Some upheld, recommendations

Summary

Mr C complained about the care and treatment given to his grandmother (Mrs A), both at home and at Monklands Hospital, in the days prior to her death. He said that while Mrs A was at home, staff changed her opiate-based medication. He believed that Mrs A suffered withdrawal symptoms causing her to fall and he was unhappy that she had been persuaded to go to hospital when she had a long-standing wish to remain at home. He said that there was confusion after Mrs A's admittance and that her family were not kept informed of either her whereabouts or her condition. Mr C said that when the family were reunited with Mrs A, she was very distressed and wanted to go home. He said that the family were not told about Mrs A needing an ECG (electrocardiogram - a test to check the heart's rhythm), which caused her further distress. Following this ECG, and at the end of visiting time, Mrs A's family were asked to leave. Mrs A's condition deteriorated rapidly and she died. Mr C complained that he was not advised of the seriousness of his grandmother's condition and that her resuscitation status should have been discussed. He said the family were totally unprepared for her death and he was upset that Mrs A had died alone.

He complained to the board who acknowledged failures in communication but said that Mrs A's deterioration and death had not been anticipated. They explained the reasons why her resuscitation status had not been discussed and added that since Mr C's complaint, Mrs A's case had been discussed with staff and changes had been made to avoid a repetition of the situation for other patients under the board's care in future. Mr C remained dissatisfied and complained to us.

We took independent advice from a nursing adviser and from a consultant geriatrician. We found that the opiate-based medication Mrs A had been prescribed at home for her pain could have side effects, particularly leading to the increased risk of a fall. Her medication had been given a detailed review and changed in view of her presenting symptoms. While Mrs A's fall required her to be admitted to hospital, we found that this was more likely due to her slow heart rate and swollen legs rather than to her change in medication. We did not uphold the aspect of Mr C's complaint regarding changes to Mrs A's medication.

We found that Mrs A's resuscitation status was not discussed with her or her family at the hospital, although there was evidence that they had been ready to talk about it. We upheld Mr C's complaints about the failure to discuss resuscitation status and keep the family updated, and the failure to reasonably take account of Mrs A's wishes regarding this. However, we found that there was no indication that Mrs A was close to death, and that she was being actively treated for her slow heart rate which is considered to be a reversible condition. As such, we did not uphold Mr C's complaint about the board failing to recognise deterioration in Mrs A's condition.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to listen to the family when they were ready to talk about resuscitation. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be reminded to inform family members about what is happening to their relatives.

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 board at Monklands Hospital. Mrs A was initially admitted to hospital for seven days, with concerns about her eating and her bowels not moving. She was discharged home for three days and received some medical treatment at home but was then readmitted to hospital. Mrs A died in hospital four weeks later. Mr C also said that the board withheld long-standing medication from his wife and that they failed to reasonably communicate with him during his wife's admission. Mr C explained that his wife had suffered a stroke previously, which impaired her ability to communicate.

We took independent advice from a consultant in general/stroke medicine and geriatrics. We did not consider that the board failed to provide reasonable care and treatment for Mrs A and did not uphold this part of the complaint. However, there were failings in the note-taking by hospital staff and we made a recommendation to address this.

The evidence suggested that Mrs A's medication was not prescribed for her during her second admission and that there was no clearly documented decision for this. We found that, as it was a long-standing medication and Mr C would have been well placed to judge the effect of this being withdrawn, the cessation of the medication should have been discussed with Mr C. We upheld this part of the complaint. We also considered that the board failed to reasonably communicate with Mr C during his wife's admission and we upheld this part of the complaint. We asked the board to provide evidence of the remedial action they said they had already taken in both of these areas.

Recommendations

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

• Staff should note details of conversations with patients' family members regarding patients' care and treatment in patients' medical records.

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 complained about the care and treatment provided to her late father (Mr A). Mr A attended the board's out-of-hours service at Monklands Hospital with throat pain and difficulty swallowing. He was seen by an out-of-hours nurse practitioner and an out-of-hours GP. An examination was performed and Mr A was not admitted at that time. Mr A's condition worsened the next day and he was admitted to the hospital where staff identified an abscess in his throat. Over the following days, Mr A had a number of operations and spent time in the intensive care unit (ICU). He was then discharged to the ear, nose and throat (ENT) ward. While on the ENT ward, Mr A suffered a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs) and died.

