Some upheld, recommendations

Summary

Ms C complained that the board failed to diagnose a ruptured Achilles tendon when she attended Western General Hospital. We took independent advice from a consultant physician in acute internal medicine. We found that given the specific test for excluding a ruptured Achilles tendon was carried out, which resulted in a negative finding, it was reasonable that the ruptured Achilles tendon was not diagnosed. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the care and treatment she received at the Edinburgh Royal Infirmary after the ruptured Achilles tendon had been diagnosed. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the care and treatment provided to Ms C was reasonable and did not uphold this aspect of her complaint.

Ms C complained that the board failed to communicate reasonably with her. We found that there was no record of any detailed discussion with Ms C prior to her surgeries about the risks or benefits of the proposed operations, the alternatives to surgery or the varying degrees of success and the possibility that her condition could be made worse. The board had a document for recording fasting and insulin instructions for diabetic patients but this was not completed in Ms C's case. Therefore, we upheld Ms C's complaint that the board's communication with her was unreasonable.

Ms C complained about the way that that the board handled her complaint. We found that Ms C's complaint was not acknowledged within three working days. There was also a delay in responding to Ms C's complaint and the board did not proactively keep her updated about the reason for the delay in responding to her complaint and provide a revised timescale for when she could expect to receive a response. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to record a detailed discussion with her prior to her surgeries about the risk or benefits of the proposed operations, failing to acknowledge Ms C's complaint within three working days and for failing to keep her updated about the reason for the delay in responding to the complaint or providing a revised timescale for the response. 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:

• Patients should be given full information about the risks and benefits of proposed operations, including the alternatives to surgery, and these discussions should be documented in line with relevant guidance.
• Diabetic patients should be given fasting and/or insulin instructions prior to surgery and these instructions should be recorded.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

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 about the care and treatment he received in relation to a coronary artery bypass graft (a surgical procedure used to treat coronary heart disease) at the Royal Infirmary of Edinburgh.

We took independent advice from a consultant cardiologist (a specialist in diseases and abnormalities of the heart). We found that Mr C was identified as having ostial left anterior descending artery disease (a narrowing in the blood vessels of the heart) and that the initial choice of treatment for this, bypass surgery, was reasonable. Mr C then had an uncommon but recognised complication of bypass surgery. We found that the decision to perform a second procedure to implant a stent (a small tube used to keep passageways open) was reasonable. We also noted that there was no reason to believe that performing a stent procedure earlier would have translated to any clinical benefit for Mr C. We considered that the clinical care Mr C received was reasonable and did not uphold this aspect of his complaint.

Mr C also complained about aspects of his nursing care during his hospital admission when the stent procedure was performed. We took advice from a consultant nurse in cardiology. We found that Mr C was not prescribed appropriate pain relief and that there was contradictory evidence in the records around the management of his pain. Mr C's pain should have been managed better and the failure to do so was unreasonable. We also identified failings in record-keeping, in particular, a failure to complete care documentation, around communication with Mr C and his family, and his discharge from hospital. We considered that the nursing care Mr C received was unreasonable and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing provide him with reasonable pain relief, failures in record-keeping, and failing to provide him with reasonable 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:

• Patients who are in pain should have their pain needs addressed as soon as possible. Following a surgical procedure, patients pain needs should be proactively addressed even though they are waiting to be clerked into the ward. Nursing staff should ensure the documentation of a patient's care following a surgical intervention should be completed. Nursing staff should maintain reasonable records, consistent with the Nursing and Midwifery Code of Conduct.

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 her late mother (Mrs A) received at the Royal Infirmary of Edinburgh. When Mrs A was admitted, it was recorded that she had known lung cancer and she was initially treated for pneumonia (inflammation of the lungs). It was subsequently planned that Mrs A would be discharged, but a CT scan showed that she had an accumulation of blood in her abdominal muscle. Mrs A later had a fall. She was monitored overnight, but died the following day.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the medical treatment provided to Mrs A had been reasonable. We did not uphold this aspect of the complaint.

Ms C also complained about the nursing care provided to Mrs A. We took independent advice from a nursing adviser. We found that there was no evidence of any failings that had led to Mrs A's fall in the hospital or that a specific injury sustained in the fall led directly to her death. A robust post falls assessment was also undertaken after the event, which did not indicate any specific injury.

