Some upheld, recommendations

  • Case ref:
    201708139
  • Date:
    June 2019
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Miss C complained about the care and treatment she received from the Princess Royal Maternity Hospital. She raised concerns about the general anaesthetic she was given during her emergency caesarean section, which she said was given the wrong way round and jeopardised her ability to breathe, risking both her and her baby's lives.

We took independent advice from a consultant anaesthetist who covers obstetric (medical specialism for pregnancy and childbirth) theatres as part of their elective and emergency work. We found that the sequence of drug administration in Miss C's case was wrong and could have caused Miss C difficulty breathing, but the awareness of this would have lasted for only a few seconds at most. There was no risk to Miss C's baby from this drug error and the risk to Miss C was limited to the unpleasant experience she suffered, but there would not have been any risk to her life. Given the failing in the administration of the drugs, we upheld this part of Miss C's complaint.

The board acknowledged their failing in this case and took appropriate remedial action on this matter. However, we made one recommendation for further action by the board.

Miss C also complained that she developed a chest infection and contracted Clostridium Difficile (bacteria that can infect the bowel and cause diarrhoea) whilst in hospital. We did not identify any failings by the board in these areas. We did not uphold this part of Miss C's complaint.

Recommendations

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

  • Consideration should be given to the supply of pre-filled syringes of suxamethonium, as raised by the board's departmental morbidity and mortality meeting.
  • Case ref:
    201801126
  • Date:
    June 2019
  • Body:
    Borders NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the overall care and treatment given to his late father (Mr A) while he was a patient in Borders General Hospital.

Mr A was elderly and had a history of acute kidney injury and fluid overload. He was admitted to hospital with gastroenteritis (inflammation of the lining of the stomach). During his stay, clinicians experienced difficulty in getting his fluid balance right between heart failure and fluid overload, and his poor kidney function and fluid intake. When he was considered fit, Mr A was discharged home; however, he was admitted to hospital again the next day. After his second admission he was discharged home, and while the high risks of this were discussed, Mr A was keen to go home. He returned home but again required to be hospitalised the next day with increasing confusion and shortage of breath. Mr A's condition continued to deteriorate and a few days later he died. Mr C was unhappy with the medical and nursing care. He said that Mr A's condition was often unkempt and he had pressure ulcers.

We found that Mr A's medical care and treatment had been reasonable and given appropriately in response to his presenting symptoms. Both times he had been discharged, he was fit. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to nursing care, we found that Mr A's nursing notes were not of the required standard. Similarly, relevant standards in relation to the prevention and management of pressure ulcers were not followed by nursing staff. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for the failure to deliver Healthcare Improvement Scotland standards appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

  • Nursing staff should be fully aware of, and apply, Healthcare Improvement Scotland standards for care of older people in hospital 2015.
  • Nursing staff should be fully aware of, and apply, Healthcare Improvement Scotland standards for the prevention and management of pressure ulcers 2016.

When it was originally published on 19 June 2019, this case wrongly referred to Health Improvement Scotland. The correct name is Healthcare Improvement Scotland.

  • Case ref:
    201800108
  • Date:
    June 2019
  • Body:
    Borders NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    admission / discharge / transfer procedures

Summary

Mrs C complained about the board's handling of two extra contract referrals for out-of-area treatment for her ongoing health problems. Mrs C said that after her first referral to the extra contract referrals panel was granted, the board failed to offer any practical or financial assistance to make the trip to a hospital in England for treatment.

We found that there was no information on how the panel reached their decision on Mrs C's first extra contract referral, and key sections of the panel decision form were left blank or appeared to contain incorrect information. It was unclear what the panel took or did not take into account when making their decision not to support Mrs C with travel/accommodation costs, and there was some uncertainty in relation to the conditions of funding and whether the panel were approving an overnight stay as part of the request. We also found that there was no mention in the panel's decision letter of a patient's right of appeal regarding the extra contractual referral panel decision process. Therefore, we upheld this part of the complaint.

Mrs C also complained that the board unreasonably failed to deal with her complaint about the handling of the two extra contract referrals in accordance with their complaints procedure. We found that the board's handling of Mrs C's complaint was appropriate and we did not uphold this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs C for failing to handle her first Extra Contractual Referral appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
  • The board should consider any application received from Mrs C now for travel and an overnight stay, taking into account any relevant policies such as their Travel Expenses Protocol.