Miss C complained that the board's staff failed to appropriately admit Mr A to hospital when he attended the out-of-hours service, that they inappropriately discharged him from the ICU to the ENT ward, and that they failed to appropriately monitor him on the ENT ward. The board considered that Mr A had been provided with reasonable care and treatment by the out-of-hours service, and that he had been reasonably discharged from the ICU. However, they acknowledged that there had been some failures in their clinical observation policy on the ENT ward.

After obtaining independent advice from out-of-hours practitioners, we did not uphold Miss C's complaint about Mr A not being admitted to hospital. We found that there was evidence of an appropriate examination being made, and a reasonable basis for concluding that the problems Mr A was experiencing were due to tonsillitis. We found that it was reasonable for staff not to have admitted Mr A to hospital at that time.

We obtained independent advice from an intensive care specialist regarding Miss C's complaint about the decision to discharge Mr A from the ICU. We found that this decision was consistent with the relevant guidance and adhered to the standards of general practice. Therefore, we did not uphold Miss C's complaint in this regard.

We obtained independent nursing and medical advice regarding the monitoring of Mr A on the ENT ward. We found failings by nursing staff in following the board's clinical observation policy to act on Mr A's deteriorating early warning scores. We found that on one day, Mr A did not receive a dose of medication given to help prevent the development of deep vein thrombosis and pulmonary embolism. However, we did not find that Mr A's outcome would likely have been any different if he had received this medication. On balance, we upheld Miss C's complaint about how Mr A was monitored on the ENT ward.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and to Mr A's family for the failings in medical and nursing care. The should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of, and follow, the board's clinical observation policy, which requires them to act on deterioration when alerted by early warning scores.
• The circumstances of this case should be fully considered for wider learning (for example by discussing the case at a mortality and morbidity meeting).
• Patients should receive appropriate preventative medication for deep vein thrombosis, and this should be reflected in the relevant records.

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 complained about the treatment that she received from her dentist, after they removed one of her teeth. She explained that, following the removal, she felt that the wrong tooth had been removed. This led her to attend another dentist, who found a crack in the remaining tooth, meaning this also had to be removed. Miss C was also unhappy with the dentist's handling of her complaint, as it took almost a year to receive a response.

In their response to Miss C's complaint, and in response to our enquiries, the dentist defended their decision to remove the tooth based on the symptoms Miss C presented with. They said that this tooth was loose and the area around it was badly infected, leading them to conclude that this was not saveable and the most likely source of Miss C's pain. We sought independent advice from a dental adviser, who reviewed the records and agreed with this assessment. For this reason, we did not uphold the first complaint.

With regards to the complaints handling, we found that there had been a considerable delay caused by the dentist awaiting an independent expert report they had commissioned in order to respond to Miss C's complaint. During this time, the dentist failed to provide Miss C with regular updates, or to formally agree extensions to the deadline for response, which is not in line with the most recent model complaints handling procedure. For these reasons, we upheld the second part of the complaint. However, we considered that the eventual response was reasonable in its content and conclusions.

Recommendations

In relation to complaints handling, we recommended:

• Adopt the model complaints handling procedure and ensure that all staff are aware of this.

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 A had a miscarriage and she felt that her appointment for a surgical evacuation of the uterus (SEU) (a procedure sometimes carried out after a miscarriage to ensure that the uterus is fully evacuated and to prevent infection) at Royal Alexandra Hospital was unreasonably delayed, which she felt put her at increased risk of infection or haemorrhage. Ms A also complained that the board had unreasonably failed to provide her with information about support groups and counselling in relation to miscarriage and that the board had unreasonably failed to provide her with details of her scan results when she elected to pursue private treatment at another hospital for the SEU.

We took independent advice from a consultant obstetrician and gynaecologist. We found that earlier treatment would have been desirable to minimise psychological distress to Ms A, but that the time she waited for the SEU was within the National Institute for Health and Care Excellence guidelines. We found that it was likely that the first available appointment was offered to Ms A, and that there was no reason to think that Ms A was at risk of infection or haemorrhage because of the wait. We concluded that the actions of the board were not unreasonable and we did not uphold the complaint.

The adviser noted that there was evidence in the medical records that Ms A had declined information about counselling and support organisations. We did not uphold this complaint.

The adviser said that it was evident from the medical records that the consultant obstetrician had refused to provide information about Ms A's scan results when she requested this information to help with pursuing private treatment for the SEU. Although the still images that were available would not have been helpful for staff at the private hospital, the adviser said that the board could have provided Ms A with copies of scan results or a handwritten letter with little inconvenience. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to provide Ms A with information about her scan results when she decided to pursue private health care.

