Some upheld, recommendations

Summary

Mr and Mrs C made a complaint on behalf of their son (Mr A) who had been diagnosed with epilepsy some years ago. Mr A had been seizure free for a number of years but in July 2014 began to experience seizures again. He was admitted to Monklands Hospital on three occasions in November and December 2014 and Mr and Mrs C complained that he was not cared for or treated reasonably. They also said that communication with him was poor.

We took independent advice from consultants in emergency medicine and in neurology and we found that at each of Mr A's admissions, emergency clinicians treated him reasonably and appropriately. He was examined and assessed and appropriate tests were undertaken. He was released from hospital with advice to contact his GP and for psychiatric follow-up. The third time Mr A went to A&E, he was admitted for observation. He was exhibiting bizarre behaviour and suffering from depressive symptoms. However, it was established that although there was clearly documented evidence to confirm that Mr A was emotionally ill, it was accepted that he was suffering epileptic seizures and no definitive tests were requested to refute or deny this. Instead doctors concentrated on altering his medication. For this reason, Mr and Mrs C's complaints about Mr A's care and treatment were upheld. However, we did not find any evidence to suggest that communication with him had been poor.

Recommendations

We recommended that the board:

• make Mr A a formal apology to recognise our findings about care and treatment;
• ensure that members of the neurology team involved in Mr A's care are familiar with the appropriate national guidance; and
• ensure that neurology staff involved in Mr A's case consider it at their next formal appraisal.

Summary

Miss C complained to us that staff at Hairmyres Hospital and Monklands Hospital failed to provide her with appropriate and timely treatment, which resulted in the removal of her gallbladder. We took independent advice on this complaint from a medical adviser, who is a consultant general surgeon. We found that Miss C had been investigated and treated appropriately for her gallbladder disease within a reasonable time-frame. Whilst there was a short delay in referring her for a scan and in providing a prescription when she was discharged from hospital, these did not have an adverse impact on her care. In view of this, we did not uphold the complaint.

That said, Miss C's consultant had referred her to another consultant when she made a complaint about him. Miss C's care was not compromised by the change of consultant, but this was not in line with guidance from the General Medical Council (GMC), which states that a doctor should not end a professional relationship with a patient solely because of a complaint the patient has made about them.

Miss C also complained to us that staff in the hospitals had failed to communicate with her adequately throughout the treatment referral process. We found that there had been some failings in relation to communication. We upheld this aspect of Miss C's complaint, although we noted that the board had already apologised to her for these failings.

Recommendations

We recommended that the board:

• make the consultant aware of the adviser's comments about Miss C's transfer of care to a different consultant being contrary to guidance from the GMC; and
• provide evidence that the failings identified have been fed back to relevant staff.

Summary

Mr C's wife (Mrs C) had a complex medical history and had been diagnosed with asthma, bronchiectasis (a long-term condition where the airways of the lungs become abnormally widened leading to a build-up of excess mucus) and frequent pneumonia. Mrs C struggled to recover between bouts of illness and she understood from healthcare professionals that she had emphysema (lung disease). In October 2013, Mrs C was told that investigations had shown mild abnormalities and that she did not have emphysema. Mr C said that his wife was very distressed at this.

Mrs C was admitted to Monklands Hospital two months later with respiratory problems. Her condition deteriorated significantly and she died several weeks after admission with sepsis (blood infection), heart failure and bronchiectasis. Mr C complained about the provision of medical and nursing care and treatment to Mrs C, and about the board's complaints handling.

We took independent advice from medical and nursing advisers. We found that the medical and nursing care and treatment provided to Mrs C was reasonable. However, at one of the out-patient appointments, the discussion about Mrs C's diagnosis was significant but there was no record of this and no comment on Mr C's understanding of the diagnosis and so, on balance, we upheld this complaint. In relation to record-keeping, we were satisfied that the board had responded to the complaint in a reasonable way.

Recommendations

We recommended that the board:

• bring the record-keeping failing and the medical adviser's comments to the attention of relevant staff; and
• apologise for the failings identified.

Summary

Mr C complained about the care and treatment of his late wife (Mrs C) during her admission to Hairmyres Hospital. Staff suspected Mrs C had a rare endocrinology (related to hormones) disease, and arranged a number of tests to investigate this over the next two months. Mrs C developed sepsis (a blood infection) while in hospital and died.

Mr C raised concerns about Mrs C's overall treatment, including delays in investigations and treatment and failure to prevent infection. Mr C was also concerned that nurses did not understand Mrs C's condition (as she was nursed on a cardiology ward, rather than an endocrinology ward). The board met with Mr C's family twice and apologised for a number of aspects of care. They arranged a meeting to ensure nursing staff reflected on their practice, and developed an action plan for improvement, which they shared with the family. The endocrinologist involved in Mrs C's care also apologised that the investigations of Mrs C's condition did not move more quickly, and explained that they expected to have more time to treat Mrs C. Mr C was not satisfied with the board's response to some parts of his complaint, and brought these to us.