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

  • Decisions by the Extra Contractual Referral panel should be appropriately documented and relevant sections of the Panel Decision Form completed, making it clear what was taken into account when reaching their decision, including any consideration of their Travel Protocol, where appropriate.
  • Notification of the Extra Contractual Referral panel's decision should include the right of appeal regarding the panel's decision process, in accordance with the Protocol.
  • Case ref:
    201802753
  • Date:
    June 2019
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C's mother (Mrs A) was transferred to hospital by ambulance with low oxygen levels. Mrs C had a power of attorney (POA) in place, enabling her to make decisions on Mrs A's behalf. Mrs A was admitted to hospital and the following day medical professionals spoke with her regarding a 'do not attempt cardiopulmonary resuscitation' (DNACPR) agreement, without first consulting Mrs C. Mrs C complained to the board that it was inappropriate for medical professionals to speak with Mrs A regarding the DNACPR as she had dementia and did not understand what was being said. Mrs C also complained about the lack of knowledge of the POA that was in place. In their response, the board explained that it was a priority to complete a DNACPR given Mrs A's deteriorating condition, and it was appropriate in the circumstances to discuss this with her. The board said that they were aware of the POA and this was appropriately recorded in Mrs A's medical records.

Mrs C complained that the board's actions in implementing a DNACPR were unreasonable, that they unreasonably failed to clearly record in Mrs A's records that a POA was in place and that the handling of the complaint was unreasonable.

We took advice from an independent medical adviser. With respect to the actions in implementing the DNACPR, we found that given Mrs A's state of health on admission to hospital, it was appropriate for medical professionals to consider a DNACPR and discuss this with Mrs A. Whilst there were concerns about Mrs A's capacity, the records indicated that this was considered by medical professionals. It was reasonable for medical staff to decide DNACPR was required and that Mrs A had capacity at the time to be involved in the discussions. We did not uphold this complaint.

With respect to the complaint that the POA was not clearly recorded in the file, we found that at the time of Mrs C's complaint, the board were unable to locate a copy of the POA on file. Whilst the medical notes showed the medical professionals were aware of the POA in place, there was not a record kept on file at all times. On this basis, we concluded that the board failed to clearly record in the file that an active POA was in place. We upheld this complaint.

In relation to Mrs C's complaint, we found that the board failed to respond to the complaint within the 20 working day time-frame and failed to provide any explanation for the delay. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs C for the failure to keep her updated on the progress of her complaint, the delay in completing the investigation or to provide a revised timescale for response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

  • Where the board have been provided with a physical copy of a POA document, a copy should be kept in the relevant patient's medical records, in a prominent position, at all times.

In relation to complaints handling, we recommended:

  • Complaints handling staff should be aware of the requirements of the Complaints Handling Procedure with respect to timescales for response and keeping complainants informed about their complaint.
  • Case ref:
    201802959
  • Date:
    May 2019
  • Body:
    A Medical Practice in the Lanarkshire NHS Board area
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained about the treatment she received from the practice in response to her symptoms of oedema (swollen tissue from retained fluid). Ms C said that she had reported symptoms to the practice on numerous occasions. Ms C said there was an unreasonable delay in responding to her symptoms. During an appointment with a GP Ms C was told to stop a certain medication. Ms C said that during the appointment she was not given proper instructions or after care, i.e. to get her blood pressure checked. A few weeks later, after a severe headache, it was found that Ms C's blood pressure was too high and she required hospital admission.

We took independent medical advice from a GP. We found that Ms C's treatment by the practice was reasonable and found no failings in the treatment offered. The practice considered Ms C's symptoms, taking into account her overall medical hisotry and chronic illnesses when considering appropriate action to respond to Ms C's reports of oedema. Therefore, we did not uphold this part of Ms C's complaint.

Ms C also complained that the board failed to provide reasonable after care, specifically that her blood pressure should be checked. There was no written record or evidence to support the practice's view that appropriate information was provided to Ms C regarding having her blood pressure checked. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs C for the failings identified by the investigation. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

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

  • The GP meets the standard of good record-keeping.
  • Case ref:
    201708023
  • Date:
    May 2019
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the physiotherapy treatment (the treatment of disease, injury or deformity using physical methods such as massage, heat treatment, and exercise) given to his wife (Mrs A) after her hip operation at University Hospital Hairmyres. Mr C also complained that the board had failed to communicate reasonably with himself and Mrs A about Mrs A's rehabilitation potential.

