Some upheld, recommendations

Summary

[When this report was first published on 19 October 2016, the Southern General Hospital was incorrectly named as the hospital being complained about. This should have said Victoria Infirmary.  This was due to an administrative error for which we apologise.]

Mrs C complained about the care and treatment her late mother (Mrs A) received at the Southern General Hospital. Mrs A died following an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). During the procedure biopsies (tissue samples) were taken, which later led to a bleed.

Following Mrs A's death, the Crown Office and Procurator Fiscal (COPFS) investigated and concluded that they would not refer the death to a Fatal Accident Inquiry.

Mrs C complained to the board at this point, saying she was advised to do this once the COPFS had finished their investigation. The NHS complaints procedure places a 12-month time-limit for considering complaints. The board said that as they had fully cooperated with the COPFS inquiry, there would be no further information to offer and they would not extend the timescale.

We used our discretion to investigate the complaint. We took independent advice from three clinical advisers. The nursing adviser noted that a SEWS (Scottish Early Warning System - a set of patient observations to assist in the early detection and treatment of serious cases and support staff in making clinical assessments) chart was missing. The gastroenterology adviser noted the recording on some of the drug charts was inadequate. The third adviser was a physician and while they noted these omissions in the medical notes, they did not find evidence that the care Mrs A received was unreasonable. While we noted some clinicians would not have biopsied Mrs A, considering her other health conditions, we found this was a degree of professional judgement and the decision to biopsy Mrs A was not unreasonable.

We did, however, uphold Mrs C's complaint about the board's response to her complaint to them and made recommendations to address the failings. We found that, given the serious nature of Mrs C's concerns and the fact that the board were not previously aware of the content of the COPFS report, it would have been good practice for the board to investigate Mrs C's concerns to identify potential learning and give her the opportunity to discuss her concerns. Additionally, the board have a duty to advise complainants that if they will not extend their timescales, the complainant has the right to come to SPSO. This did not happen in this case.

Recommendations

We recommended that the board:

• apologise to Mrs C for the fact that a SEWS sheet was missing from the clinical records;
• apologise to Mrs C for the fact that drug charts were incomplete and ensure all relevant staff are aware of the necessary record-keeping flowing from the guidelines on anti-coagulation in endoscopy;
• apologise to Mrs C for not advising her of her right to refer her complaint to the SPSO for consideration;
• share the learning from this complaint with relevant staff; and
• reflect on the impact on Mrs C of their refusal to consider investigating her complaint and advise us of the outcome of their reflection.

Summary

Miss C complained about care provided by her GP practice. She attended the practice a number of times over a period of six months with various symptoms which were ascribed to depression and treated as such.

When Miss C began displaying slurred speech, her GP urgently referred her to hospital where she was diagnosed with a brain tumour.

We sought independent advice from a medical adviser. Their view was that Miss C's symptoms were reasonably ascribed to other causes and it was not until the symptom of slurred speech occurred that it became clear there might be another cause for Miss C's condition. The adviser said the GP then took appropriate action by urgently referring Miss C. For this reason we did not uphold this complaint.

We did however uphold the complaint about post-operative care as the practice had acknowledged that their normal practice is to contact patients once they have been discharged from hospital and this did not happen in this case. The practice said they intended to carry out an Enhanced Significant Adverse Event (ESAE), and we made a recommendation in relation to this.

Recommendations

We recommended that the practice:

• apologise to Miss C for the failings they identified; and
• share with Miss C any learning from the ESAE.

Summary

Mr C complained about how a prison investigated and responded to his complaint and the time taken to do so.

Mr C had submitted a Complaint about Confidential Matters using a PCF2 form. Scottish Prison Service (SPS) guidance states that on receiving a PCF2 form a response should be given within seven days. We found that the prison failed to investigate Mr C's complaint within the required timescale and did so without giving Mr C a reason for the delay and a revised timescale. We upheld this aspect of Mr C's complaint.

