Some upheld, recommendations

Summary

Mrs C complained about the care and treatment that was provided to her late father (Mr A) by the practice on two occasions. Mr A was initially suffering with urinary problems and later, with symptoms of heart failure. Mrs C was concerned that there had been a failure to identify urinary retention as the cause of his symptoms and that, when he was seen by a GP registrar (trainee GP), a few months later, they attributed a seizure-like episode to medication changes, when he was actually suffering from aspiration pneumonia (a complication of pulmonary aspiration. Pulmonary aspiration is when you inhale food, stomach acid, or saliva into your lungs).

We took independent advice from a GP. We found that there had been no unreasonable failure to diagnose urinary retention and that Mr A's symptoms were more consistent with urinary infection when he was seen by the practice. Therefore, we did not uphold this aspect of Mrs C's complaint.

We found that, when Mr A was seen by the GP registrar, the relevant guidance for diagnosis of heart failure had not been followed. We found that it was not possible to rule out the medication changes as a cause of the seizure-like episode and there was no indication in the medical records that Mr A was suffering from aspiration pneumonia at the time he was seen by the GP registrar. We upheld this aspect of Mrs C's complaint as the issue around diagnosis of heart failure had not been identified as a training issue for the GP registrar.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in the management of Mr A's suspected heart failure. 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:

• Suspected heart failure should be managed in line with national guidance. Where this is not considered appropriate, a clear rationale for alternative action should be recorded.
• Issues with care and treatment provided by GP registrars should be taken forwards as part of the training process. Clear information should be available on a daily basis so GP registrars know who to approach for help and supervision.

Summary

Mrs C complained about a delay in diagnosing her child's (Child A) kidney condition. Mrs C was concerned that despite several years of symptoms, appropriate investigations to diagnose Child A's condition had not been carried out and that this had resulted in loss of kidney function. Mrs C also considered that the issue could have been identified on an antenatal scan. Mrs C complained to the board but was unhappy with their response to her complaint.

We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that Child A's condition would now likely be identified during antenatal anomaly scanning but that at the time of Mrs C's pregnancy, there was no requirement for this type of scan to be carried out. We did not find that the diagnosis had been unreasonably missed. We noted that the board had already reflected on this case and now have a lower threshold for referring children for scans where they report pain moving towards the back. We did not uphold this aspect of Mrs C's complaint.

In relation the board's handling of Mrs C's complaint, we found that the board had not addressed her comments about the potential for diagnosing Child A's kidney condition during an antenatal scan. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not addressing the issues raised about prenatal diagnosis in the complaint investigation or explaining why it was not considered reasonable to do so. The apology should meet the standard set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Issues raised in complaints should be addressed or an explanation provided as to why it is not considered reasonable to do so.

Summary

Ms C complained about a delay in the results of a magnetic resonance imaging (MRI) scan being reported which showed that a small pancreatic tumour, which was being monitored, had grown in size. Ms C also complained that when a computerised tomography scan (CT - a scan which uses x-rays and a computer to create detailed images of the inside of the body) was carried out around four months later, there was a failure to identify a breast lump.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant in acute medicine. We considered that there was an unreasonable delay in the MRI scan being reported which would have impacted on the time taken to carry out further investigation of the pancreatic tumour. We upheld this aspect of Ms C's complaint and noted that the board were taking steps to address the delays in the service. We also recommended further action to be taken.

In relation to the CT scan, we found the actions of the board to be reasonable. The scan was intended to concentrate on Ms C's pancreas and liver rather than a general look for cancer anywhere. We found that it was reasonable that every organ was not examined in great detail given Ms C did not have concerning symptoms. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Patients receiving MRI scans should have them reported within a reasonable time frame.

Summary

Ms C complained about the care and treatment her partner (Mr A) received during his admission to Queen Elizabeth University Hospital. After Mr A had been discharged he became unwell and was readmitted the following day. On the day of Mr A's readmission he was transferred to another hospital for specialist care where he died two days later.

