prescribed were reasonable. We noted that pain was not identified as a problem or symptom during A's hospital stay, therefore, discharge without regular morphine medication was reasonable. On discharge, the board appropriately handed over care to the GP, the local hospice and community palliative care. We found that when A exhibited pain, they were reviewed in line with guidance and appropriate medication was prescribed. District nurses administered pain medication through the 'just in case' medications prescribed while A was at home. As such, we did not uphold this aspect of C's complaint.

C complained that the board failed to reasonably discharge A from hospital. We found that, while the decision to discharge A was a reasonable one, and most services were appropriately notified of A's discharge, district nurses were not, impacting on the support provided by this service immediately after discharge. There was also a failing in providing a reasonable level of support for A to dress immediately prior to discharge. As such, we upheld this aspect of C's complaint. We noted that the board were sorry that more support was not offered.

C complained that the board unreasonably failed to provide a new mattress in a timely manner. We found that, while the delay in notifying the district nurses of the arrival of the mattress was unfortunate, we accepted that the board provided a mattress within 24 hours which was a reasonable response to an equipment request. We accepted that the district nurses were unaware of delivery on the day of delivery but once they became aware, a plan to transfer A was put in place. We considered that the delay in transfer was due to a holistic assessment of A's needs at that time which was appropriate in the circumstances. As such, on balance, we did not uphold this aspect of C's complaint.

Finally, C complained that the board failed to provide reasonable nursing care when transferring A to the new mattress. We found that the board had provided reasonable nursing care when transferring A onto the mattress, based on the records available. We noted that pain medication was administered prior to the transfer, which was reasonable. As such, we did not uphold this aspect of C's complaint. However, we noted that there was limited documentation of the event and fed this back to the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's discharge. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Referrals to the palliative care team should contain all relevant information.
• The rapid discharge algorithm for last days of life should be followed for future discharges.
• When there is the presence of confusion and/or deteriorating function in a patient, assistance should be considered to ensure a patient is dressed appropriately before leaving the ward.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained to us on behalf of their adult child (A). A had several attendances at Victoria Hospital and admissions for further investigation following a period of illness with severe stomach pain, nausea and vomiting. C raised concerns about A's medical care and their nursing care.

We took independent advice from a consultant gastroenterologist (a specialist in diagnosing and treating disorders of the stomach and intestines). We found that A was given appropriate medical care and treatment and we did not uphold that aspect of C's complaint.

We also took independent advice from an acute nursing specialist. We found that there were delays or issues in getting some of A's prescribed medications. Also, on one occasion, A was given a dose of a medication that was higher than recommended. We found that as A developed a staph aureus bacteraemia (SAB, where a bacteria commonly found on the skin enters the body) infection during their admission, the board appropriately carried out a significant adverse event review and took steps to improve this aspect of care. However, we found that the specific concerns that A's family raised about what caused A's SAB infection should have been addressed in their significant adverse event review. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Adverse event reviews should address questions or concerns raised by the patient/their family, in line with relevant guidance.
• Medication should be administered to patients safely, appropriately and in line with their prescription.
• The board should have an appropriate system in place for accessing and administering less common medications.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that their adult child (A)'s dyslexia was not taken into account when the board provided them with care and treatment, and that the care and treatment was not of a reasonable standard. C believed that if A's treatment had been better, then they would have had a better chance of surviving their cancer diagnosis. C felt that A's condition had been misdiagnosed because of A's age, as they were much younger than most people who suffered from this type of cancer.

We took independent advice from an appropriately qualified adviser. We found that the board accepted that they had not been aware of A's dyslexia. We also found that there was no evidence that A lacked the capacity to make decisions about their care and treatment and that at the majority of their appointments, they had been accompanied by their other parent. Therefore, we did not uphold this aspect of C's complaint.

In terms of their care and treatment, we found that A had been difficult to diagnose because the options were limited for medical staff, due to A's unwillingness to agree to treatment. However, it would have been appropriate for A's case to have been discussed earlier at a multidisciplinary team meeting. This might have resulted in A's cancer being identified sooner. We upheld this aspect of C's complaint. However, this did not mean that the outcome for A would have been different, as the cancer was very aggressive, and it was unlikely that its progression could have been slowed or halted.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not having held a multidisciplinary team meeting to discuss A's case at the earliest opportunity. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should ensure clinicians have time to access multidisciplinary team meetings including all appropriate specialties to discuss unusual cases.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about a failure to accurately diagnose and treat their parent (A)'s pancreatic cancer. A was being investigated by Raigmore Hospital in the months prior to their death. C complained that too many invasive tests were carried out and an accurate diagnosis was not established.

We took independent medical advice from a consultant surgeon, who noted that A had an advanced pancreatic cancer which can be difficult to diagnose. We considered that repetition of invasive tests was reasonably required in order to pursue a diagnosis. We noted, however, that A's lung abnormalities were discussed by a lung multidisciplinary team (MDT), but an upper gastrointestinal MDT was not involved despite the fact the suspicion of pancreatic cancer could not be ruled out. We fed this back to the board. However, overall, we considered that there was a comprehensive attempt to obtain a diagnosis. On balance, we did not uphold this complaint.