We were satisfied that apart from the unreasonable delay, the prison's investigation and their response to Mr C's complaint were adequate. We did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that SPS:

• ensure staff involved in the investigation of PCF2 complaints at the prison are aware of the relevant sections of the SPS guidance; and
• apologise to Mr C for a failure to adhere to the relevant timescales set out in the SPS guidance.

Summary

Mr C has a diagnosed personality disorder and post-traumatic stress disorder (PTSD). He complained that the practice had refused to come to his home for a house call in relation to physical symptoms he was experiencing including a cough. When the practice initially declined the house call request, Mr C said that his PTSD had rendered him housebound. He later asked for a mental health referral. The practice advised that they needed to see him at a consultation at the surgery before this could be made and Mr C also complained about this decision. In addition, Mr C complained that his complaint to the practice had not been handled properly.

After taking independent advice from a GP, we did not uphold either of Mr C's complaints about his care. We found that Mr C had been seen recently at the practice and that it was reasonable to ask him to attend for an assessment of his physical symptoms. The GP adviser also considered that it was reasonable to require a face-to-face consultation before making a mental health referral. We also took independent advice from a mental health adviser. The mental health adviser said that the practice's approach was reasonable but highlighted the fluctuating symptoms of PTSD and considered that their approach may need to change in future. These comments were drawn to the practice's attention.

However, we found no evidence that Mr C had been provided with information about the Patient Advice and Support Service and the final response to Mr C's complaint did not include information on how to progress his concerns if he remained dissatisfied. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the practice:

• review their complaints handling procedure to ensure that it reflects the requirements of the Scottish Government's 'Can I help you?' guidance.

Summary

Mr C complained that following surgery for a hernia repair at Stracathro Hospital, he suffered severe and continuing pain. Mr C complained to the board about the surgery and the reasons for his continuing pain, which he said had an adverse effect on his daily life. Mr C was dissatisfied with the response he received from the board.

We took independent advice from a consultant surgeon experienced in performing hernia repairs and related complications. They advised that the treatment Mr C received was appropriate. The adviser did not identify failings in either the surgical procedure or in Mr C's post-operative care. The adviser said that Mr C was one of the small percentage of patients who develop pain following this procedure. The steps taken by the board to address Mr C's ongoing pain had been appropriate and reasonable. We accepted this advice and did not uphold Mr C's complaint.

Mr C also complained that the board had failed to respond appropriately to his complaint. The board had accepted they had not dealt with Mr C's complaint in a timely and reasonable manner and that the delay in responding to the complaint was unacceptable. The board had apologised and mentioned action taken to improve their complaints handling.

It was clear to us that the board had failed to deal with Mr C's complaint in a timely manner and in accordance with their complaints procedure. We also considered in particular that their communication with Mr C about the reasons for the delay was poor. We therefore upheld this complaint.

Recommendations

We recommended that the board:

• issue Mr C with a formal apology for their failure to handle his complaint in a timely manner and in their communication with him; and
• provide evidence of the action taken to review and improve their complaints handling.

Summary

Mrs C was referred to a specialist bone clinic in relation to ongoing pain symptoms, but the doctors were not able to find an explanation for this and told Mrs C she had chronic pain syndrome. Mrs C was concerned that the doctors did not undertake any tests or investigations before concluding this.

Mrs C asked for a second opinion from a specialist outside the board's area, and they arranged an out-of-area referral. However, the out-of-area specialist was not able to offer any further explanation for Mrs C's pain. Mrs C was concerned that this was because the referral letter to the specialist was factually inaccurate and did not explain why a second opinion was being sought. She did not consider this review constituted a second opinion.

Mrs C complained to the board with a number of questions about her treatment. The board responded to this, but Mrs C was not satisfied with the response and asked a number of additional questions. The board said they had already responded to the best of their ability, and suggested that instead of engaging in correspondence they could arrange a further out-of-area referral for Mrs C if she wished. Mrs C agreed to this and a referral was arranged, but this specialist declined to see Mrs C as she had already been reviewed by two experienced doctors.