Ms C raised concerns about the administration of an iron infusion which led to Mr  A receiving an overdose of iron. Ms C questioned whether this may have contributed to Mr A's death and wondered if a blood transfusion would have been a more appropriate treatment. Ms C also questioned Mr A's discharge and whether, if he had been in hospital rather than at home when he became unwell, this would have affected his outcome.

The board had acknowledged that although the total dose of iron calculated for Mr A was accurate, he received a dose of iron higher that the recommended dose for a single infusion. They said that Mr A was monitored appropriately in case of an infusion reaction and his observations were stable on his discharge. The board also acknowledged there was an error in Mr A's medication on his discharge.

We took independent advice from a consultant in acute medicine. We found that all appropriate investigations and interventions were undertaken and it was reasonable to have discharged Mr A with the follow-up plans the board had set out. We also noted that Mr A was well enough for these to be arranged on an out-patient basis.

In relation to the iron infusion, we found that it was reasonable to have given this to Mr A to treat his anaemia and that this was more appropriate than a blood transfusion. While we could not exclude it absolutely, we considered that there was no evidence to suggest that the larger dose of iron that Mr A received had contributed to his death. We noted that Mr A's' sudden deterioration appeared to have been due to a rare cardiac problem that was unpredictable. However, Mr A did receive an overdose of iron and there was an error in his medication on discharge. Therefore, we upheld this aspect of Ms C's complaint and asked the board to provide evidence of action they said they had taken.

Ms C also complained about the nursing care Mr A received. We took independent advice from a nursing adviser. We found that the nursing care was reasonable and appropriate. 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 and her family for Mr A having received too high a dose of intravenous iron and the error in Mr A's medication on his discharge. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

Summary

Mr C attended Queen Elizabeth University Hospital for a hernia repair operation (an operation to correct a hernia, which is a bulging of internal organs or tissues through the wall that contains them) but complained that he was not properly advised of the risks. After the surgery Mr C suffered from significant bleeding and swelling and was discharged from hospital nine days after the operation. Mr  C returned a week later as he had to be readmitted for his wound to be cleaned and re-stitched. Mr C complained that both the medical and nursing care he received was unreasonable and that the board's communication with him was unreasonable.

We took independent advice from a consultant general and colorectal surgeon (colorectal surgey is the branch of surgery which deals with repairing the damage caused by disorders of the rectum, anus and colon) and from a registered nurse. We found that Mr C had signed a consent form which detailed the possible risks of surgery and did not uphold this aspect of Mr C's complaint.

In relation to the medical care received, we found that there had not been consultant involvement in Mr C's discharge and that he should have been followed-up afterwards given his significant complications. Therefore, we upheld this aspect of Mr C's complaint.

We found that Mr C's nursing care had been reasonable and that their records were clear and detailed. We did not uphold this aspect of Mr C's complaint.

Finally, we found that there was little documentation of an explanation for Mr C's complications, of the treatment options available and what he could expect. There was also no indication that Mr C had been provided with reasonable reassurance at a time when he was suffering understandable anxiety. We considered that communication with Mr C was unreasonable and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to give proper consideration to his complications after surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Where significant complications develop, patients should be offered an explanation and this should be documented.
• When significant complications develop after hernia surgery, an appropriate consultant should be involved in the decision to discharge and a follow-up appointment should be made.

Summary

Mr C, a patient adviser, complained on behalf of his client (Ms B) regarding the care and treatment provided to her father (Mr A) at Western Infirmary.

Mr A was an in-patient receiving dialysis (a form of treatment that replicates many of the kidney's functions) at the hospital for 12 weeks before he died. Ms B was concerned that Mr A did not receive appropriate dialysis treatment during the admission. We took independent advice from a consultant nephrologist (a  specialist in kidney care and treating diseases of the kidneys). They noted that the delivery of dialysis was difficult in this case because Mr A was frequently confused and unable to co-operate with the dialysis treatment. We considered that the records showed that Mr A received a reasonable number of dialysis sessions during the admission, and that the dialysis treatment prevented the toxins in his blood from reaching excessive levels. We found no evidence of failings in dialysis treatment, and we did not uphold this aspect of Mr C's complaint.

