Some upheld, recommendations

Summary

Ms C complained that she had been provided with an unreasonable service by the board's orthotic service (service that designs, makes and fits devices to support or control a part of the body). She said she had been provided with substandard footwear, and that she had suffered unacceptable delays whilst trying to arrange an appointment. Ms C was unhappy that the board had failed to communicate with her properly, resulting in unnecessary travel for appointments which were cancelled on her arrival. She also complained that it had taken an unreasonable length of time to fit her orthotic footwear when it was delivered.

We took independent advice on this complaint, which stated that the standard of communication with Ms C was not acceptable and that Ms C's notes were not maintained to a professional standard. There was, however, no set time-frame for fitting specialist footwear and Ms C had not been treated unreasonably in this respect.

Our investigation found the board had unreasonably delayed in providing Ms C with an appointment, although there was no evidence the delay was as severe as Ms C suggested. We also found that the board had failed to communicate appropriately with Ms C. We did not find the length of time taken to fit Ms C's specialist footwear was unreasonable.

Recommendations

We recommended that the board:

• remind staff involved in this case of the importance of communicating timeously with patients, especially when an appointment requires cancellation;
• remind all staff of the importance of responding timeously to requests for appointments;
• remind staff of the importance of recording any delays in requesting appointments; and
• apologise for the failures identified in this investigation.

Summary

Mrs C complained on behalf of her husband (Mr C) about his care and treatment in Monklands Hospital. In particular, she believed that an x-ray taken immediately before his admission showed sufficient evidence of respiratory problems that he should not have been allowed home, only to be admitted the next day as an emergency. She further complained that, once in hospital, Mr C should have been kept in either intensive care or in a high-dependency unit, and not moved between wards as he was. Mrs C also said that insufficient care was taken to prevent him falling, and that a nil-by-mouth (NBM) instruction was ignored.

We took independent clinical advice from two advisers, a consultant respiratory and general physician and a nursing adviser. We found that Mr C had been discharged after his x-ray without the results being seen or taken into account, and without him being given appropriate treatment. In light of this, this part of his complaint was upheld. Similarly, we found that staff did not adhere to an NBM instruction and this complaint was also upheld. However, after he was admitted to hospital, all ward transfers were made with Mr C's medical condition in mind and were all appropriate. The evidence also showed that staff took all reasonable steps to prevent Mr C from acquiring pressure ulcers or from falling.

Recommendations

We recommended that the board:

• bring the comments of the consultant respiratory and general physician to the attention of the consultant neurologist concerned;
• make a formal apology for their communication failures;
• remind relevant staff (nurses and doctors) of the necessity of good, clear communication;
• apologise to Mr and Mrs C for their failure to follow Mr C's NBM instruction; and
• emphasise to relevant staff the importance of following a NBM instruction.

Summary

Mrs C complained on behalf of her mother (Mrs A) about the care and treatment she received at Monklands Hospital in 2013 and 2014 for liver-related disease. Specifically, she complained that a specialist procedure was not performed in 2013 and the aftercare arrangements were poor; that during a second admission in 2014 Mrs A's condition continued to deteriorate until she was transferred to a different hospital where a liver transplant was performed; and that she was malnourished prior to the transplant.

In their complaint response, the board did not identify failings in the care and treatment but acknowledged that communication with the family could have been better.

We took independent advice from two of our medical advisers, a consultant gastroenterologist (who specialises in the treatment of conditions affecting the liver, intestine and pancreas) and a consultant gastroenterologist and hepatologist (who specialises in liver disease). We found that the treatment given in 2013 was in line with national guidance and, whilst there were records to show that there was an appropriate discharge plan in place, there was no evidence to demonstrate that this had been explained to either Mrs A or her family. Furthermore, given that Mrs A had abnormal blood tests, we were critical that the consultant who discharged her failed to reasonably monitor her. Therefore, we upheld this aspect of the complaint and made three recommendations. We considered that the care given in 2014 was appropriate and, having also taken independent advice from our nursing adviser, we found that there were factors that impacted on Mrs A's ability to take oral nutrition and we did not uphold this aspect.

