Some upheld, recommendations

When it was originally published on 15 February 2017, this case referred to a medical practice in the Highland NHS Board area. This was incorrect, and should have read a medical practice in the Grampian NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

We have put measures in place to help avoid recurrence of this issue.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) by the practice. She said that the care had been poorly organised and gave specific examples of what she believed was a substandard examination of Mr A by a GP and a failure to follow up on blood test results. Mrs C also said the practice had insisted on some care being provided by the practice nurse, whom she said was not competent. Mrs C felt the practice's response to her complaint had also been inaccurate. Mrs C believed that had the care Mr A received been of a higher standard, he may have been able to undergo treatment before his cancer became terminal.

We took independent medical advice. We found that Mr A's examination had failed to identify a condition which merited urgent referral. We therefore upheld this aspect of Mrs C's complaint. This failure had not, however, had any impact on Mr A's prognosis as the condition was unrelated to Mr A's cancer. The other aspects of Mr A's care were, however, reasonable.

We also took independent nursing advice. The adviser said that the actions of the practice nurse were adequately documented and there was no evidence of incompetency.

We found that while Mr A did not receive a reasonable standard of examination from the practice on one occasion, in other respects his care, including his nursing care, was reasonable. The practice's complaint response was detailed and provided a full explanation of Mr A's care and showed the practice had reflected carefully on the actions they had taken. We therefore did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings identified during this investigation.

Summary

Mrs C complained about the care and treatment given to her father (Mr A) after his referral to Glasgow Royal Infirmary. Mr A underwent a colonoscopy (his bowel was examined with a camera on a flexible tube), a number of polyps were removed and a likely cancer of the rectum was biopsied. He was discharged home but began to feel unwell and was later admitted to hospital as an emergency. He had a perforated bowel which required repair.

Mrs C complained that Mr A was not given appropriate advice about the risks of his initial surgery or about what to do if his health deteriorated after being discharged. She further complained that Mr A had not been fully advised of his state of health by the clinician who was treating him. In particular, she complained that he had not been told that his cancer had returned, for which he would be given no treatment as agreed by a multi-disciplinary team who discussed his case. Mrs C said that as a result, the family was not prepared when Mr C died, seven months after his initial referral to the hospital.

We took independent advice from a consultant general and colorectal surgeon. We found that before his operation, Mr C had been given clear information about the possible risks, including of the possibility of a perforation. Although Mr C became unwell following the procedure, we found that he had been given written advice about what to do in such circumstances. We therefore did not uphold this aspect of Mrs C's complaint.

We found that while Mr C had been told that his cancer had been removed and that, unlike most colorectal cancers, showed no further involvement in his liver, lungs or abdomen, he had not been told that, unusually, it had spread to his bones. In their reponse to Mrs C's complaint, the board said it was difficult to achieve the right balance in terms of how much information to give to patients and their families. In this case, Mr A had already undergone multiple surgeries and the multi-disciplinary team decided not to provide Mr A with chemotherapy because of his very weak and frail condition. However, we established that he and his family should have been told that the cancer had spread. This would have been in line with the General Medical Council guidance on effective communication. We therefore upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• make the relevant staff aware of the outcome of this investigation;
• apologise for the failure to inform Mr C and his family of a multi-disciplinary team meeting and the decision it reached; and
• remind the clinician concerned of the relevant General Medical Council guidance.

Summary

Mrs C complained about the care and treatment of her late father (Mr A) who was admitted to Queen Elizabeth University Hospital with pneumonia. While Mr A's health improved at first, he contracted sepsis (an infection in the bloodstream or tissues). Although he was given antibiotics, he died a few days later. Mrs C raised concerns about the medical and nursing care and queried why antibiotics were not started earlier. Mrs C also complained that she was not properly recorded as Mr A's power of attorney and that staff did not include her in important discussions about his future care.

Staff from the board met with Mrs C on two occasions and apologised for some aspects of care. However, they considered the medical care was reasonable and said staff did not consider the power of attorney was relevant as Mr A still had capacity when he made decisions about his care.

After taking independent medical and nursing advice, we did not uphold Mrs C's complaint about medical care. We found staff appropriately administered antibiotics when Mr C's blood tests showed signs of infection. We upheld Mrs C's complaint about recognition as power of attorney, as staff had incorrectly recorded 'N/A' in relation to power of attorney on Mr A's admission notes. However, we found that it was reasonable for staff not to include Mrs C in the discussions about Mr A's care decisions as Mr A had capacity at that time and asked the doctor not to discuss these decisions with Mrs C.