We took independent advice from a senior physiotherapist. We found that Mrs A had been provided with reasonable physiotherapy. The advice we received from the senior physiotherapist was that there were two treating physiotherapists which was excellent practice. We also found that the decision not to provide physiotherapy following discharge had been reasonable and that the communication about Mrs A's rehabilitation potential had been reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

Mr C also complained about the pressure area care given to Mrs A. We took independent advice from a nursing adviser. We found that the pressure area care given to Mrs A was unreasonable. In particular, that there was a lack of risk prevention strategies implemented when Mrs A was admitted to reduce her risk of developing pressure damage; when the first damage to Mrs A's skin was identified no care plan was put in place to reduce further risk of damage; and when Mrs A's ulcer developed into a grade three pressure ulcer (grade four is the highest form of damage) the relevant guidance was not followed. We also found that the nursing communication with Mr C had been unreasonable and that there was no evidence of a care plan being initiated to address Mrs A's weight loss. We also noted that that the nursing records were unreasonable Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C and Mrs A for the failings identified in pressure area care. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/leaflets-and-guidance.

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

  • Nursing staff should ensure risk assessments for pressure ulcer prevention are accurate. SSKIN care bundles should be followed appropriately to reduce the risk of a patient developing a pressure ulcer.
  • Patients with pressure ulcers should have an individualised care plan implemented to further reduce risk of deterioration to the skin.
  • Nursing staff should ensure the Healthcare Improvement Scotland standard for prevention and management of pressure ulcers is followed.
  • Ensure that there is appropriate communication with patients and/or their families during a patient's stay in hospital.
  • Patients with a pressure ulcer should have appropriate nutritional assessments undertaken and receive effective nutritional care, which is in line with relevant guidance.
  • Accurate records should be maintained in line with Nursing and Midwifery Council code of record-keeping.
  • Case ref:
    201708611
  • Date:
    May 2019
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C raised concern about a number of issues in relation to the Child and Adolescent Mental Health Service (the service) provided to her child (Child A) by the board. We took independent advice from a consultant child and adolescent psychiatrist (medical practitioner who specialises in the diagnosis and treatment of mental illness) and a registered mental nurse in a child and adolescent mental health service.

Ms C complained about the assessment and care provided to Child A and the way staff behaved to them both. We did not find evidence that staff within the service behaved inappropriately towards Ms C or Child A. We concluded that the assessment and intervention provided to Child A by the service was reasonable. We did not uphold this complaint.

Ms C also complained that the service failed to manage the sharing of confidential information appropriately. The board apologised to Ms C for failings in taking and recording consent for information sharing with the local authority and agreed to take action for learning and improvement. We identified a further instance where information was shared with the local authority without consent. We upheld this complaint and made recommendations in light of our findings.

Ms C was unhappy with the way that the board investigated her complaints and she raised concern that the investigating officer was not sufficiently independent. We did not find evidence that might indicate bias or partiality on the part of the investigating officer. However, we noted that the board reported inconsistent findings between two complaint responses. We felt that the board's failure to 'get it right first time' prolonged the complaints process. We upheld this complaint

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms C and Child A for sharing information with the Social Work Service without appropriate consent; and reporting inconsistent findings between the complaint responses. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

  • Patient confidentiality should be maintained in line with Data Protection legislation. Where information is shared, this should be documented.

In relation to complaints handling, we recommended:

  • An investigation should establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response that represents your final position. The investigation should 'get it right first time'.
  • Case ref:
    201707418
  • Date:
    May 2019
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Miss C complained about the care and treatment she received at the Royal Alexandra Hospital. Miss C complained that staff failed to recognise that her waters had broken, that she was not allowed an epidural (anaesthetic introduced into the space around the spinal cord to produce loss of sensation below the waist) and that she was advised that she was not allowed gas and air as it was not available.

We took independent medical advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a midwife. We found no evidence in the records of Miss C's water breaking. However, we considered that the management of Miss C's analgesia (pain relief) as she awaited transfer to the obstetric unit for epidural was unreasonable as she should have been offered pain relief such as gas and air, further oral analgesia or injections of opiate analgesia. Therefore, we upheld this aspect of Miss C's complaint.

