Some upheld, recommendations

Summary

Mr C had been taking warfarin (a blood-thinning medication). Following a review at an out-patient cardiology clinic, his International Normalised Ratio (INR, a blood test that checks how long it takes for blood to clot) target range was changed to between 2 and 3. Previously, it had been 2.5 to 3.5. Mr C's GP practice did not update the change on their systems and Mr C only became aware of the change 18 months later. Mr C complained to the practice and was dissatisfied with their handling of his complaint.

Whilst the practice accepted that they failed to update Mr C's INR target, the advice we received was that this failing was not significant. The adviser said the change in Mr C's INR target was not clearly communicated by the cardiologist to the practice as it did not contain a sufficient alert to notify the change in his INR target level. Furthermore, the practice could not be expected to be aware of national changes. We accepted this advice. The adviser also commented that as Mr C's INR target was to be reduced rather than increased, there was no significant clinical risk resulting from the failure of the practice to update the target. Taking account of this advice, we did not uphold this aspect of the complaint.

We accepted that the practice had provided Mr C with an apology and an explanation for the error but they had delayed in doing so. While we accepted the delay was due to difficulty in obtaining information that they needed from the cardiology department, we considered the practice could have made Mr C aware of this. We also found that the practice's response to Mr C's complaint did not contain details for this office. We upheld this aspect of the complaints.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings in complaints handling identified in this investigation; and
• review their complaints handling procedures to ensure that they are in line with NHS Scotland's 'Can I Help You?' guidance.

Summary

Mrs C complained that she had been given a bill by her dentist which included costs for work which was either corrective or had already been paid for. Mrs C also complained that she was being charged for work that had not been carried out. Additionally, Mrs C complained that the dentist had failed to communicate with her about her treatment needs, in particular that she had once been given a treatment plan with no costs on it.

We took independent dental advice. We found that what Mrs C had believed to be a bill was in fact an estimated treatment plan and therefore she was not being charged for work at the time of her complaint. We did not uphold this aspect of Mrs C's complaint. However, we found that it was unreasonable that she had on one occasion been presented with a treatment plan with no costs on it and therefore we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the practice:

• apologise to Mrs C for issuing a treatment plan without any costs on it.

Summary

Mr C was receiving care and treatment from one of the board's community mental health services. He complained that he was unhappy with aspects of his care and services provided by the board.

We took independent advice from a psychiatric adviser and a mental health nursing adviser. The psychiatric adviser found that Mr C's initial referral to the consultant psychiatrist had been lost, and we were critical of this. However, they were satisfied that Mr C received reasonable treatment from the psychiatrists he saw and considered that it was evident from the records that this treatment had resulted in an improvement in his condition. The mental health nursing adviser was satisfied that, for the period the community psychiatric nurse (CPN) was engaging with Mr C, the CPN's input was reasonable and of an appropriate standard. However, the mental health nursing adviser was critical that, following a referral to a practitioner of CBT (cognitive behavioural therapy), the CPN discharged Mr C from their caseload without waiting to see whether the CBT service would take on Mr C. The mental health nursing adviser considered that this had denied Mr C the opportunity to explore other support, and considered that Mr C's continuity of care had been interrupted and that this was unreasonable. We found that the CPN's clinical correspondence could have been better worded, and although the adviser did not consider that the CPN's actions could be considered to be a breach of professional conduct, they felt that this was a learning point. We therefore upheld this aspect of Mr C's complaint.

Mr C also complained that when the CPN was absent, the board did not provide him with a replacement CPN. We noted that the board had written to Mr C to ask him to call the service if he wanted a different counsellor in the absence of his CPN. The board said that if there was no response to this letter within two weeks, no follow-up letter would have been sent. The mental health nursing adviser considered that asking Mr C to maintain continuity of care was unreasonable, especially at a point when Mr C had not yet been seen by a psychiatrist. They noted that Mr C therefore had no CPN input for four months, which was unacceptable. We upheld this aspect of Mr C's complaint.