We found that the overall nursing care had been reasonable. Although the board acknowledged there had been issues with call buzzers during the admission and a catheter bag that was not placed on a stand, they had taken appropriate action in response to these issues.

Recommendations

We recommended that the board:

• apologise to Mrs C and her family for the failings identified; and
• ensure they have adequate processes in place to monitor that power of attorney is being accurately recorded on admission.

Summary

Mr C complained about the care and treatment he received during a number of admissions to Borders General Hospital.

Mr C was concerned that given previous surgery, he should not have been offered endoscopic retrograde cholangiopancreatography (ERCP, a procedure where a flexible tube is passed into the small intestine). Mr C also complained that the ERCP was not carried out in an appropriate manner and led to the need for further surgery and treatment, which were also not carried out in an reasonable manner.

We took independent advice from a consultant general surgeon. The advice we received was that the care and treatment provided to Mr C was appropriate and reasonable. Mr C suffered a number of recognised complications following what the adviser considered was a reasonable decision to offer him ERCP. The advice we received was that the clinical management decisions made in Mr C's care and treatment were in accordance with accepted good practice. We therefore did not uphold these aspects of Mr C's complaint.

Mr C also complained that he was not given appropriate information about what might happen should the drain fail. We found that the medical records did not detail any discussion held with Mr C about alternatives to ERCP and failed to detail what advice was given to Mr C. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• consider reviewing their procedure-specific consent form for ERCP to include a section to record any alternatives to the procedure;
• consider the adviser's comments on the importance of including in the medical records detail of discussions held with patients with regard to treatment options and their potential outcomes and report back to this office on any action taken;
• remind staff of the importance of recording key information given to patients; and
• consider the adviser's comments on the use of a leaflet for patients with information on how to manage surgical drains, including information on what to do if a drain appears blocked and report back to this office on any action taken.

Summary

Mrs C's father (Mr A) was treated with radiotherapy for cancer of the tongue. Following his treatment, Mr A received ongoing support from the board's community dieticians and regular reviews at a joint cancer clinic in another health board. He also received speech and language therapy (SALT) as part of the cancer clinic for about six months, and was then referred back to the board for ongoing SALT care.

In the 18 months following his treatment, Mr A had increasing difficulty swallowing and suffered from recurrent mouth ulcers and pain. He also had several short hospital admissions with bleeding from the mouth. He was subsequently admitted to Borders General Hospital in June 2014 with weight loss, decreased ability to swallow and stridor (noisy breathing caused by a narrowed or obstructed airway). He underwent endo-tracheal intubation (insertion of a tube to maintain an open airway to the lungs) and was transferred to a different hospital. Mr A passed away about ten days later.

Mrs C complained about Mr A's care during this period, and raised concerns that clinicians failed to adequately respond to Mr A's mouth pain, malnutrition and weight loss, as well as infections in his mouth. Mrs C also raised concerns about communication during two hospital admissions, including that Mr A was incorrectly told that his cancer had returned in May 2014.

After taking independent advice from a consultant in general medicine, a SALT therapist and a dietician, we upheld two of Mrs C's complaints. We found that when Mr A's SALT care was referred back to the board, the referral was not actioned properly, which meant that Mr A did not receive any SALT support for about a year (until shortly before his final admission). We also found there were failings in communication during Mr A's final hospital admission (although we noted that the board had acknowledged and apologised for this). However, we found no evidence that Mr A was given incorrect information during his May 2014 admission.

Recommendations

We recommended that the board:

• apologise to Mrs C's family for the failings our investigation has found;
• demonstrate to us what action has been taken to ensure SALT referrals are properly actioned in future;
• review their processes for ensuring joined-up post-treatment care for patients with head and neck cancer; and
• demonstrate to us what steps are being taken to improve communication with patients and their families (and documentation of this) at Borders General Hospital.

Summary

Mrs C complained about the care and treatment given to her husband (Mr A), who suffered from dementia and was wheelchair-bound. Mr A was admitted to University Hospital Ayr with a urinary tract infection, was kept in hospital for about a week, then discharged on a Friday. Mrs C required a lot of assistance to manage Mr A over the weekend, and following a GP visit the following Monday, he was readmitted to hospital. It was agreed that Mr A would be transferred to a nursing home for his future care. However, while in hospital he suffered ischaemia (lack of blood supply) to his left leg and died. Mrs C complained about a number of aspects of care, including that nursing staff did not seem to have a good understanding of dementia and did not understand Mr A's needs.

The board met with Mrs C and apologised for some aspects of care. They developed an improvement plan in response to Mrs C's complaint, which included changes to improve continuity of care and staff communication with families. The board also introduced a 'dementia champion' on the ward to raise awareness of dementia. However, they did not tell Mrs C about the action that had been taken in response to her complaint until prompted by this investigation.