Overall, the nursing care provided to Mrs A had been reasonable. However, there were gaps in the nursing notes provided. There was also a lack of evidence of communication with Mrs A's family. In addition, the board's response to Ms C's complaint did not address many of the points she had raised. Given these failings, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to provide evidence that nursing staff communicated with her appropriately. 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:

• Nursing staff should maintain records in line with the Nursing and Midwifery Council's guidance on record-keeping.

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 about the care and treatment his late wife (Mrs A) received from the practice during a number of attendances.

We took independent advice from GP adviser. We found that the care provided to Mrs A by the practice, when she presented with a swelling in her groin and a lump on her breast, to be reasonable.

Mrs A had also attended the practice with a swelling in her neck. We found that there was a failure by the practice to document a full history relating to the neck swelling, how long it was there for, and to consider further investigation of the swelling and safety netting. We considered this to be below a reasonable standard and upheld this aspect of Mr C's complaint. However, we also acknowledged that by the time Mrs A presented with the swelling in her groin, she already had incurable cancer. While earlier referral for investigation of the neck swelling could have possibly led to an earlier diagnosis, it was unlikely to have changed Mrs A's overall outcome.

Mr C also complained that Mrs A had been treated in an unsympathetic and dismissive manner by the practice, and said that he and Mrs A were unaware that she had suspected heart failure. Our investigation found no evidence of this.

Mr C also complained about the way in which the practice had responded to his complaint. We found that the practice responded to Mr C within a reasonable time, and did not identify any inaccurate information in their response. We also acknowledged that the practice had offered to meet with Mr C. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to document a full history relating to Mrs A's neck swelling; how long it was there for; or to consider further investigation of the neck swelling and safety netting. 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:

• Relevant staff should ensure they review and are aware of General Medical Council Good Medical practice guidance and the Scottish cancer referral guidelines on Head and Neck Cancers.

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

Mrs C, an advocate, complained on behalf of her client (Mrs B) about the medical and nursing care that Mrs B's late husband (Mr A) received at Wishaw General Hospital.

Mrs B was concerned that a urine sample was not taken around the time Mr A was admitted to hospital; that sepsis may not have been treated properly; that staff did not recognise the severity of a fall Mr A sustained; and an opiate painkiller was not given at a particular time. Mrs B was also concerned that; no falls assessment was carried out and wheelchair transportation was inappropriate after Mr A's second fall; record-keeping regarding a fall was contradictory and did not capture the severity; intravenous paracetamol should have been given instead of oral paracetamol; and Mr A's blood pressure and heart rate were not properly monitored.

We took independent advice from a GP consultant and from a registered nurse. We found that there was a failure to take a urine sample which the board had accepted and apologised for. However, overall we did not identify any significant failings in Mr A's medical care and did not uphold this aspect of the complaint.

However, we found that it was unreasonable that Mr A was not transported by trolley to have his scan carried out and that there was a failure to escalate his worsening blood pressure reading to medical staff. Therefore, we upheld the complaint that Mr A's nursing care was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to escalate Mr A's blood pressure reading to medical staff; and for not transporting Mr A by trolley for his scan. 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:

• Nursing staff should comply with the board's policy on deteriorating patients and NEWS escalation.
• Nursing staff should ensure that appropriate consideration is given to a patient's transportation following falls.

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 nursing care that her partner (Ms A) received at Queen Elizabeth University Hospital while she was recovering from brain surgery. We took independent advice from a nursing adviser. We found that the nursing care provided to Ms A was reasonable and did not uphold this aspect of Ms C's complaint.

Ms C also complained about the medical care and treatment that Ms A received. We took independent advice from a consultant in acute medicine and from a consultant neurosurgeon (specialist in surgery on the nervous system, especially the brain and spinal cord). We found that there was a lack of documented medical assessments regarding Ms A's orientation/confused status, and when confusion was identified, this was not appropriately investigated and documented. We also found that there was no consultant medical review prior to Ms A's transfer from Queen Elizabeth University Hospital to another hospital. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Ms A for the lack of documented medical assessments regarding Ms A's orientation/confusion status and the failure to carry out a consultant medical review prior to Ms A's transfer between hospitals. 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:

• Patients recovering from neurosurgery should have documented medical assessments of their orientation and where confusion is identified this should be investigated and appropriately documented.
• Where possible, in-patients should receive daily senior clinical review and these reviews should be documented.

