Some upheld, recommendations

Summary

Mrs C complained about the care and treatment her late husband (Mr A) received at the Western General Hospital during two admissions. Mr A had been admitted to hospital with side effects of chemotherapy that he was receiving for plasmablastic lymphoma (a rare and aggressive form of blood cancer). During his first admission, Mr A had a couple of falls and was later discharged. Mr A was then readmitted and died a short time later. Mrs C complained that communication with the family about Mr A's condition was unreasonable and that nursing staff did not administer his medication properly. Mrs C also complained that the medical care and treatment Mr A received was unreasonable and that the board failed to handle her complaint appropriately.

We took independent advice from a consultant haematologist (a doctor who specialises in medicine of the blood) and from a registered nurse. We found that there had been communication failings with the family during Mr A's hospital admissions, in particular towards the frailty of his condition. Therefore, we upheld this aspect of Mrs C's complaint. However, we noted that the board had acknowledged these failings and had apologised.

In relation to Mr A's medication, we could not find any evidence to show that his medication had been administered inappropriately by nursing staff. Therefore, we did not uphold this aspect of Mrs C's complaint.

Overall, we found that the care and treatment Mr A received was reasonable and we did not uphold this aspect of Mrs C's complaint.

Finally, we found that the board's response to Mrs C's complaint was generally of a good standard. However, they had not kept her informed of delays in their response and they did not address a new issue that was raised. On balance, 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 failing to handle her complaint to a reasonable standard. 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:

• There should be proper discussions about advanced care planning with patients and their relatives/carers, where relevant, and these discussions documented clearly.

In relation to complaints handling, we recommended:

• Updates should be provided where the 20 working day timescale for complaints cannot be met; and follow-up correspondence should be carefully reviewed and appropriately responded to.

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 that the practice failed to provide appropriate care and treatment to her late husband (Mr A). Mr A, who had type 2 diabetes, had thought he was suffering from a urine infection but the practice dismissed the suggestion and did not provide medication. Mr A subsequently developed chest and back pain over the next week. A house visit was then requested early in the morning but it took until early evening for a GP to visit. The GP felt that Mr A required a hospital admission and an ambulance was called to take Mr A to hospital. He died the following day. Mrs C complained that the practice failed to diagnose that Mr A had a urine infection and that, on the day he was taken to hospital, there was an unreasonable delay in a GP making a home visit.

We took independent advice from an adviser in general practice medicine and found that the practice provided Mr A with reasonable treatment regarding his perceived urine infection. The practice carried out an appropriate assessment, including testing for a urine infection, which was reported as negative. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to the home visit, we found that there was an unreasonable delay in arranging the home visit to Mr A as there was a breakdown in communication when the request for a home visit was considered. Initially, it was felt that an advanced nurse practitioner should visit but they felt that it was outwith their remit and there was a delay in the request being picked up by the GP. 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 the delay in advising the duty doctor that a home visit had been requested. The apology should meet the standards set out in the SPSO guidelines on apology available at https://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

Miss C was referred for an endoscopy (a camera test into her stomach) by the practice to investigate stomach pain she was suffering from. She complained that this was not appropriately followed up and that further specialist investigation was not arranged. The practice said that all relevant investigations appropriate to Miss C's condition were undertaken by them. Miss C disputed this, noting that her psychiatrist had referred to anticipated follow-up investigation for her stomach issues, in a letter to the practice. Miss C said that this follow-up was not arranged by the practice.

We took independent advice from a GP, who considered that the investigations arranged by the practice were appropriate. We found that the psychiatrist's letter was written in advance of the endoscopy appointment and that it referred to this investigation. It did not suggest that further investigation was expected. Therefore, we did not uphold this aspect of Miss C's complaint.