After taking independent medical advice from a consultant physician and rheumatologist, we did not uphold Mrs C's complaints about care and treatment. We found that the relevant investigations had already been arranged when Mrs C was reviewed in the bone clinic and it was reasonable for them to rely on the results of these. We also found that the referral was reasonable and Mrs C had received a second opinion (although this did not find any explanation for her pain). While we found the board's reply to Mrs C's complaint was reasonable, we were critical of delays and several administrative failings in their handling of the complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the complaints handling failings we found; and
• review their processes for handling repeat complaints correspondence (to ensure a quick and accurate response is given when a person has already completed the complaints handling procedure).

Summary

Mr C complained about the care and treatment provided to his mother (Mrs A) during her admissions to Monklands Hospital and Coathill Hospital. Mrs A was suffering from dementia when she was admitted with a urinary tract infection. Mrs A deteriorated whilst in hospital and died just over two months after admission. Mr C said he had visited his mother every day and repeatedly asked to speak with the consultant responsible for her care. He was not given an appointment for over two months. Mr C said Mrs A's medical notes also showed that his mother had been designated as not fit for resuscitation on the day of her admission to Monklands Hospital. Mr C had not been informed of this for two months despite having welfare power of attorney for Mrs A, who had only a very limited ability to communicate. Mr C said Mrs A's ring had gone missing and that staff had failed to look for it. Mr C added that the board's complaints process had taken too long and been inadequate. Mr C also complained that an advocate was inappropriately involved by medical staff against Mrs A's wishes and that staff refused to explain why. Mr C also complained Mrs A had been forced to attend a Christmas party, which her family did not want her to do.

We took independent medical advice on the care and treatment provided. The advice said that Mrs A's designation as not for resuscitation was a medical decision and did not need the family's approval. It should, however, have been discussed with them as a matter of good practice. The advice noted the paperwork for the decision was not properly completed and this had not been reviewed at any point during Mrs A's admission. The advice concluded that the standard of communication with Mr C had fallen below a reasonable standard and that he should have had the opportunity to discuss Mrs A's care much earlier in her admission. The reason for involving an advocacy service should have been recorded and it was inappropriate for board staff to imply that it was required due to difficulties in communicating with Mr C without evidence to support this. The advice also said whilst taking Mrs A to a Christmas party on the ward was done with kind intentions, it should have been discussed with Mr C and the failure to do this had caused the family great distress.

We found communication with Mr C fell below a reasonable standard. Records for the decision to designate Mrs A as not for resuscitation and referral to an advocacy service were not completed properly. These decisions should have been discussed with Mr C, but were not. We also found that staff failed to communicate appropriately about the missing ring and that the evidence did not show any significant effort being made to locate it, despite promises being made to the family. We upheld the complaint.

Recommendations

We recommended that the board:

• provide evidence that the actions identified in response to this complaint have been implemented;
• provide evidence of how they are monitoring the effectiveness of their new communication measures;
• review the process for discussing the decision to designate a patient as not for resuscitation with the patient or their carers, in light of the failure by medical staff to follow existing procedures in this case;
• remind ward staff of the need to ensure valuables are logged on admission, especially if the patient has a limited or impaired ability to communicate;
• provide evidence they have reviewed their procedures when items go missing so that staff are clear on the procedure to follow and information is shared appropriately between shifts; and
• review the process for referring patients to advocates to ensure that reasons for referral are clearly documented and discussed with the patient or their carers.

Summary

Miss C attended her GP after injuring her leg in a fall. Her pharmacist thought she might have a deep vein thrombosis (DVT) but after examination she was diagnosed as having a calf strain. However, her pain continued and the next day she attended Raigmore Hospital. She was diagnosed with a soft tissue injury to her lower leg. Over the next few days Miss C made three further visits to the A&E department and on her second visit she was seen by a nurse practitioner. A fracture was diagnosed and she was put in plaster. It was not until after another two visits that serious circulation problems were diagnosed but by this time, Miss C's leg was so affected that it required to be amputated below the knee.