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 urological surgery care provided to her son (child A). At birth, child A was diagnosed with hypospadias (a condition where the opening of the urethra is on the underside of the penis). He also had severe chordee (where the penis is curved) and a right side hydrocele (accumulation of fluid in a body sac). He underwent a number of operations over several years to attempt to correct these issues. Ms C complained that her son was now in a worse condition that when the treatment began, and she felt that the multiple operations he had been through had not been done correctly.

We took independent advice from a paediatric urological surgeon. We found that the type of surgeries child A had undergone have a high rate of complication and that there was no evidence that the surgeries had not been carried out to a reasonable standard. However, we found that there was at one point a delay of over a year between child A being reviewed and him being listed for further surgery. We considered this delay in adding child A to the waiting list to be unreasonable. We upheld this aspect of Ms C's complaint.

Ms C also complained that the board had failed to provide a response to her complaint within a reasonable timescale. We found no evidence that the board had failed to follow their complaints procedure or that there had been an unreasonable delay, and 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 failing to enter child A onto the waiting list for further surgery after his review. 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:

• Robust mechanisms should be in place to ensure that patients are entered on the surgical waiting list 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.

Summary

Ms C complained to us that she had been given morphine both during and after an operation at the Royal Alexandra Hospital, despite refusing consent for this to be used because she was allergic to it. The board had disputed that Ms C had refused consent. They told us that the anaesthetist had explained to Ms C before the operation that she had a sensitivity to morphine, but was not allergic to it. They said that they also told Ms C that it would be almost impossible to give a general anaesthetic for an operation of this nature without the use of morphine or a derivative.

We took independent advice from a consultant in anaesthesia and intensive care medicine. We found that the anaesthetic technique used by the anaesthetist was appropriate for the procedure Ms C had, even with the risk of side effects. However, given Ms C's concerns about morphine, we found that there should have been an informed discussion about the risks and benefits, which should have been documented. The anaesthetist failed to adequately document such a discussion. Given the importance of this in relation to whether morphine should have been used, we upheld this aspect of Ms C's complaint.

Ms C also complained that the anaesthetist had failed to consider alternative anaesthetic for the operation. We found that the anaesthetist had acted reasonably by putting measures in place to treat any complications during the operation and by ensuring that anti-sickness drugs were available. However, we also upheld this aspect of the complaint, as the anaesthetist had failed to document any discussion with Ms C about alternative anaesthetic for the operation, in line with the relevant guidance.

Ms C complained that the board had lost images taken during the surgery. In their response to our enquiries, the board said that they had been unable to locate the images referred to and apologised for this. We, therefore, also upheld this aspect of the complaint.

Finally, Ms C complained about the board's handling of her complaint. We found that although there had been a short delay in responding to her complaint, this delay had not been unreasonable. We did not uphold this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• not adequately documenting any discussion about the risks/benefits of using morphine and any alternatives
• being unable to locate the images taken during the operation.
• 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:

• Discussions about the risks and benefits of using medication that the patients is concerned about, and discussions about any alternatives, should be documented appropriately.

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, who works for a voluntary agency, complained on behalf of the family of Miss A. Miss A had suffered complex medical problems from birth. Mr C complained that Miss A had not been provided with appropriate care and treatment at the Southern General Hospital and Yorkhill Children's Hospital. He said the family believed there had been repeated failures by medical and nursing staff. They believed that they had not been communicated with appropriately and the board had failed to action their complaint in accordance with the NHS procedure. Miss A had had to undergo surgery on her windpipe and had multiple medical complications, which required on-going medical treatment.

We took independent advice from a consultant paediatrician and a paediatric nurse (specialists in the care of infants, children and young people). They concluded that the main failing on the part of the board was the failure to appoint a lead clinician to oversee Miss A's treatment. While we found that the clinical care and treatment provided to Miss A had been appropriate, this failure to appoint a lead clinician had contributed to the communication failures with the family. The nursing advice we received was that staff had not monitored Miss A's oxygen saturation levels appropriately and that the family had been forced to request that oxygen monitoring be provided.

We found that the board had failed to communicate adequately with the family and, although they had acknowledged this, we found that the board had provided no evidence to show that they had taken steps to avoid a reoccurrence. We also found that the board's response to the complaint had taken an unreasonable length of time and that the responses the family had received had been inaccurate.

We asked the board to apologise for their failings and take a number of actions to address them.