Miss C also complained that some of her prescription requests were not appropriately responded to and that she had to go for long periods without her pain-killing and anti-anxiety/depression medication. The practice acknowledged that one monthly prescription for Miss C's anti-anxiety medication was missed and they apologised to her for this oversight. They also acknowledged some recording and communication issues, meaning some of Miss C's medication requests were not responded to appropriately. In particular, they recognised that an improved system was required for communicating with patients where medication requests have been declined. We upheld this aspect of Miss C's complaint, however, noted that the practice had appropriately reflected on the communication issues highlighted by this complaint and had instigated a reasonable plan to avoid similar future problems.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the identified failures to clearly communicate with her regarding her medication requests; to issue her with her medication; and to respond to her complaint about her medication. The apology should meet the standards set out in the SPSO guidelines on apology available at https://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 that his late mother (Mrs A) did not receive appropriate physiotherapy and rehabilitation whilst she was a patient at Tippithill Hospital. He was also concerned that the consultant in charge of Mrs A's care had unreasonably refused consent for another doctor to examine her. Mr C also complained that the board's response to his complaint was inadequate.

We took independent advice from a consultant in old age psychiatry. We found that Mrs A had advanced dementia and that she did not have the potential for further rehabilitation as a result. We found that there had been appropriate referrals and assessments for physiotherapy, which took reasonable account of the risks involved in Mrs A's case. We did not uphold Mr C's complaint about physiotherapy and rehabilitation.

We also did not uphold Mr C's complaint that consent had been refused to allow a further doctor to examine Mrs A. We found no evidence that consent had been refused, although it was confirmed that an examination by the further doctor did not take place. The advice we received was that, in the particular circumstances of Mrs A's case, it was reasonable that this examination was not carried out. We found that the doctor in question had previously reviewed Mrs A and did not consider this to have been of any assistance to the management of her care.

Regarding the board's response to Mr C's concerns, we found that they had not directly addressed Mr C's complaint and that, when Mr C alerted them to this, they advised that they had nothing further to add. We considered this response to be inadequate and 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 failing to adequately respond to his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints responses should address the key issues raised.

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 advocacy worker, complained on behalf of her client (Mr B) regarding the care and treatment of his late father (Mr A). During an admission to Hairmyres Hospital, Mr A was assessed and deemed not to meet the criteria for hospital-based complex clinical care (HBCCC), as it was considered that his needs could be met in a nursing home. He was transferred to Stonehouse Hospital for interim care while awaiting completion of a community care assessment. Before a transfer to a nursing home could be arranged, Mr A died. Mrs C complained that the decision to transfer Mr A to another hospital was unreasonable as he was not well enough and that the hospital was not equipped to meet his needs. Mrs C also complained that the decision that Mr A was fit to be discharged to a care home was unreasonable. Finally, Mrs C felt that communication with Mr B surrounding the transfer and fitness for discharge decisions was poor.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the hospital was equipped to meet Mr A's need and that the need for acute hospital care was not indicated. In particular, we noted that the medical input into Mr A's care following the transfer was reasonable. Therefore, we did not uphold this aspect of Mrs C's complaint.

In regards to the decision to discharge Mr A to a care home, we found that a second opinion was arranged by the board. This was followed by a formal appeal of the decision, both of which maintained that the criteria for HBCCC was not met. We found that this decision was reasonable. We did not consider that Mr A's subsequent deterioration and death suggested that there had been a requirement for HBCCC. Therefore, we did not uphold this aspect of Mrs C's complaint.

Finally, we found that there was appropriate communication with Mr B in advance of Mr A's transfer between hospitals. We noted that the initial communication following the transfer was good, with medical staff having met with Mr B to explain the HBCCC criteria and their views on why Mr A did not meet this. However, while the outcome of Mr B's subsequent appeal was verbally communicated to him within a reasonable timescale, he had to request formal written confirmation of this and there was an unreasonable delay in this being provided. We considered that the board need to clarify their process for formally communicating the outcome of HBCCC appeals. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

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

• The board's HBCCC appeals process should make clear how decisions will be formally communicated to appellants, including the timescale for doing so.