After taking independent medical and nursing advice, we upheld Mrs C's complaints about the first discharge and about nursing care. While we found most aspects of nursing care were reasonable, we were critical that the board used a standard chart for monitoring Mr A's pain, whereas they should have used a chart designed for people with cognitive impairment (such as dementia), who are not always able to express their pain verbally. We did not uphold Mrs C's complaint about communication, as we found there was evidence that staff had regular conversations with Mr A's family about his condition. While Mrs C said she always had to initiate conversations, it was not possible to tell this from the clinical records, and we found no evidence that staff did not communicate reasonably. However, we found that some conversations between staff discussing Mr A's care were not recorded, and we made a recommendation regarding this.

Recommendations

We recommended that the board:

• feed back the findings of this investigation relating to Mr C's discharge to the doctor involved for reflection and learning;
• review the discharge planning process on the ward to ensure there is adequate planning, including assessment of ongoing care needs where appropriate;
• remind relevant medical staff of the importance of recording multi-disciplinary team discussions about patients' care (including 'whiteboard meetings');
• introduce a tailored pain assessment tool for use with people with dementia;
• provide us with information on steps taken (or an action plan) to indicate how dementia awareness is being carried out, in line with the national Promoting Excellence framework; and
• apologise to Mrs C for the failings found during this investigation.

Summary

Miss C complained about the care and treatment received by her partner (Mr A) at University Hospital Ayr. Mr A attended the hospital for a urology review as he had been experiencing problems involving his testicles, perineum and groin area. Miss C complained that no cause could be found for his pain and that although he had previously undergone a procedure involving his scrotum, this would not cause the sharp pain about which he was complaining. Mr A was subsequently admitted to hospital as an emergency. A scan showed that there was no blood flow to his left testicle, and it had to be removed.

Miss C complained that Mr A had been discharged too soon and without being seen by the consultant. She also said that the consultant concerned had refused to do further tests to establish the cause of Mr A's problems.

We took independent advice from consultants in emergency medicine and urology. We found that Mr A's treatment in A&E was of a reasonable standard and in line with his presenting symptoms, and that he was admitted and referred to the appropriate specialist in a timely way. We also found that the surgery Mr A had was reasonable. However, the level of documentation justifying the consultant urologist's decision-making and the information given to Mr A to allow him to make informed consent was not in accordance with General Medical Council (GMC) guidance. Furthermore, Mr A received little in the way of explanatory information and he was not examined when he attended for review. We upheld this aspect of Miss C's complaint.

In response to Miss C's complaint to the board, Mr A was referred to a urologist in another area, which we found to be good practice. However, Miss C's complaint to the board was not handled within the relevant timeframe and we upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• apologise formally for identified failings;
• ensure that the consultant urologist involved is made aware of the findings of this investigation and remind them of their obligations regarding note-taking and consent as per GMC guidance; and
• remind staff involved of their responsibilities in relation to the complaints process, and the importance of addressing complaints within the relevant time frame.

Summary

Mr C complained on behalf of Mr A. Mr A had previously submitted an academic appeal to the University of Aberdeen in relation to the examination of his PhD thesis. The appeal was not upheld.

Mr A had concerns about the administration in relation to the oral examination of his thesis, as well as the conduct of the examination. We found that the university had double-booked the room in which Mr A's examination had been scheduled to take place. We were critical of this and upheld this part of Mr C's complaint.

We also found that Mr A's examination had lasted for three hours and that he had not been offered a break. We noted that the university's Code of Practice in relation to oral examinations stated that breaks must be agreed when examinations last longer than two hours. This had not happened and we considered that it was the responsibility of the university to ensure that a break was offered. Since the university's guidance on oral examinations did not explain the process of agreeing breaks, we considered that the university should consider reviewing this.

Mr C raised a number of concerns about the way the university handled Mr A's academic appeal. We found that the university had adequately explored Mr A's concern about the partiality of the internal examiner who examined his thesis and we did not uphold this complaint. Mr C also raised concerns about the appeal panel's consideration of Mr A's concerns about monitoring and feedback. We found that the university had been unable to provide copies of progress-monitoring records. We therefore upheld this complaint.

Mr C further complained that the university had unreasonably allowed the school to introduce a document into the appeal when Mr A had not been given prior notice of the document. We found that the procedure in relation to appeal hearings encouraged prior submission of documentary evidence. We were critical that Mr A was not provided with a copy of the document, and that the appeal panel allowed the evidence to be heard when Mr A had not received a copy. We upheld this complaint.