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

Mrs C complained on behalf of her late son (Mr A) about the care and treatment he received from his GP practice. Mr A phoned the practice as he was coughing and felt unwell. Mr A was considered to have symptoms of a cold and he was prescribed a cough suppressant. Around a week later, Mr A died from pneumonia (an infection of the lungs).

Mrs C complained that the practice unreasonably diagnosed Mr A over the phone, even though he had asthma and learning difficulties. We took independent advice from a GP. We found that as Mr A was noted to have symptoms of a cold, it was reasonable that he was diagnosed over the phone, even though he was a vulnerable adult. We did not uphold this aspect of the complaint.

Mrs C also complained that when she was admitted to hospital shortly afterwards, the practice did not contact her son to check on his condition. We found that the practice had not been informed of Mrs C's hospital admission or advised of any concerns about Mr A. Therefore, we found that the practice had no cause to check on Mr A's condition. We did not uphold this aspect of the complaint.

Lastly, Mrs C complained about the practice's handling of her complaint. We found that there were failings in their complaints handling, which the practice had already acknowledged and apologised for. We noted that Mrs C's complaint was not acknowledged within the relevant timescale and her request for a phone call was not followed up. Therefore, we upheld this aspect of the complaint.

Recommendations

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the NHS Scotland Model Complaints Handling Procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

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 psychiatric treatment she received for anxiety. She complained that there were unnecessary delays and a lack of communication regarding her treatment which added to her anxiety. Ms C complained that her psychiatrist did not assess her properly and proceeded with options for therapy without first carrying out an appropriate assessment.

We took independent advice from a consultant psychiatrist. We found that Ms C's assessment had been appropriate and reasonable, and that medical staff tried to work constructively with Ms C and to tailor treatment to her specific needs and wishes for treatment. We considered that the board had taken Ms C's social anxiety into consideration when arranging appointments. Therefore, we did not uphold this aspect of the complaint.

Ms C also complained about the board's complaints handling. We considered that the board could have clarified aspects of the complaint at the outset, with a view to agreeing a reduced number of complaints. This may have provided for a more manageable complaint from the point of view of investigation. We noted there had been significant delay in providing complaint responses, which had added to Ms C's stress. We considered that the delays were unreasonable and we therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in providing a response to her complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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 about the care and treatment he received at Ayr Hospital. Mr C attended the orthopaedic department (specialising in the treatment of disease and injury of the musculoskeletal system) in relation to knee pain. He had surgery but despite that he continued to experience pain. Mr C was unhappy because he was discharged by the consultant without his pain being fully investigated.

We took independent advice from an orthopaedic consultant. We found that the standard of care that Mr C received for his knee was reasonable and that post-operative follow-up was appropriate. Therefore, we did not uphold this aspect of the complaint.

In addition, Mr C became aware of comments written in his clinical record by the consultant which Mr C described as slanderous. We found that the language used was unreasonable, inappropriate and unfair. However, we noted that the consultant had apologised to Mr C and had reflected on the fact that the language used was open to misinterpretation. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the inappropriate comment written by the consultant in the clinical letter. The apology should meet the standards set out inthe 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

Ms C complained about the care and treatment provided to her by Crosshouse Hospital both during and after her pregnancy. She felt that she was not monitored appropriately during pregnancy and that her concerns had not been taken seriously. She also raised concern that she had requested a caesarean section but this had been denied, and that planning for delivery had not been reasonable.

We took independent advice from a midwife and an obstetrician (a doctor specialising in pregnancy and childbirth). We noted that there was an inappropriate remark recorded in Ms C's records by a midwife and we made a recommendation to the board about this. We found that, whilst many aspects of the care and treatment provided to Ms C were reasonable, there was a failure to take appropriate and timely action when Ms C presented with polyhydramnios (increased fluid) and accelerated foetal growth. Therefore, we upheld this aspect of Ms C's complaint.

In relation to Ms C's concerns about post-pregnancy care, we found that this was appropriate and in line with standard practice. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the inappropriate description in her medical records, and the failure to investigate the cause of polyhydramnios and accelerated fetal growth in a timely manner. 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:

• Notes made in medical records should be appropriate and in line with relevant nursing and midwifery standards.
• Polyhydramnios and accelerated fetal growth should be investigated in a timely manner.

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.