Mr C also complained about a weight-loss programme provided by the board. In particular, Mr C complained that he was not provided with recipes as part of the programme, and that the programme was not sufficiently holistic. We took independent advice on this aspect from a nursing adviser. They noted that recipes were not a specific aspect of the programme and considered that it was reasonable for the practitioner to recommend that Mr C use the library to find recipes. They also found that it would not have been appropriate for the practitioner to have supported Mr C with his other issues, including his mental health. We therefore did not uphold this complaint.

Mr C said that whilst the doctors and psychiatrists he saw considered that CBT would be useful for him, when he saw the CBT practitioner, they did not think that it would be suitable. Both the psychiatric and mental health nursing advisers agreed that the CBT practitioner had provided reasonable reasons for their decision that Mr C was not a suitable candidate for CBT. We did not uphold this complaint.

Mr C also complained that the board did not respond reasonably to his complaint. Although we considered that many aspects of the board's complaints handling had been reasonable, we found that it had taken the board a disproportionate length of time to respond to Mr C's complaint. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• feed back the adviser's comments to the CPN involved so that the CPN reflects upon their style of report and letter writing;
• take steps to ensure that referrals within the community mental health team are received and appropriately processed;
• review the discharge procedures of the community mental health team, taking into account the adviser's comments;
• review the community mental health team's practice of writing to patients (in similar cases) and giving them two weeks to respond if they wish to have continued community mental health team input; and
• apologise to Mr C for the failings identified in this investigation.

Summary

Mr C, who received treatment for high blood pressure and kidney disease, complained that GPs at his medical practice had not monitored his blood pressure reasonably, and that this had caused damage to his kidneys. In response to Mr C's complaint, the practice said that his blood pressure had been monitored in accordance with the relevant guidelines.

We took independent medical advice. The adviser was satisfied that it was appropriate for the practice to measure Mr C's blood pressure at whatever time he attended for an appointment and noted that there was no requirement in the guidelines stating that blood pressure cannot be taken in the morning, or after a patient's medication has been taken. The adviser considered that both Mr C's blood pressure and kidney function had been monitored with reasonable regularity and in accordance with the relevant requirements. Furthermore, the adviser did not have concerns about the medication prescribed to Mr C by the practice and concluded that there was no evidence that the practice had failed to adequately monitor Mr C's blood pressure or that their actions had contributed to reduced kidney function. We therefore did not uphold this aspect of Mr C's complaint.

Mr C also complained that the practice did not respond reasonably to his complaint. In response to our enquiries, the practice identified that some of the complaint correspondence did not meet a number of the requirements of the Patients Rights (Scotland) Act 2011. The practice told us that the practice manager had undertaken to fully familiarise themselves with the requirements of the Act and that they would update the practice's complaints procedure to reflect the requirements. Although we found that many aspects of the practice's handling of the complaint were reasonable, we were critical that the practice had not followed the guidance in relation to acknowledging complaints and updating complainants after a delay. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the practice:

• apologise to Mr C for failing to handle his complaint in accordance with the relevant guidance; and
• provide this office with a copy of their updated complaints procedure.

Summary

Mr C complained about the care and treatment provided to his wife (Mrs A) at Raigmore Hospital. Mrs A needed surgery to dilate and place a stent (a tiny tube inserted into a blocked passageway to keep it open) in the artery in her chest supplying her left arm, to assist with her kidney dialysis. The board were unable to place the stent in a satisfactory position and carried out surgery to remove the stent. This caused internal bleeding and Mrs A was taken to theatre for emergency surgery. The surgery proved too much for Mrs A's vital organs and she died. Mr C raised several concerns about his wife's care and treatment by the board. These included that the board failed to give Mrs A appropriate explanations about the risk of the stent procedure and failed to obtain Mrs A's informed consent for the procedure.

We obtained independent medical advice from a consultant vascular and endovascular surgeon and a consultant interventional radiologist. The board said they did not advise Mrs A of the risk of death, as they consider it to be below the threshold required to be specifically mentioned as a complication. The radiologist adviser said that as Mrs A was unwell and suffered from heart failure and other conditions, the risk that any complication of the procedure would result in very serious consequences for Mrs A was increased. It would, therefore, have been reasonable for the board to have discussed the risk of death with Mrs A. We upheld this part of the complaint.