Finally, we considered whether the appeal panel unreasonably took inaccurate or incomplete information into account at the appeal hearing. We did not find this to have been the case and therefore we did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the university:

• apologise to Mr A for the inconvenience and anxiety caused by their failure to make reasonable arrangements to book the room;
• take steps to investigate the university's room booking system so that steps can be taken to prevent double-booking from happening again;
• apologise to Mr A for failing to offer a break during his oral examination;
• review and consider amending paragraph 11.3 of the university Code of Practice to ensure that the process of agreeing breaks is clear and ensure that when a break is offered, this is recorded;
• provide this office with evidence that improved procedures regarding record-keeping have been adopted; and
• apologise to Mr A for failing to ensure that he had an opportunity to consider the evidence prior to the appeal hearing.

Summary

Mr C complained about a decision taken by the Scottish Prison Service (SPS) to downgrade him (return him to closed conditions from less secure conditions). He said that they did not follow the proper process in taking the decision, and that the decision was based on inaccurate evidence.

Mr C was unhappy that he was not placed on a disciplinary report for the incident which triggered the downgrading process. We found that the disciplinary process is a separate process and that it is at the discretion of staff whether to place prisoners on disciplinary reports. A disciplinary hearing does not have to take place before downgrade action can be taken. While Mr C was frustrated that he was not afforded a disciplinary hearing in order to protest his innocence, we noted that the downgrading process allows prisoners the opportunity to make representations against the decision. However, the SPS said that they had lost the relevant form and were unable to evidence that this happened in this case. We therefore concluded that the proper process was not followed and upheld this complaint.

Whilst Mr C denied the allegations made against him that triggered the downgrade action, we found nothing to indicate that the decision was taken based on inaccurate evidence. We noted that the SPS are entitled to take action to evaluate a prisoner's risk if they have concerns and that the decision in this case appeared to have been taken based on an accumulation of concerns and not solely on the one incident. We did not uphold this complaint. However, while we did not conclude that the SPS decision was based on inaccurate evidence, we considered that it may have been based on incomplete evidence (given the absence of evidence of Mr C's representations having been taken into account).

Recommendations

We recommended that SPS:

• apologise to Mr C for their failure to follow the proper process when taking the decision to downgrade him;
• remind relevant staff of their responsibility to ensure all appropriate documentation is completed and transferred to the receiving establishment when a prisoner is returned to closed conditions; and
• invite Mr C to make representations against the decision to downgrade him and ensure that they are duly considered and responded to.

Summary

Mr C complained that a prison manager unreasonably failed to take action to notify a family member that he had been assaulted in prison and taken to hospital. Scottish Prison Service (SPS) rules state that requests from prisoners for a relative or friend to be informed must be actioned if the prisoner becomes seriously ill, sustains serious injury or is admitted to hospital.

Mr C initially had his injuries assessed in the prison by a nurse and the SPS told us that his injuries were not determined as serious at that stage. They said a hospital medical assessment was required before this could be established. Mr C's injuries were not found to be serious following assessment at A&E and he was discharged back to the prison from there without being admitted to hospital. On this basis, we were satisfied that the relevant prison rule had not been triggered and that the prison manager's failure to notify the family member was not unreasonable. We did not uphold this aspect of the complaint.

However, we considered that it would have been good practice for the prison manager to have documented their decision and the rationale behind it at the time. We also noted that the SPS referred on more than one occasion to Mr C's injuries having not been life-threatening when this is not a test applied by the relevant prison rule. We made recommendations about this.

Mr C also complained that an officer who escorted him to hospital inappropriately advised hospital staff not to inform his family member, as he thought that the prison manager had already done so. However, the officer indicated that he had provided this advice as it was not looking likely that Mr C would be admitted to hospital. We found no evidence that the officer provided inaccurate or misleading information to hospital staff and we did not uphold this complaint.

Finally, Mr C complained about the appropriateness of the prison governor's response to his complaint. In responding, the governor advised that the family member was not informed as Mr C had not been admitted to hospital. The relevant prison rule was only partially quoted and no reference was made to the need to assess the seriousness of the injury/illness. The prison manager indicated that a decision was taken that hospital assessment was required before the seriousness of Mr C's injuries could be established, but the governor's response did not reflect this position. We upheld this complaint and made a recommendation.

Recommendations

We recommended that SPS:

• highlight to relevant staff that it would be good practice to document their rationale when reaching a decision on a request of this nature received from a prisoner;
• remind relevant staff of the specific criteria under which a prisoner may request that their relatives/friends be contacted; and
• apologise to Mr C for failing to fully and accurately respond to his complaint.