Some upheld, recommendations

Summary

C is the parent of a teenaged adult (A). A was admitted to an acute admissions ward of a mental health unit as an informal patient. The following day, A contacted C from the ward. A told C that they were in possession of razor blades and intended to self-harm. C contacted the ward to advise them of this and ward staff obtained the razor blades from A. A day later, A contacted C and told C they had left the hospital. C contacted the ward and the police, and A was returned to the ward. A was transferred to another location shortly afterwards. C complained that A had not been properly searched or reasonably assessed on their first arrival at the ward. The board told C that the routine risk assessment at admission had shown no indication A was at risk of absconding, and that this had led to the decision not to lock the ward door. They also said that a check of A's belongings when they were admitted had led to razor blades being taken from A's possession. C was dissatisfied with the board's response and brought their complaint to us.

We took independent advice from a mental health nurse. We found that A had not been properly searched upon their arrival, that it was unreasonable that the board had not carried out a medical, nursing or joint assessment on the day of A's admission and that the standard of assessment and care-planning at the point of admission fell significantly below professional expectations. We upheld C's complaint.

C also complained that the board unreasonably failed to call C, as they had promised, following C reporting A was in possession of razor blades and intended to self-harm. We found that the available written evidence and staff recollection did not support C's recollection that they had been promised someone would call them back. Therefore, we did not uphold C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that they were not properly searched or reasonably assessed upon their arrival at the ward. The apology should meet the standards set out inthe SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Medical/nursing assessments should be carried out and clearly documented as part of the admission process, and each patient has a documented initial care plan based upon the information gathered during the admission assessment process.
• The belongings of patients assessed as being at imminent risk of harm to self or others are checked for the presence of harmful objects or substances.

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

Mr C sustained a serious pelvic injury with internal bleeding following a road traffic accident and was admitted to Ninewells Hospital where he underwent surgery to repair the internal bleed and his fractured pelvis. Mr C suffered a further internal bleed and complained that there was a delay in identifying this bleed. Mr C also complained that the physiotherapy input he received following his surgery was unreasonable and may have caused his fracture to move; and that he was provided with inappropriate pain relief and his respiratory rate was not monitored properly.

The board considered that Mr C was monitored appropriately and that any delay in identifying the internal bleed was due to the fact that the CT scan was occupied by another patient. The board also considered that the physiotherapy input and pain relief provided were reasonable.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system), a physiotherapist and a general physician . We found that Mr C was appropriately reviewed and monitored and that there was no unreasonable delay in identifying the internal bleed. We also considered that the pain relief provided was appropriate and Mr C's respiratory rate remained stable. We did not uphold these complaints. However, with regards to the physiotherapy input, we found the standard of record-keeping to be poor and there was a failure to establish a treatment plan with agreed goals. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain all relevant information about him prior to beginning treatment and failing to establish a treatment plan with agreed goals. 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:

• Physiotherapy records should meet the minimum documentation standards and the quality of records should be audited regularly.
• The physiotherapist should reflect on their handling of this case and discuss their learning from it in a supportive manner with their line manager.

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 the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an emergency ambulance service for their child (A). C expressed concern about the overall time taken for A to be taken to hospital; which was approximately two hours from the original call being made requesting an emergency ambulance, to A arriving at hospital and being reviewed by a doctor. C also complained about how SAS responded to their complaint about that matter.

SAS upheld C's complaint on the basis of a longer wait than would have been expected for this category of call and offered an apology for that wait. They explained that this was a very busy time for the service but confirmed that a call audit had concluded that the call was handled very well and was of high compliance with their dispatch system.

We took independent advice from a paramedic. We found that there were concerns with SAS's response for an emergency ambulance, including:

The delay in elevating the response level which relied on the subjective opinion of a non-clinical call handler.

The lack of clinical advisor input into the call which could have negated the limitations of the system and possibly changed the level of acuity, and as such the response time and time taken for A to reach hospital.

The decision of the original ambulance crew to wait on the second responding crew to transport A.

Therefore, we upheld the complaint that SAS failed to respond reasonably to the request for an emergency ambulance to attend to A.