After taking independent medical and nursing advice, we upheld one of Mr C's five complaints. We found the medical and nursing care was reasonable in relation to most of the specific points Mr C raised, and that although there were some failings in nursing care, the board had already addressed these. However, we found that there was an unreasonable delay in sending laboratory samples to be tested.

The medical adviser also commented on Mrs C's overall care and said the board should have considered transferring her to a larger endocrine unit (which might have resulted in quicker treatment). We shared these comments with the board, but did not make any specific recommendations as the relevant guidelines do not require treatment in a particular setting and the endocrinologist involved had already apologised to the family and reflected on their practice.

Recommendations

We recommended that the board:

• review their processes for arranging external laboratory testing of samples, to ensure this is being completed in a reasonable timeframe.

Summary

Mr and Mrs C complained to us that the board had failed to inform Mrs C of a diagnosis of diverticulitis (a common disease of the digestive system) that was reached when she had a colonoscopy (examination of the bowel with a camera on a flexible tube) under the Scottish bowel screening programme. Mrs C had undergone the colonoscopy following the detection of blood in samples she submitted under the bowel screening programme. During the colonoscopy, a minor non-cancerous growth had been removed and it was assumed that this had been the cause of the blood. The unit who carried out the colonoscopy wrote to Mrs C's GP practice to inform them of this. However, in the cover letter sent to the GP practice, they did not refer to a diagnosis of diverticulitis that had also been made during the colonoscopy. They also failed to inform Mrs C that she had also been diagnosed with diverticulitis at that time.

We took independent advice on Mrs C's complaint from a medical adviser who is a GP and from another medical adviser who is a consultant physician. Mrs C clearly should have been informed of the diagnosis of diverticulitis and we found that the unit who had carried out the colonoscopy should have made her aware of this. We considered that this problem originated from the lack of clarity in the board's procedures in relation to the Scottish bowel screening programme regarding sharing information with patients. We upheld the complaint, although we found that the board had already apologised to Mrs C for this.

Mr and Mrs C also complained that the board had failed to provide Mrs C with treatment for diverticulitis within a reasonable timescale. We found that it was unlikely that she required any treatment for this, although she should have been told to increase the fibre in her diet. We did not uphold this aspect of the complaint.

Recommendations

We recommended that the board:

• consider adding further guidance about sharing information with the patient when they review their procedures in relation to the Scottish bowel screening programme.

Summary

Mr C complained about the medical and nursing care and treatment he received in Raigmore, Broadford and Ross Memorial hospitals between June and December 2012. Mr C had a complex medical history and began to experience chronic back pain at the end of June 2012. This proved to be a lumbar disc infection and he was treated conservatively. Mr C complained about various aspects of his care and treatment during his various admissions to the hospitals including the frequency and standard of consultant review, treatment decisions, diagnosis, pain management, communication and the decisions to discharge him home or to other hospitals.

We took independent advice from a nursing adviser and two medical advisers, one in emergency medicine and the other in orthopaedics (conditions involving the musculoskeletal system). We found that the standard of medical care and treatment provided by Raigmore Hospital was reasonable and that the nursing treatment was also reasonable with the exception of the use of a commode for showering purposes. We made a recommendation to address this.

We also found that the standard of medical and nursing care and treatment provided by Broadford Hospital was reasonable. However, in relation to the standard of medical care and treatment at Ross Memorial Hospital, while we found no failings in relation to nursing care, we found that there was a missed opportunity to potentially manage Mr C's pain more effectively and that a planned discharge home was unreasonable. We made a number of recommendations to address these failings.

Recommendations

We recommended that the board:

• bring the shortcoming in nursing care to the attention of relevant staff;
• bring the failings to the attention of relevant staff;
• clarify referral procedures to the chronic pain team and ensure staff are aware of the procedure; and
• apologise for the failures we identified.

Summary

Mr C complained about how his new dentist communicated with him after taking over his care. He was also concerned that the dentist had failed to provide appropriate dental treatment to him over a number of appointments. The new dentist took over Mr C's care after his dental practice was sold to a new owner. Mr C advised he had not been told about the changes and felt uncomfortable.

After taking independent advice on this case from a dental adviser, we upheld Mr C's complaint regarding communication. The adviser explained that in order to obtain valid consent, patients must be given all options including the risks and benefits of each. We found that there was insufficient evidence that this had been done, particularly with regard to the option of extracting the tooth in question. The adviser also considered that there was a lack of evidence that the changes to staff providing Mr C's care had been properly explained to him, particularly after his treatment became problematic and required referral to a more experienced dentist at the practice. We made two recommendations to address the issues highlighted during the investigation. The adviser found no issues with the actual treatment that had been provided to Mr C by the dentist and so we did not uphold this element of his complaint.