Recommendations

We recommended that the board:

• apologise to Mrs A for the lack of communication surrounding her discharge plan;
• review their procedures for arranging follow-up clinic appointments and for reviewing abnormal blood results, specific to this case, to identify any learning; and
• share the failings identified with relevant staff.

Summary

Mrs C complained about the treatment her father (Mr A) received from the board. In 2013 Mr A began to experience difficulties with his mobility and memory. Mr A was referred to the board's Falls, Stroke and Memory clinic at Coathill Hospital where he was seen by a consultant. A CT scan (computerised tomography scan) was arranged, which showed some shrinkage of the brain. The consultant referred Mr A for an MRI scan (magnetic resonance imaging scan - a more detailed scan than the CT scan). However, the radiologists questioned whether the scan was required, as they did not feel that an MRI would provide any additional useful information. They suggested a discussion with the referring consultant, however, Mrs C said that this did not take place.

Mr A was disappointed that the MRI scan did not go ahead and arranged for the scan privately. This resulted in a diagnosis of vascular Parkinsonism (a form of Parkinson's disease, a progressive neurological condition in which part of the brain becomes more damaged over many years). Mrs C complained that the radiologists inappropriately rejected a test that had been identified as necessary by Mr A’s consultant.

We took independent medical advice from one of our advisers. We accepted the advice that the consultant's decision to request an MRI scan was reasonable but that it is a radiologist’s duty to ensure that patients are not subjected to unnecessary imaging. When a radiologist believes imaging might be unnecessary, they should get clarification on the need for it. We were satisfied that a discussion did take place between the referring consultant and radiology, and that it was agreed that the MRI would not necessarily add anything to the diagnosis that had already been made. Whilst we found that Mr A’s treatment may have differed slightly had the MRI been carried out, we did not consider there to be a significant impact on his treatment.

We were critical of the board’s handling of Mrs C’s formal complaint and made a recommendation to address this.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings in complaints handling which have been identified in this report.

Summary

Ms C complained that when she first registered with her new GP she had difficulty in getting an appointment. When she first saw a GP, two weeks after joining the medical practice, she was refused a prescription for regular medication for various conditions as her medical notes had not yet been transferred from her old practice. Ms C also complained that she was removed from the practice list for alleged abusive behaviour, and that the practice failed to deal with her subsequent complaints.

We took independent advice from one of our GP advisers. They told us that records can sometimes take up to 12 weeks to be transferred between NHS practices when a patient changes GP. Therefore, it is common practice for basic information, including details of repeat medications, to be faxed over to the new practice to prevent any delays in prescriptions being issued. The adviser was particularly concerned that Ms C was on medication that can have serious withdrawal symptoms if stopped suddenly. We upheld this aspect of Ms C's complaint.

On the issue of Ms C being removed from the practice list, there was evidence that the staff at the practice found Ms C's behaviour, at times, to be unacceptable. While there does not have to be any intention to behave in an unacceptable way by the patient, where a GP considers that a patient's behaviour is unacceptable, they have the right to ask for that patient to be removed from their list. We did not uphold this aspect of Ms C's complaint.

In relation to the handling of the complaint, Ms C said that she had hand-delivered four letters of complaint between October and December 2014 but the practice said they had no record of the letters being received by any staff member. Following contact with our office, the letters were copied to the practice and were dealt with within the timescales laid down by the NHS guidance on complaints handling. We did not uphold this aspect of Ms C's complaint.

Recommendations

We recommended that the practice:

• issue a written apology for the failings identified; and
• implement a system for contacting the previous practice of NHS patients transferring to them to obtain basic details of previous medical history and regular medications.

Summary

Ms C, who is an advice worker, complained on behalf of Mrs A's family about the care and treatment provided to Mrs A by Southern General Hospital when her life-support machine was switched off. Mrs A was admitted to hospital after sustaining a severe injury at home, and put on a life-support machine. After being told by hospital staff that she could not survive, the family agreed to switch off the life-support machine. However, unexpectedly, Mrs A continued to live for a further 20 days. During this period, the family said there were communication failures; they did not know what was being done and what to expect in terms of care. They were also concerned that staff failed to provide appropriate care, particularly in relation to pain relief, fluids and nutrition. At the end of Mrs A's life, she was transferred to another hospital (Glasgow Royal Infirmary). The family said that her medical records were not transferred with her which meant that appropriate care could not be provided within a reasonable time at the second hospital. Finally, the family complained about the way the board had handled the complaint.