In relation to complaint handling, we found that SAS's response to C's complaint was appropriate. We also noted that their apology was in line with SPSO guidance. Therefore, we considered that SAS reasonably responded to C's complaint and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to respond reasonably to the request for an emergency ambulance to attend to A. 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:

• Clinical advisors should be able to assess a patient's condition in line with current guidance - which provides that a clinical advisor's first point of contact should be at 45 minutes from the time of call within the yellow patient cohort. If a decision is made for this not to happen, the reasons for that decision should be clearly recorded.
• Patients should be transported by ambulance using the appropriate harness.

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

Ms C complained about the care and treatment she received at the Royal Infirmary of Edinburgh. Ms C complained that she was unreasonably prescribed a drug, uniphyllin, in order to treat her asthma.

We took independent advice from a consultant in respiratory and general internal medicine. We found that it was reasonable to prescribe uniphyllin for Ms C's asthma and long-term breathing difficulties. Therefore, we did not uphold this aspect of the complaint.

Ms C experienced a tonic-clonic seizure (type of seizure that involves both stiffening and twitching or jerking of a person's muscles) whilst taking the drug and said that she was not advised that this was a possible side effect. We considered that it would have been reasonable for Ms C to have been provided with information so that she could be involved in decisions made about her care and the possible side effects of medication. We upheld this aspect of Ms C's complaint.

Ms C also complained that she was given an increased dose of the drug without the effect of this being monitored. We found that the symptoms Ms C was experiencing were not necessarily a sign that the dose she was given was too high. An increase was also reasonable for maximum therapeutic effect. We did not uphold this aspect of Ms C's complaint.

Finally, Ms C complained that there was an unreasonable delay in advising her to stop taking the drug after she had a seizure. We considered that it would have been reasonable for Ms C to have been advised in A&E to stop taking the drug when she was admitted after her seizure. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to advise her of the possible side effects of the drug and for failing to advise her when she attended A&E with a seizure that she should stop taking the drug because she was at risk of further seizures. 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:

• To ensure General Medical Council good practice is followed when considering treatments to ensure patients are aware of significant side effects.

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

Mr C has autistic spectrum disorder (a developmental disability that affects how a person communicates with, and relates to, other people). After attending an advice clinic, Mr C was assessed by a psychologist. He was then referred to a community mental health service to see if they could help him with social skills and managing anxiety. The community mental health service did not consider they could meet Mr C's specific needs; and they explained that he might be able to access support from a charity instead.

Mr C complained that after his psychology assessment, he was not referred for care and treatment suitable to his needs. We took independent advice from a psychologist. We found that Mr C was appropriately assessed and referred for help with social skills. We found that the community mental health service gave the referral careful consideration. We also found it was reasonable that they refused it, as the charity was better equipped to meet Mr C's needs. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to handle his complaint in a reasonable manner. We found that the board did not communicate clearly with Mr C about his complaint, in particular in relation to the scope of their investigation. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to handle his complaint in a reasonable manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• The board should communicate with complainants in a way that is clear and easy to understand.

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

Mr C complained that the board had not made reasonable decisions around whether to provide plasma exchanges (a procedure which separates your blood into its different parts: red cells, white cells, platelets and plasma. The plasma is removed from the blood and replaced by a plasma substitute) to his wife (Mrs A) and whether to further explore the possibility of thrombectomy (procedure of removing a blood clot from a blood vessel), or reasonably monitor her levels of consciousness during an admission to hospital following a stroke. We found that the board's decisions around plasma exchanges and the possibility of thrombectomy had been reasonable, but that the board had not reasonably monitored Mrs A's levels of consciousness for a period. This meant that there was a delay to the board providing her with specific treatment. Although this treatment had only a small chance of success, we decided that the board's actions had been unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained about how the board had responded to his complaint. We found that the board's responses had been reasonable and did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A's family for their unreasonable failure to monitor Mrs A's consciousness levels hourly, which caused a delay in providing reasonable treatment to her. 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 reasonably monitor patients' consciousness levels.

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 had a history of metastatic cancer (cancer which has spread to another part of the body). A attended their GP with a sudden on-set headache and was advised to attend the Glasgow Royal Infirmary (GRI). A arrived at GRI as an emergency attendance and was admitted for investigation. Scans were carried out which revealed that A had an intracranial metastasis (a malignant growth that had spread to the brain from a tumour in another organ). C complained that there was an unreasonable delay in the scans being carried out. C also complained that A had unreasonably been advised that surgery was not an option.