We took independent advice from a consultant in emergency medicine. We found that the diagnosis of a soft tissue injury after the first visit to hospital had been a reasonable one. Miss C had been thoroughly and appropriately examined. The possibility of a DVT had been considered but there was no evidence of this. However, after her second unplanned visit to the emergency department, she should have been seen by a more senior doctor rather than a nurse practitioner. Her subsequent visits should also have been treated more seriously and a senior emergency doctor should have been involved. This did not happened and thus there was delay in diagnosing Miss C's condition. We upheld this aspect of the complaint.

Miss C also complained that the board failed to fully respond to points raised in her complaint and that they provided inaccurate information. The adviser said that he could see no evidence that the correspondence contained incorrect information and was satisfied with the action taken. We did not uphold this aspect of the complaint.

Recommendations

We recommended that the board:

• apologise for the fact when Miss C made further unplanned visits to the emergency department, she was not seen by a more senior emergency doctor; and
• consider the root cause of the delay in diagnosis and the benefits of introducing a system where 'unplanned return' patients to the emergency department are seen by a senior emergency department doctor.

Summary

Mr C's late father (Mr A) was admitted to Lawson Memorial Hospital for several months for a period of rehabilitation following a stroke. He was then discharged to a care home but died two days later. The cause of death was established as methicillin-resistant staphylococcus aureus (MRSA), which came as a shock to Mr C and his family as it had not been communicated to them that Mr A had been diagnosed with this. Mr C complained about the lack of communication in this regard and also about a lack of treatment for MRSA.

We took independent medical advice from a hospital consultant who considered that the evidence available to demonstrate the clinical thinking behind Mr A's care was poor. They noted that Mr A's care was complex and that there would have been other factors for medical staff to consider. They said that more consideration should have been given to urine culture results and the potential for persistent infection. Consideration should also have been given to changing his catheter in line with NHS guidelines and the board's own policy on treating infections but there was no evidence that this happened. Neither was there any evidence of Mr A being informed of his diagnosis. The adviser said that this should have been communicated to Mr A and his permission sought to share this information with the family. We upheld this complaint.

Mr C also complained about the appropriateness of Mr A being discharged with MRSA. While Mr C considered that Mr A was still displaying symptoms of urine infection around the time of his discharge, we were advised that an appropriate medical review was carried out and no evidence was found to suggest that the discharge could not go ahead. We noted that the board's MRSA policy confirmed that a diagnosis of MRSA should not prevent discharge of a patient. We did not uphold this complaint.

Recommendations

We recommended that the board:

• feed the findings of this investigation back to relevant staff;
• arrange staff training on catheter related infections and MRSA;
• highlight to microbiology staff the importance of offering additional support to off-site wards in interpreting complex results;
• take steps to ensure future compliance with their MRSA policy, particularly in relation to the communication of a diagnosis to patients and carers;
• take steps to address the identified record-keeping failings and ensure future compliance with General Medical Council guidance in this regard; and
• apologise to Mr C for the failings this investigation has identified.

Summary

Mrs C complained to us about the care, treatment and support provided to her son (Mr A) by the board's mental health services before his death from an overdose. We took independent advice on Mrs C's complaint from a psychiatrist. We found that the clinical care provided to Mr A by the mental health services was reasonable and was consistent with current practice. We also found that there had been appropriate communication with other relevant parties. It had been reasonable to delay psychotherapy treatment for Mr A as the uncovering of previous trauma during therapy can sometimes lead to distress and increased suicidal ideation. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained to us that the board had failed to communicate with her adequately about the significant event review that was carried out after Mr A's death. We found that the conduct of the review had been consistent with good practice and was reasonable. However, the completion of the review was delayed and there were also errors in the draft report that was issued. In addition, Mrs C had not been signposted to support in relation to bereavement. We upheld this aspect of the complaint.

Finally, Mrs C complained that the board had failed to deal with her complaints about Mr A's care and treatment appropriately. Whilst we recognised that there had been a large number of complex issues to cover, we considered that the time taken by the board to respond had been unreasonable. We upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• provide evidence that they have considered how they communicate with relatives and other interested parties where an investigation becomes protracted and delayed and whether setting a standard for this would be beneficial; and
• provide evidence of the steps they have taken to avoid delays of this nature in the future.