Ms B was also concerned that the board failed to take appropriate steps to ensure Mr A was comfortable and safe when receiving dialysis treatment. We took independent advice from a consultant in old age psychiatry and from a registered nurse. We considered that medical staff appropriately managed Mr A's delirium with the input from the hospital's old age psychiatry team. We found that the board had taken reasonable steps to help to ensure Mr A was comfortable when receiving dialysis and we noted that a number of fall risk assessments were carried out throughout the admission. The records showed that Mr A sustained a number of falls during the admission, and we were unable to conclude that the board followed their referral criteria for the hospital falls prevention co-ordinator. Although we were unable to conclude that earlier involvement from the hospital falls prevention co-ordinator would have prevented Mr A's third fall, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for the delay in referring Mr A to the hospital falls prevention co-ordinator. 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 at risk of sustaining a fall in hospital should be referred to the hospital falls prevention co-ordinator if they meet the board's referral criteria.

Summary

Ms C was admitted to Aberdeen Maternity Hospital as she had symptoms of preeclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine). Ms C complained about decision making in terms of induction of labour, and the care and treatment provided during her labour, including administration of opiate pain relief and the decision that it was appropriate to proceed with a vaginal delivery, rather than a caesarean section. Ms C's baby experienced breathing difficulties following birth, believed to be associated with the opiate pain relief Ms C received, and was cared for by the neonatal team for around five days before they were both discharged home. Ms  C also complained that the board's view that her baby's physical and mental development will not be affected by this was unreasonable.

We took independent advice from a consultant obstetrician and gynaecologist (a  doctor who specialises in pregnancy and childbirth as well as the female reproductive system). We found that it was reasonable to induce Ms C's labour in the circumstances of her case. The records indicated that appropriate discussions had taken place with Ms C and that she had taken the decision to proceed with induction. Therefore, we did not uphold this aspect of Ms C's complaint.

In relation to Ms C's concerns about care and treatment during her labour, we found that it was reasonable to provide opiate pain relief. We found that the guidance indicates that whilst morphine administration may have significant side effects for mother and baby, these side effects are considered to be short-term. We found that the board had already offered an apology to Ms C in relation to delays in obtaining blood test results and that they had taken steps to improve service in this area. We noted that the blood should have been sent urgently for testing but that the delays were unlikely to have had any bearing on the care and treatment that Ms C received. We also found that it was reasonable to proceed with vaginal delivery in the circumstances, particularly as Ms C's labour had progressed very quickly. However, Ms C's notes indicated that there was a plan made that day for her to have a caesarean section and that the board's local policy on preterm labour and birth indicated that steroids should have been administered as a result. We considered that, in line with the local policy, Ms C should have received steroids. Therefore, we upheld Ms C's complaint about the care and treatment during labour and made further recommendations in this connection.

We took independent advice from a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns) in relation to the board's view that Ms C's baby would have no long- term effects from the breathing difficulties following birth. We found that the board's view was reasonable as there was no indication of any issues. 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 failing to administer steroids in line with their local policy and that blood tests were not sent as urgent. 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:

• The local policy should be followed regarding the administration of steroids. If policy is not followed, the reasons for this should be documented in the records. Patients awaiting blood tests for an emergency caesarean section or with severe preeclampsia in labour ward should have bloods sent as urgent.

Summary

Ms C complained that her prescribed medications had been mismanaged by the practice. She said that her medications were rarely available to collect from her local pharmacy after she had ordered them through the practice. Ms C said that she had been without key medication due to these access problems.

We took independent advice from a GP. We found that the practice prescribed Ms C's blood pressure medication regularly, however, we could not say whether this was provided within a reasonable time of Ms C's requests because there was insufficient evidence available. We also found that the practice was not unreasonable in failing to prescribe an updated contraception medication because they were not notified of the change prior to the medication being issued. Therefore, we did not uphold this aspect of Ms C's complaint.