Recommendations

We recommended that the dentist:

• review the process followed for obtaining patient consent and ensure this is in line with the General Dental Council Standards; and
• issue an apology for the standard of communication with Mr C.

Summary

Mr C complained that his uncle (Mr A) who suffered from dementia was not reasonably cared for after he was admitted to hospital and when a catheter was fitted. He said that Mr A was not discharged appropriately and that as his uncle's next of kin he was not always kept informed about what was happening about his care and about arrangements being made.

We took independent advice from a consultant urologist and from a senior nurse. We found that Mr A's clinical and nursing care were well within a standard that could be reasonably expected. However, there were occasions when Mr C was not kept informed and when he was given confusing information about out-patient appointments. He was also sent an appointment for Mr A which was for a location 50 miles away from his home. For these reasons, Mr C's complaints about poor communication were upheld.

Recommendations

We recommended that the board:

• make a formal apology for the communications shortcomings identified; and
• remind staff involved in this case of their professional responsibility to communicate with relatives, particularly next of kin, in a clear and timely manner.

Summary

Mr C, who works for an advice agency, raised a complaint on behalf of his client (Ms B) about the care her mother (Mrs A) received while in Glasgow Royal Infirmary. In particular, Ms B was concerned that staff failed to take account of her advice about her mother's early onset of Parkinson's Disease and that they failed to deal appropriately with Mrs A's mobility issues and the risk of falling while in the hospital. She also complained that the communication between the hospital staff about Mrs A's care was inadequate and that the board's complaint response was inadequate.

During our investigation, we took independent advice from a mental health adviser and a nursing adviser. We were satisfied that Mrs A's risk of falling was reasonably assessed on admission and there were regular and focussed assessments of mobility with involvement from medical, nursing and physiotherapy staff. We also found that the nursing assessments, charts and notes were of a good standard and that Mrs A's medical records were clear about her level of mobility and the assistance required. However, we were concerned that, while the advice we received from the mental health adviser was that Mrs A may have been able to comprehend and recall instructions and that prior to a fall in the hospital she had been assessed as safe and independent with a walking frame, Mrs A's abbreviated mental test score was ineffectively recorded in the medical records. We found that there was a failure to re-assess Mrs A's cognitive state and keep this under review while in the hospital.

We were also concerned that, while the board apologised for the delay in replying to Ms B's complaint, there was a failure to provide updates or provide an explanation for the delay.

Recommendations

We recommended that the board:

• ensure that where a patient presents with confusion and memory impairment, their cognitive state is assessed on arrival to the ward and kept under review;
• ensure that cognitive testing results are effectively recorded in the medical records; and
• remind staff of the importance of adhering to the NHS Scotland complaints procedure.

Summary

Mrs C, who works for a voluntary agency, complained about the care and treatment that her client (Mrs A) had received during admissions to the Southern General Hospital, the Victoria Infirmary and the New Victoria Infirmary. Mrs A was initially admitted after a fall where she broke her arm and leg. Whilst Mrs A was in hospital, she suffered a series of falls, some of which resulted in further injury.

After taking independent advice from a nursing adviser, we did not uphold Mrs C's complaint that a fall Mrs A had while using the toilet at the Southern General Hospital was caused by unreasonable circumstances. The advice we received was that it was appropriate for Mrs A to have been allowed privacy to use the facilities after being assisted there by nursing staff. Although we did not uphold this aspect of the complaint, we did make a recommendation about this.

We also took independent advice from a consultant physician and geriatrician who considered whether it was reasonable that staff at the New Victoria Infirmary had not identified a hip fracture following a fall there. We did not uphold this complaint as the advice we received was that there was no indication that, following the fall, Mrs A had sustained a fracture. The adviser also said that an appropriate medical assessment had taken place. We also did not uphold Mrs C's complaint that Mrs A had to wait too long for surgery following admission to the Victoria Infirmary. We found that surgery had taken place within the recognised standard of 48 hours.

We did, however, uphold a complaint about Mrs A's premature discharge from the New Victoria Infirmary. We found that records, including National Early Warning Scores (NEWS), were unavailable and it was not clear whether there had been a failure to complete these or if they had been lost. These records, had they been available, would have enabled the adviser to confirm whether the decision to discharge was reasonable.

We also found that nursing staff caring for Mrs A should have requested a medical review before she was discharged due to her recent falls history and the level of pain she was experiencing.

Recommendations

We recommended that the board:

• ensure that the relevant staff are made aware of the nursing adviser's comments on toilet supervision requirements and facilities checks;
• issue an apology for the failing to request a medical review prior to discharge;
• make the relevant staff aware of the nursing adviser's comments on requesting a medical review; and
• take steps to ensure NEWS scores are appropriately taken and recorded on the ward and that medical records are appropriately stored.