Recommendations

We recommended that the board:

• provide evidence that they have reviewed their oxygen saturation monitoring policy to ensure it corresponds with national guidance for children;
• review care planning for children with respiratory vulnerabilities to ensure that pulse oximetry values (used to measure the oxygen level of the blood) are monitored;
• review care planning to ensure that parental concerns for the child are recorded;
• remind the nursing staff involved in Miss A's care of the importance of comprehensive respiratory care plans to ensure less experienced staff are able to monitor patients effectively;
• provide evidence of the outcomes of the multi-disciplinary review considering continuity of care between acute and community services;
• provide evidence of the outcomes from the multi-disciplinary review of the allocation of lead-care coordinators;
• provide evidence of the changes made to the process for feeding back sleep study results to the parents of children undergoing treatment;
• review their processes in relation to complaint handling of complex cases where more than one department is involved to ensure that a single clinical lead is appointed to oversee the response; and
• apologise for the failings we identified.

Summary

Miss C complained that the medical practice had failed to carry out an appropriate assessment or refer her late father (Mr A) to hospital when he attended a consultation. Mr A was very breathless and suffered from pulmonary fibrosis (scarring of the lungs). The GP did not take Mr A's temperature or provide medication, as they felt that no further treatment was required at that time. Mr A was told to wait until his next scheduled respiratory clinic at the hospital, which was in nine days time. When Mr A attended the clinic, a clinician arranged an immediate hospital admission. Mr A deteriorated and died a few days later. Miss C felt that the GP should have referred Mr A to hospital sooner.

We took independent advice from an adviser in general practice medicine. We concluded that, although the GP had arranged for an ECG (electrocardiogram - test to check the rhythm of the heart), the GP failed to record Mr A's oxygen saturation, temperature and blood pressure. We found that the GP had failed to carry out an examination of the heart, which would have been appropriate for a patient who had presented with increased breathlessness and chest pains. We also concluded that, while it was possible that the GP's decision for Mr A to wait until his clinic appointment may have been reasonable, we were unable to establish this as the standard of record-keeping for the consultation was inadequate. We upheld Miss C's complaint that the GP failed to provide Mr A with appropriate treatment in view of his reported symptoms. However, in view of the inadequate record-keeping, we could make no finding on the complaint that the GP should have referred Mr A for a hospital assessment.

Recommendations

What we asked the organisation to do in this case:

• Send Miss C a written apology for the failure to carry out a thorough assessment in view of Mr A's reported symptoms.
• Send a written apology to Miss C for the inadequacies in record-keeping which meant we could not determine whether a hospital referral was required.

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

• The GP involved should ensure that a thorough assessment is carried out in view of a patient's reported symptoms.
• The GP involved should ensure that their record-keeping meets the standard of what would be expected under the General Medical Council's Good Medical Practice guidance, in terms of clinical assessment, record-keeping and safety netting.

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 provided to his late wife (Mrs A). Mrs A had amyloidosis (a condition caused by abnormal deposits of a protein called amyloid around tissues and organs in the body) and Mr C felt that the diagnostic process for this was slow. Mr C had concerns that biopsies undertaken by the board were found to be negative for amyloidosis, but were later found to be positive when tested at the UK's National Amyloidosis Centre. We took independent advice from a consultant physician, a cardiologist, and a pathologist. We did not find that there were any unreasonable delays in determining that Mrs A had amyloidosis. The advice we received was that it was reasonable that the National Amyloidosis Centre was able to make a diagnosis when the board did not, as the National Amyloidosis Centre is more experienced in the techniques for testing. We did not uphold this complaint.

Mr C also complained about failures in communication and failures in providing adequate support to Mrs A and her family during Mrs A's illness. We took independent advice from a consultant physician and found that the board's communication with the family throughout Mrs A's illness, and the support provided to Mrs A, was unreasonable and insufficient. We considered that a protocol for earlier involvement of specialist nurses, and consideration of how to access information from the National Amyloidosis Centre, would have minimised this issue. We made recommendations regarding this.

Finally, Mr C complained about the board's handling of his complaint. We found that the board had failed to meet deadlines and had failed to provide clear explanations to Mr C. We upheld this complaint. However, we found that the board had implemented a new complaints handling procedure since Mr C's complaints and so we did not make any recommendations around this issue.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to communicate with the family properly during Mrs A's illness, for failing to provide Mrs A with adequate support and for failing to handle Mr C's complaints about Mrs A's treatment reasonably.

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

• There should be a protocol for how to involve specialist nurses in the care of patients with very rare conditions, and where to get specialised information and support.
• The board should consider how they could access information and support from the National Amyloidosis Centre to provide to patients.

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.