Ms C also complained that the practice refused to take complaints by phone and did not respond to complaints made in writing. Ms C submitted two complaints. We found that the tone used by the practice in their response was confrontational, did not recognise the inconvenience Ms C had experienced, and did not reflect on whether there was learning to be taken from the complaint. We also found that Ms C was given no information about the complaints process and was not told whether she could escalate her complaint, either to stage two of the complaints process or to our office. In responding to the second complaint, there was no acknowledgement that Ms C had not received the previous response, despite it being clearly mentioned to them. We considered that the practice's responses to Ms C's complaints were unreasonable. 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 for the failure to provide reasonable responses to her complaint and for the inappropriate tone and content of their letters responding to her complaints. The apologyshould meet the standards set out in the SPSO guidelines on apology availableat www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• The practice must have a complaints procedure in place which meets the requirements of the NHS model complaints handling procedure and the Patient Rights (Scotland) Act 2011.
• The practice must ensure that staff respond to complaints fully, in a timely manner and any responses should remain respectful at all times.

Summary

Mrs C complained that the board failed to carry out her total knee replacement appropriately in Dumfries and Galloway Royal Infirmary. Mrs C suffered pain and stiffness after the operation and eventually had to have a revised total knee replacement at another hospital.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). Although there was evidence of malalignment (incorrect or imperfect alignment) of the knee on the x-rays and CT scan carried out some time after the operation, a few degrees of variation would not be unusual. This was unlikely to have contributed to the stiffness Mrs C experienced. We found that that without the benefit of hindsight, there was no evidence that the operation had not been reasonably carried out. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the care and treatment provided to her after the operation was unreasonable. We found that, in general, the care and treatment provided to Mrs C after the operation was reasonable. However, we found that a letter the board issued to the hospital where she had the revised total knee replacement contained a number of inaccuracies. For this reason, we upheld this aspect of Mrs C's complaint.

Finally Mrs C complained that the board refused to lend her a continuous passive motion (CPM) machine. We found that it would not be routine for a patient to be given a CPM machine. We found that the board's actions in relation to this matter were reasonable. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that their referral letter to another hospital contained inaccuracies. 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:

• Referral letters should be accurate.

Summary

Ms C and Ms C raised their concerns about the care and treatment their late mother (Mrs A) received when she was admitted to University Hospital Crosshouse, in particular, about the clinical and nursing care and treatment Mrs A received. They also complained about the communication with their family and that the board had failed to handle their complaint in a reasonable way.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that there had been a failure to identify how unwell Mrs A was and a delay in initiating a higher level of care. We considered that the clinical care Mrs A received was unreasonable and upheld this complaint. However, we noted that it was possible that Mrs A would have died even with appropriate care, given the severity of her illness.

In relation to the nursing care given to Mrs A, the board acknowledged that Mrs A would have found it difficult to use the call system. As a result of a fall that Mrs A had suffered, the board staff had been advised that all patients with any degree of cognitive impairment should not be left unassisted within the ward where they could not been directly seen by nursing staff. We were satisfied with the action taken by the board. We also found no failings on the part of nursing staff regarding Mrs A's dehydration and dietary intake, medicine administration and Mrs A's personal care. Therefore, we did not uphold this aspect of the complaint.

In relation to communication, while we found there was evidence of some good communication, we found that overall the communication was poor, particulary after it was clear to medical staff that Mrs A's condition had deteriorated. We also found failings in relation to the communication surrounding the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision. Therefore, we upheld this aspect of the complaint.

Finally, in relation to complaint handling, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings in clinical care, communication and complaints handling. 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:

• Staff should recognise signs of deterioration in patients and actively manage this.

In relation to complaints handling, we recommended:

• Written responses should normally be sent within 20 working days of receipt of the complaint, or a revised timescale agreed with the complainant.