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 maternity care and treatment she received at Raigmore Hospital in relation to her labour and birth. Ms C had previously had a caesarean section and had planned a vaginal delivery for this birth. Ms C went to the hospital as her waters had broken, however, she was not experiencing contractions. She was admitted and the following day, a drip was administered to augment her labour. Ms C's labour progressed with continuous monitoring of the baby's heart rate. When this dropped, the drip was stopped and Ms C had an emergency caesarean section to deliver her baby. During the operation, it was discovered that a scar from a previous caesarean section had ruptured. Ms C complained about the care she received as she considered that she was left too long without action after her waters had broken and that the drip had not been prescribed at a safe level, given her previous caesarean section. Ms C was also concerned about the board's handling of her complaint as there were delays and inaccuracies in the final response.

We tookindependent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the risks and benefits of vaginal delivery following caesarean section had been discussed during Ms C's pregnancy. We found that the care and treatment Ms C received was in line with local protocols and national guidance. We did not uphold this aspect of Ms C's complaint. However, we made a recommendation that the board consider recording that the Royal College of Obstetricians and Gynaecologists leaflet on birth options after previous caesarean section is provided to patients like Ms C.

Regarding complaints handling, we found that during the board's own consideration of the case, they apologised that there had been delays in Ms C's complaint reaching the appropriate team, although we were unable to determine the reason for the delay. We found the board's final response was open to misinterpretation in terms of the timeline and plan for Ms C's care. We also noted there was an inaccuracy in relation to the rate that Ms C's drip was administered at. We upheld Ms C's complaint about the way the board handled her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the inaccuracies in the final response to Ms C's complaint. 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:

• Consider ensuring (and documenting) that the Royal College of Obstetricians and Gynaecologists Patient Information Leaflet on Birth Options After Previous Caesarean Section has been provided to patients to confirm that the risks and benefits have been appropriately shared.
• The final response to complaints should be clear, accurate and easy to interpret.

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 on behalf of his mother (Mrs A) who was admitted to Glasgow Royal Infirmary's Acute Assessment Unit (AAU). Mr C complained that there was a delay in providing a bed for his mother. Mrs A's complaint to the board was originally made on her behalf by an MSP. Mr C also complained that the board's handling of this complaint was unreasonable.

We took independent advice from a consultant in acute medicine and from a nurse. We found that the care and treatment provided to Mrs A was reasonable. We noted that there is often a wait for a bed to become available in a hospital ward, so that a patient can be transferred to an appropriate ward from a unit such as the AAU. However, we found that it took six hours for Mrs A to be moved from a trolley to a bed in the AAU. Given Mrs A's age and several health problems, we considered that this delay was unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the board's complaints handling, Mr C said that there were errors in their response to the complaint that the MSP had made. We found that there was an error in Mrs A's name, however, this was the name used by the MSP when making the complaint. We noted that the board could have confirmed Mrs A's name with the MSP's office and used the correct name in their response. However, we found that, other than the error in Mrs A's name, the board's response to the complaint was reasonable and appropriate. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

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

• The board should consider whether the current prioritisation in the hospital's AAU for moving elderly patients with additional diseases from a trolley to a bed is appropriate, taking account of the relevant 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

Ms C, an advocacy and support worker, complained on behalf of her client (Mrs B) regarding the care and treatment of her late husband (Mr A). Mr A was referred to the respiratory team at Inverclyde Royal Hospital with a worsening cough, and lung cancer was suspected. However, the diagnosis was not formally confirmed until a number of months later. Mr A was then informed that his condition was terminal and that he only had a few weeks left to live.

Ms C complained about the delay in diagnosing Mr A's cancer. Mr A was diagnosed with an empyema (a collection of pus between the lungs and inner chest wall) in the interim period and the board indicated that treating this became the priority. They said that delays caused by Mr A's impaired health meant that biopsies could not be carried out sooner.

We took independent medical advice from a respiratory consultant. We found that it was reasonable for the medical team to have focussed on the management of the empyema. It was noted that Mr A's case was discussed with the lung cancer multidisciplinary team on a regular basis. We considered that the cancer diagnosis was not unreasonably delayed and therefore, we did not uphold this part of Ms C's complaint. However, we found that there was a delay in commencing Mr A on antibiotics when an infection was identified following a bronchoscopy (a procedure that examines the inside of the lungs and airway). While we did not consider that this contributed to the delay in diagnosing the cancer, we made a recommendation in relation to this.