Both advisers said that the evidence suggested that the board failed to follow their consent procedure, as they only appear to have discussed the stent procedure with Mrs A on the day of the operation. Therefore, Mrs A would not have had adequate time to reflect on the surgical options. We therefore considered that the board failed to obtain Mrs A's informed consent for the procedure. We upheld this part of the complaint.

Recommendations

We recommended that the board:

• feed back our findings on explanation of the stent procedure and informed consent to the staff involved;
• provide us with evidence that a revised consent form has now been implemented;
• ensure that in future, they appropriately advise patients of the risk of death;
• ensure that in future, when they discuss surgical procedures with patients, they give them adequate time to reflect on the information provided before surgery is carried out; and
• provide Mr C with a written apology for the failings identified.

Summary

Mrs C complained about the care the board gave to her father (Mr A). Mr A had Parkinson's Disease and was admitted to Glasgow Royal Infirmary as he had fallen a few weeks before and had become confused and unable to cope at home. Mrs C said that shortly afterwards, he became constipated and was given an enema. She said that he was then left alone and when he attempted to go to the bathroom, he had fallen out of his bed which had the side rails raised. He broke his hip. Mrs C complained that if Mr A been properly assessed on arrival at hospital and properly supervised after the enema, he would not have broken his hip. She also complained that after the accident, he was not given appropriate physiotherapy treatment.

Mrs C complained to the board who agreed that there had been shortcomings with regard to Mr A's care. They said that a falls and bedrails assessment should have been carried out in a timely way and they should have ensured that Mr A understood the instructions he had been given about the enema. They apologised and put procedures in place to try to avoid the same thing happening in the future. However, with regard to physiotherapy, they said that as Mr A's condition had plateaued, it had come to an end.

We confirmed that there had been shortcomings in Mr A's assessments regarding falls, bedrails and cognitive condition. Although a comprehensive care plan was put in place, this should have been within 24 hours of Mr A's admission. Had this been the case, the risk of him falling may have been minimised or prevented. However, we further established that procedures with regard to the enema had been reasonable, as had Mr A's physiotherapy.

Recommendations

We recommended that the board:

• demonstrate to us the processes put in place as a result of Mrs C's complaint.

Summary

Mr and Mrs C complained about the care and treatment provided to their daughter when she was delivered. At the time of, or shortly after, the delivery by forceps, she sustained a deep cut to her foot. The board were unable to provide an explanation for the cut. Mr and Mrs C complained that board staff failed to perform the forceps delivery in a reasonable manner, and that they subsequently failed to provide appropriate treatment for the injury.

During our investigation, we took independent advice from an obstetrician and a paediatrician. We found that the forceps delivery was not the cause of the cut and that the cut was most likely to have been sustained after the delivery. We did not uphold this aspect of Mr and Mrs C's complaint. Additionally, we found that the treatment given was timely and reasonable and, therefore, did not uphold this aspect of Mr and Mrs C's complaint.

Mr and Mrs C also complained about how the board handled their complaint. They said that the board had taken a long time to respond to their complaint and that they had not made efforts to contact all of the staff involved in the delivery. The board said they had initially not thought that the complaint was to be treated as such, and that they had confirmed this with Mr and Mrs C. However, they could not provide evidence of this being confirmed with Mr and Mrs C. We found this to be unreasonable. In addition, we found that the board could have made further efforts to contact staff involved in order to give a fuller explanation of events surrounding the cut. We also found that in recording the incident, the board had not made efforts to contact midwifery staff and we did not find this to be reasonable. Therefore, we upheld this aspect of Mr and Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the complaints handling failures identified by this investigation;
• feed back the findings of this investigation to the relevant complaints handling staff; and
• feed back the comments of the obstetrician adviser to the relevant staff.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the care and treatment her father (Mr A) had received at the Queen Elizabeth University Hospital before his death. We took independent advice on the complaint from a consultant in acute medicine. Mr A had been diagnosed with cancer and Ms C complained that he had been discharged from the hospital on two occasions, despite the fact that he was still very ill. Ms C also said that there had been a delay in carrying out a biopsy. We found that it had been reasonable to discharge Mr A on the first occasion and that there had not been an unreasonable delay in carrying out the biopsy. However, it had been unreasonable to discharge Mr A on the second occasion, as he had not been medically reviewed for at least two days at that point, despite concerns being raised about his fitness for discharge.