Miss C also complained that her baby (Baby A) was not fed or put in a nappy after delivery, did not go to special care and nobody checked on them when she was still in theatre. We found that appropriate steps were taken by the board to ensure that Baby A was cared for. Due to an emergency situation with Miss C, and as findings of Baby A's examination were normal, we found that it was reasonable for Baby A to be left with a family member. We also found that the delay in transferring Baby A to special care was not unreasonable, given that Miss C's care was the priority post-delivery. Therefore, we did not uphold this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Miss C for the failing in the provision of pain relief. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

  • Appropriate pain relief should be provided to patients awaiting transfer to the obstetric unit for epidural.
  • Case ref:
    201706201
  • Date:
    May 2019
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained about the care and treatment her late brother (Mr A) received at Glasgow Royal Infirmary. Mr A had previously suffered a brain injury and required to be managed under the Adults with Incapacity Act 2000. Mr A had difficulty swallowing and was considered unsafe for all food by mouth. Although Mr A required to undergo a number of investigative procedures, these could not be carried out due to his reluctance. Mr A also fell twice and after Ms C raised concerns with staff, he was later found to have broken his hip for which he required surgery. Before this could be carried out, Mr A suffered a heart attack and died a few days afterwards. Ms C complained that the gastroenterology (digestive system), nursing, orthopaedic (musculoskeletal system) and cardiology (heart and circulatory system) care and treatment Mr A received was unreasonable.

We took independent advice from consultants in acute care, orthopaedics and cardiology and from a registered nurse. We found that the team looking after Mr A struggled to balance the need to perform interventions with a desire not to treat him forcibly or against his will. We considered that the gastroenterology care Mr A received was reasonable. Mr A's cardiology treatment was also found to be reasonable. Therefore, we did not uphold these aspects of Ms C's complaint.

In relation to Mr A's nursing care, we found that he was not properly supervised and a number of nursing procedures were not correctly followed or recorded. In particular, despite being unsteady on his feet, he was sent for x-ray unsupervised and he fell. This incident was not recorded or followed-up as it should have been. After this fall, we found that the orthopaedic care was poor and there was a delay in planning the surgery required which was contrary to national guidelines. We considered the nursing care and orthopaedic care to be unreasonable and, therefore, we upheld these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms C for failing to properly follow procedures, to keep full records and notes and for the delay in proposed surgery. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

  • All nursing records should be completed as appropriate in accordance with the requirements of the Nursing and Midwifery Council.
  • Patients should undergo surgical intervention within 48 hours in line with national guidelines.
  • Case ref:
    201707109
  • Date:
    April 2019
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    admission / discharge / transfer procedures

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client (Ms  B) about the care and treatment her elderly mother (Mrs A) received at Wishaw General Hospital and Kello Hospital. Mrs A had been in hospital after being diagnosed with lung cancer. Due to her frail condition, Mrs A was unsuitable for further care and could only be made comfortable. She was discharged home. Mrs A's condition deteriorated further and she was admitted to hospital for pain relief and palliative care. Mrs C complained that Mrs A was not fit for discharge and there was insufficient discussion with the family about this or about the medication Mrs A required to take at home. Mrs C also complained that the support provided by a nurse was unreasonable and on admission to Kello Hospital, staff failed to communicate reasonably with Mrs A family and delayed in providing appropriate pain relief.

We took independent advice from a doctor and from a specialist registered nurse. We found that discharge planning for someone with a terminal illness was complicated and difficult. While it was acknowledged that Mrs A wanted to go home, the arrangements made for her discharge had been hasty with insufficient discussion with the family who were unprepared for the demands of looking after her; they had no clear understanding of the medication prescribed and needed by her. Therefore, we upheld these aspects of Mrs C's complaints.

In relation to the nursing care, we found the support to be reasonable. We also considered the communication from staff at Kello Hospital to be appropriate and found no concerns with the pain relief given to Mrs A. Therefore, we did not uphold these aspects of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms B for failing to fully discuss with her the advanced nature of Mrs A's illness and discharge medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

  • Patients and their family/carers should receive appropriate information on discharge arrangements and, where appropriate, have an adequate understanding of the nature and seriousness of the condition. Conversations about this should be recorded.
  • Patients should receive the medication prescribed and this should be documented.