We took independent advice from a consultant in acute medicine and from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques). We found that there had been an unreasonable delay in the first scan being carried out given A's history, current medications and symptoms. All relevant information was not provided to the radiologist to determine the priority of the scan and, when the scan was not carried out as planned, the board failed to query this with the radiology department when it had not occurred as scheduled. We upheld this aspect of C's complaint.

In relation to the second complaint there was little information available to confirm exactly what was said between the board, C and A regarding the discussion that surgery was not an option for A. We found, based on the information available, that the board had reasonably informed A that curative surgery was not an option in relation to their intracranial metastasis. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to carry out A's scans in a reasonable timescale. 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:

• All relevant information should be provided to the radiology department when requesting a CT scan.
• Patients presenting with a headache and taking anticoagulant medication should receive appropriate investigations to identify whether an urgent scan is needed.
• The board should carry out scans in the timeframe agreed.

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

Ms C was referred by her GP to the board's Assisted Conception Service (ACS). At her appointment with ACS months later, she was told that it was too late to proceed with screening/referral to the Assisted Reproductive (ART) Clinic tertiary centre, as the waiting time for an appointment at the ART is five to six months, by which time she would be over the age limit (the upper limit to be eligible for in vitro fertilisation (IVF, a process of fertilisation where an egg is combined with sperm outside the body) treatment on the NHS). Ms C complained that, according to the information on the board's website, she should have been eligible for NHS fertility treatment.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system) and from a GP. We found that the information on the board's website regarding timescales for referral for fertility treatment had originally been incorrect, as it stated that a patient need only be referred prior to their 42nd birthday, as opposed to needing to be screened before their 42nd birthday. However, we found that the board had amended this information in order to ensure it was accurate. Whilst we welcomed this, we were concerned that the incorrect information was not noted by the board until drawn to their attention by our office.

We considered that, whilst changes had been made, the information on the website was still unclear as it did not explain the steps involved in screening, and the waiting times involved in these steps. We also found that the board's position regarding how they communicate this information to GPs is not in line with current primary care practice. We upheld this aspect of Ms C's complaint.

With regard to Ms C's complaint that she was unreasonably denied fertility treatment, we found that Ms C did not meet the criteria, and therefore it was reasonable to deny her fertility treatment. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C that the information on their website regarding timescales for referral for IVF is unclear. 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 information available to patients and GPs should make clear the referral pathway, screening process, and timescales involved in these steps, are explained clearly; including how long before the patients 42nd birthday they may need to be referred to complete the screening process in time.

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

Ms C complained about the care and treatment provided to her husband (Mr A) at the Royal Alexandra Hospital when he attended A&E with a headache, nausea, resolved left sided weakness and a facial droop. Mr A underwent medical review and scanning and was admitted into hospital. The following morning Mr A's condition appeared to deteriorate and following a further scan he was found to have had a type of stroke.

We took advice from a consultant in acute medicine, and a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the care and treatment provided to Mr A had been reasonable, with timely assessments and investigations. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the communication with Mr A's family, particularly when he deteriorated. The board had reviewed Mr A's care and acknowledged that there were failings in communication. Whilst the board had already shared the findings of their investigation widely, we made a further recommendation on this point. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failure to communicate reasonably with Mr A's family. 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:

• Communication with families/next of kin should be part of the response to a deteriorating patient.

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

Ms C, an advocacy worker, complained to us on behalf her client (Mr A) about the care and treatment Mr A received at a consultation when he disclosed details of his mental ill health. Ms C said that the GP did not make eye contact with Mr A and rushed through the consultation. Ms C also complained that Mr A was subsequently removed from the practice list after they submitted a complaint.

We took independent advice from a GP. We were unable to comment on the amount of eye contact made during the consultation as there was no evidence in relation to this. We noted, however, that the GP had stated that they would try to learn from this. The practice had also stated that the consultation took longer than the ten minutes allocated. We found that the practice had a lot of history available for Mr A and the decision to decline referral to psychiatric services was based on their knowledge of Mr A and his medical history. We considered that the care and treatment provided to Mr A at the consultation was reasonable and we did not uphold this aspect of the complaint.

In relation to the complaint that the practice unreasonably removed Mr A from their list, we found that the practice should have issued a warning letter to Mr A before removing him from their list. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to issue a warning before removing him from their practice list. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Consider any application to re-register on the practice list received from Mr A.

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

• A breakdown in a doctor/patient relationship should be managed in line with the General Medical Council's guidance and the relevant regulations.

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.