C also complained about a failure to communicate clearly with A and the family regarding the diagnosis. They said that they were never made aware of the suspected cancer diagnosis, despite this having been documented throughout the records. We found no evidence to support that timely and meaningful discussions took place with A and their family. A consented to multiple invasive tests without being made aware that suspected cancer was being investigated. We considered that the risks and benefits of these tests should have been clearly discussed with A, in order for them to have made a fully informed decision as to whether to proceed with them. In the circumstances, we upheld this complaint. We also noted that the board's response to C's complaint did not provide a sufficient explanation of the extent of the tests carried out.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that timely and meaningful discussions did not take place with A and the family to inform them of the suspected cancer diagnosis and make them aware of the purpose, potential benefits and risks of invasive investigations; and that the complaint response did not comprehensively address the specific concerns raised. The apology should meet the standards set out in the SPSO guidelines on apology: www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients should be provided with all the information they need to be able to make informed decisions about their care. This should include information about their diagnosis; any uncertainties in this regard; and a clear explanation of the purpose of any proposed investigations or treatment, including potential benefits and material risks. This should be adequately recorded in the case notes to evidence that meaningful dialogue has taken place.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their spouse (A) about the treatment they received from the board. A was originally referred to a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system) at a different health board. Following further investigations, A's case was discussed at a multidisciplinary team meeting (MDT) which includes specialists from health boards in the west of Scotland. As Glasgow has a subspecialty in gynaecological cancers, Greater Glasgow and Clyde NHS Board took the lead in determining A's treatment plan. A was diagnosed with probable ovarian cancer and was treated with chemotherapy and surgery.

C complained about a delay in starting A's treatment, about the decision not to offer chemotherapy first and about how the board responded to their contacts during this time.

We took independent advice from a consultant gynaecological oncologist (cancer specialist). Scottish Government guidance, NHS Scotland performance against Local Delivery Plan standards, says that 95% of all patients diagnosed with cancer are to begin treatment within 31 days of decision to treat. A's treatment was not provided until 40 days later (nine days more than the guidance). Greater Glasgow and Clyde NHS Board were responsible for meeting this target, and it was not met. We upheld this complaint.

We found that while some clinicians would have treated with chemotherapy first, it was also completely acceptable practice, and indeed encouraged by relevant clinical guidelines, to provide surgery first. We did not uphold this complaint.

We considered the communication between C, A and the board. We found that while not every contact was responded to as quickly as the board said it would, and some communication was passed on without acknowledgement, the board did respond to the substantive questions C and A raised and had appointed a single point of contact to help communication going forward. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to meet the Local Delivery Plan standard. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about a number of different aspects of the board's communication with them. Firstly, C complained about how the outcomes of two magnetic resonance imaging (MRI) scans were communicated to them. In respect of one scan, a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system) advised there had been “no change”. A later scan was then described as “unchanged over time”. After C obtained their medical records, they concluded that there were changes identified in both of the MRI scans.

We took independent advice from a consultant neurologist. We found that it was reasonable to describe the results as unchanged. We noted that most clinicians would, on receiving a report which described changes in a lesion which were of no clinical significance, report to the patient that there was no change. We understood why C may consider the information passed to them to be inaccurate compared to the more detailed records they obtained through a subject access request. However, we concluded that the results of the MRI scans were communicated to C in an acceptable manner and the board did not fail to carry out any follow-up actions that they should have. Therefore, we did not uphold this complaint.

C also complained about the board's communication with them following a consultation with a consultant ear, nose, throat and skull base surgeon. C had been referred by another consultant for a second opinion. Following the consultation, the consultant wrote to the referring consultant and copied in C's GP. However, C did not receive any communication about the outcomes of the consultation and their GP advised them that it is not a GP's responsibility to share results of tests initiated by a secondary care doctor with patients. In C's view, the board should have communicated the outcome of the consultation to them directly.

We found that local policies and procedures may affect how outcomes of consultations are communicated to patients. We were satisfied that the board appeared to agree that it is not a GP's responsibility to relay such outcomes to their patients. However, we would expect the patient to be copied into documentation unless there is a specific reason not to. We considered it unreasonable that the outcomes of the consultation were not communicated directly to C in some form. As such, we upheld this complaint.

Finally, C complained that the board failed to respond reasonably to their complaint. In C's view, the board's stage 2 response did not address several important points of their complaint and contained inaccuracies. We considered the board's stage 2 response to be a broadly reasonable and good faith attempt to address C's concerns. However, we concluded that there were specific aspects of the board's stage 2 response that undermined their efforts to address C's concerns. Firstly, a poorly worded statement caused it to be fundamentally inaccurate and confusing. Secondly, in some instances, the board failed to provide direct responses that tied clearly into C's complaint points. Given these shortcomings, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable response to certain aspects of their complaint and for failing to communicate the outcome of their ear, nose and throat consultation directly to them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should ensure that the outcomes of consultations carried out by secondary care clinicians are communicated to the patient in an appropriate and recognised method. It should not be assumed that the patient's GP will forward any correspondence to them.