We also found that medical staff should have been clearer about Mr A's poor prognosis and likelihood of death. Some of the communication with his family had not been reasonable and as a result, they not been prepared for his death. The board had already apologised to the family for this. There should also have been better communication between the oncology and respiratory teams and a more realistic assessment of Mr A's fitness for chemotherapy. In view of these failings, we upheld this aspect of Ms C's complaint.

Ms C also complained about the nursing care Mr A had received. We took independent advice on this complaint from a nursing adviser. Although there were problems with replacing Mr A's water, we found that the nutritional care and personal care provided to Mr A had been reasonable. Whilst a nurse had incorrectly told Mrs B that her father was nil by mouth, the nurse had then phoned her back to apologise for this. We also found that the pain relief provided to Mr A had been reasonable and we did not uphold this aspect of the complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mrs B for the failings in relation Mr A's discharge from hospital on the second occasion; and
• provide evidence that the failings identified in this investigation have been fed back to the staff involved in Mr A's medical care.

Summary

Mrs C complained about the treatment provided to her by the board at two appointments regarding her breast implants at Cannisburn Plastic Surgery Unit at Victoria Infirmary. Mrs C complained that at the first appointment she had not been offered a chaperone and had not been introduced to the trainee doctor who was present during her appointment. She also complained that at the second appointment the doctor had examined her without discussing her problems first. Mrs C said that she had not been offered appropriate medical treatment for the problems she had been having with her breast implants and she further complained about the way the board handled her complaint.

During our investigation we took independent medical advice from a consultant plastic surgeon. We found that, while Mrs C and the consultant's accounts of the first appointment differed, it was not recorded whether any discussion regarding a chaperone took place. This was contrary to national guidance issued by the General Medical Council in relation to intimate examinations. We therefore upheld this aspect of Mrs C's complaint. During our investigation, the board had implemented local guidance regarding these issues which we considered reasonable, but we also recommended an apology be given to Mrs C.

With regards to Mrs C's second appointment, we did not identify evidence to suggest that the appointment was not carried out in a reasonable manner. We found that Mrs C had been offered appropriate clinical care for the issues she was having with her breast implants. We also found that the board had made efforts to deal with her complaint in a timely manner. Therefore we did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation.

Summary

Mr C complained that the staff at Glasgow Royal Infirmary failed to appropriately assess and treat his mother (Mrs A) when she was referred there by her GP. His concerns included that the consultant in acute medicine who treated Mrs A made a diagnosis of temporal arteritis (where the temporal arteries, which supply blood to the head and brain, become inflamed or damaged), despite there being no supporting evidence from investigations or tests. Mrs A was discharged home that day. Mr C also complained that the staff at the hospital failed to appropriately monitor and manage Mrs A's blood pressure readings when she was admitted the following day.

We obtained independent medical advice from a consultant physician in acute and internal medicine. The adviser explained that Mrs A was referred to the hospital by her GP as they felt she might have temporal arteritis and it would, therefore, have been reasonable for the consultant to have considered this condition as part of the list of possible diagnoses. The adviser explained that after examination and consideration of Mrs A's history and blood test results, the consultant, correctly, did not consider Mrs A to be suffering from temporal arteritis. However, the adviser said that Mrs A should have been admitted to the hospital and treated for her high blood pressure and failure to do so sat outside the scope of standard practice. Mrs A was subsequently admitted to the hospital the following day as a medical emergency. We upheld this part of Mr C's complaint.

The adviser said the board did not unreasonably fail to take into consideration the effect of the reintroduction of Mrs A's existing high blood pressure medications when assessing her fall in blood pressure, and that it would have been reasonable to start Mrs A on her blood pressure medication in the circumstances. Therefore, we did not uphold this part of Mr C's complaint.

Recommendations

We recommended that the board:

• provide Mr C and Mrs A with a written apology for failing to admit Mrs A to hospital for treatment of her high blood pressure; and
• feed back the failings identified to the doctor involved for reflection for future practice.