Ms C also complained that there was a lack of communication with Mrs B and Mr A by the medical team. We found that the medical records documented reasonable efforts by staff to communicate with both Mrs B and Mr A. However, the board reflected that their communication fell short of what they would expect. In particular, they acknowledged that sickness absence of key staff directly impacted on the level of support Mr A received. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for the unreasonable delay in commencing Mr A on antibiotic medication for the infection identified following the bronchoscopy procedure. 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:

• When test results identify the need for antibiotic treatment, medical staff should ensure that this is commenced within a reasonable timeframe.

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's child, (child A), was born with a cleft palate (an opening or split in the roof of the mouth that occurs when the tissue doesn't fuse together during development in the womb) which led to difficulties in breathing and feeding. After treatment at one hospital, child A was transferred to Forth Valley Royal Hospital. They were discharged 11 days later, however, Mr C had to return child A to Forth Valley Royal Hospital that night because they had been struggling to breathe since their discharge. Child A was admitted and within a few days they were referred to another hospital. Mr C complained that child A should not have been discharged from Forth Valley Royal Hospital given their medical condition at the time. Mr C also complained that the board failed to address his complaint in a reasonable way.

We took independent advice from a paediatrician. We found that the decision to discharge child A was reasonable given his medical condition at the time. There were no medical concerns noted in the days prior to their discharge and we considered that the board's actions were appropriate. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, we found that the board fully addressed Mr C's concerns. However, we found that there was an unreasonable delay in arranging a meeting and that there had been a lack of communication with Mr C regarding this. 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 failing to deal with his complaint in a reasonable way. 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:

• Meetings with complainants should be arranged within a reasonable time; complaint files should record any delays; and complainants should be told within a reasonable time of any alterations to the arrangements.

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 to us about the care and treatment that her late father (Mr A) had received from the practice. Mr A had attended the practice as he was feeling some discomfort in his chest after exertion and increasing fatigue. He was referred to hospital urgently for a chest x-ray. The GP also increased the dose of Verapamil (a medication used for high blood pressure and angina) Mr A was receiving. Mr A had a scan of his heart at the hospital approximately ten days later This showed valve disease in Mr A's heart, which can lead to heart failure. An appointment was made for him to see a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) and the Verapamil was stopped and his medication changed. Mr A's condition deteriorated and he returned to the practice several days after the hospital appointment. He complained of chest pain radiating to his back and said that he was no better with the new heart medication. The GP thought that this might be caused by gastric irritation and increased his medication for stomach acid. Mr A died from heart failure the following morning.

Ms C complained about the practice's decision to increase her father's Verapamil. We took independent advice from a GP adviser. We found that Mr A had been referred to hospital because it was considered that he had worsening angina. The GP had consequently increased Mr A's Verapamil, which is a recognised and common treatment for angina. The GP could not have foreseen the echocardiogram result at that time and, therefore, could not have foreseen that increasing the Verapamil was not the best treatment. Mr A's valve disease had not been caused by Verapamil, but is a condition that deteriorates over many years. We did not uphold this aspect of Ms C's complaint.

Ms C also complained that the GP did not examine Mr A's chest at the appointment after his hospital visit. We found that the GP should have examined Mr A, as he was complaining of persistent chest pains and had no improvement with cardiac medication, despite recent cardiology confirmation that he had developed new heart failure. We upheld this aspect of Ms C's complaint, although we were unable to say if an examination by the GP would have changed the overall outcome for Mr A.

Finally, Ms C complained that the practice had delayed in processing a medication request for Mr A. The practice had accepted that there had been failings in relation to processing this request and had apologised to Ms A for this. We also, therefore, upheld this aspect of her complaint. We made no further recommendations regarding this, but we asked the practice for evidence of the action they said they had taken.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to carry out an examination of Mr A. 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:

• Staff should be aware of the symptoms, signs and management of unstable angina and should carry out and record an adequate clinical assessment in appropriate cases in line with General Medical Council 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.