In relation to complaints handling, we recommended:

• In line with the Model Complaint Handling Procedure, stage 2 complaint responses should be clear and easy to understand, and address all the issues raised and demonstrate that each element has been fully and fairly investigated.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their spouse (A). A was urgently referred to a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system) at Forth Valley NHS Board. Following further investigations, A's case was discussed at a multidisciplinary team meeting (MDT) which included specialists from health boards in the west of Scotland. A different health board took the lead in determining A's treatment plan. A was diagnosed with probable ovarian cancer and was treated with chemotherapy and surgery.

C complained about a delay in starting A's treatment, about the decision not to offer chemotherapy first and about how the board responded to their contacts during this time.

We took independent advice from a consultant gynaecological oncologist (cancer specialist). Scottish Government guidance, NHS Scotland performance against Local Delivery Plan standards, says 95% of those referred urgently with a suspicion of cancer to begin treatment within 62 days of receipt of referral. From A's urgent referral to the start of treatment was 63 days, one day more than the guidance. As Forth Valley NHS Board was responsible for meeting this target but did not meet it, we upheld this complaint.

We found that while some clinicians would have treated with chemotherapy first, it was also completely acceptable practice, and indeed encouraged by relevant clinical guidelines, to provide surgery first. We accepted this advice and did not uphold this complaint.

We considered the communication between C, A and the board. We found that while not every contact was responded to as quickly as the board said it would, and some communication was passed on without acknowledgement, the board did respond to the substantive questions C and A raised. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to meet the Local Delivery Plan standard. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C raised a number of concerns about the social work service provided by the council in relation to the contact between their child (A) and A's non-resident parent. At the time of the complaint, the social work service was responsible for managing contact between A and the non-resident parent.

We took independent advice from a social work adviser. C firstly complained about the way the council acted in relation to concerns they raised about what was in A's best interest. We found that the council acted reasonably in relation to a number of the concerns C raised. However, we also found that there was a failure in one instance to carry out a risk assessment timeously. On balance, we upheld C's complaint.

C also complained about the way the council handled a meeting that had been arranged to discuss A's contact arrangements. We did not identify failings in relation to this aspect of C's complaint and we did not uphold the complaint.

Finally, we considered the council's handling of C's complaint. We found that the council's complaint response did not address a number of C's points of complaint and that it failed to include an apology for a service failing the council identified during their own investigation. We made recommendations in relation to complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a risk assessment timeously; for the service failing identified in the council's stage 2 response; and for the issues with complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• National Guidance for Child Protection in Scotland and the National Framework for Risk Assessment should be followed in relation to assessing risk.

In relation to complaints handling, we recommended:

• Under the Local Authority Model Complaints Handling Procedure, an investigation should explore the complaint in more depth and establish all the relevant facts. The aim is to resolve the complaint where possible, or to give the customer a full, objective and proportionate response. Where failings are identified, an apology should be offered.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their parent (A) after A was unwell and a GP made a home visit to assess them. The GP called for an ambulance for a 'within the hour' response. The ambulance service called back later and spoke with C to advise that the ambulance was delayed and would attend as soon as possible. C later called 999 and advised that A's condition had deteriorated. This resulted in a higher priority ambulance being assigned.

C complained to the ambulance service about the failure to respond to the requests for an ambulance. In response, the ambulance service acknowledged they failed to meet the initial one-hour response requested, but explained that one-hour ambulance responses are not automatically upgraded. They said that in these circumstances they call back to explain the delay, ask if there is a change in the patient's condition and advise patients to call 999 if there is a change.

C complained to our office that the ambulance service had failed to take account of A's diagnosis provided by the GP, and had therefore not attributed the correct level of priority to the response. C also considered that there was no attempt by the ambulance service to undertake clinical triage of A, resulting in the response level not being upgraded as it should have been. C was unhappy with the investigation and response to their complaint and believed the ambulance service's response to the complaint was not plausible.

We found that whilst there was a significant delay in the ambulance attending to A, this was attributable not to failings on the part of the ambulance service in prioritising the request for an ambulance, but on the lack of available resources at the time.

However, we found that during the welfare call back, the ambulance service should have sought to clarify whether C considered A's condition had deteriorated before continuing with the call. On this basis, we upheld the complaint with respect to unreasonably failing to respond to the request for an ambulance. With respect to the complaint about the complaints investigation, we found the complaints investigation and response was reasonable and did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to confirm whether or not A's condition had worsened before continuing with the call. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• In circumstances where a call handler calls a patient, in line with the Urgent Welfare Call Back Process, they should make reasonable efforts to confirm whether or not the patient's condition has worsened. Where a call handler is unable to obtain clarification as to whether the patient's condition has worsened, the call handler should process the call through the MPDS system in line with the normal emergency call handling process.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.