We took independent advice from one of our medical advisers. We found that the standard of care provided in relation to medication, nutrition and fluids was reasonable, and that sufficient information accompanied Mrs A when she was transferred to the second hospital. We were also satisfied that the evidence indicated that the family were kept fully informed of Mrs A's condition and prognosis. However, we found that the language the board used in their response to the complaint was inappropriate and insensitive, and that the response was overly technical and difficult for a layperson to understand.

Recommendations

We recommended that the board:

• take steps to ensure that Glasgow Royal Infirmary are complying with Records Management: NHS Code of Practice (Scotland);
• ensure that appropriate and sensitive language is used in complaint responses; and
• apologise for the failures this investigation identified.

Summary

Mrs C complained about the care and treatment her husband (Mr C) had received from the board in relation to brain tumours. We took independent advice on this part of her complaint from one of our medical advisers, who is a consultant neurosurgeon. We found that it had been reasonable not to give Mr C radiotherapy after a tumour had been removed at the Western Infirmary. However, Mr C had also been receiving other treatment that would have increased the risk of early or more rapid progression of a recurrent tumour. We found that it had been unreasonable for the board to wait eleven months before carrying out a follow-up scan. In view of this, we upheld this part of Mrs C's complaint. When the follow-up scan was then carried out, it showed a large recurrent tumour.

Mrs C also complained about the nursing care provided to Mr C whilst he was in the Southern General and Beatson Hospital. We took independent advice on this from a nursing adviser and we found that the care provided had been reasonable so we did not uphold this aspect of her complaint. Mrs C also said that the board had failed to adequately explain Mr C's condition and prognosis. Whilst the evidence in relation to this was not conclusive, the comments made by the consultant about the information given to the family were somewhat vague, and Mr and Mrs C had not fully understood what the consultant was trying to say. We found that, on balance, the information had not been satisfactorily communicated to Mr and Mrs C and so we upheld this aspect of the complaint. Finally, Mrs C complained about the board's handling of her complaint. We found that the board's response had been difficult to understand. It contained too much medical terminology and jargon that was not adequately explained. We upheld this part of her complaint for this reason.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings we identified;
• make the relevant staff involved in Mr C's care and treatment aware of our findings; and
• remind the staff involved in the handling of Mrs C's complaint that responses to complaints should be clear and easy to understand.

Summary

Ms C complained that the board failed to adequately manage her Von Willebrand Disease (VWD – an inherited bleeding disorder) when she was admitted to Aberdeen Royal Infirmary for gall bladder surgery. She said she had previously been given medication for her VWD before dental treatment and treatment for cancer, but said this did not happen for her gall bladder surgery. Ms C also complained that the board failed to communicate properly with her about her VWD when she was in hospital.

We obtained independent medical advice on Ms C’s case from a consultant haematologist with specific expertise in blood clotting disorders. Our adviser said that Ms C’s VWF levels (levels of a blood protein which helps blood to clot) were checked on the day of her surgery and found to be within the normal range. As a result, the board decided not to treat Ms C with a concentrated form of the clotting agent, but to have it ready in case any problems arose. Our adviser said that this approach was reasonable.

The board apologised for the lack of communication with Ms C about her VWD and said that staff should have explained and discussed her condition with her. Our adviser said that communication could have been improved by checking Ms C’s VWF levels the day before surgery, rather than on the day of her surgery, and making a decision on whether she required treatment with the concentrated form of the clotting agent at that time. This would have allowed more time for discussion with Ms C about VWD and the proposed treatment, and at a less stressful time than on the day of her operation. This would have increased the chances of Ms C understanding and accepting the apparently conflicting advice about the management of her condition. We were critical of the board in this regard.

Recommendations

We recommended that the board:

• feed back our decision on the complaint about the board's communication regarding VWD to the staff involved.

Summary

Mr C had treatment to extract two teeth. Immediately after the treatment, he complained about the treatment received and that the dentist had failed to take reasonable account of his hearing condition. He complained that his dentist took too long to carry out the extractions and that he did not appear able to carry out the extractions. He also said that he had advised his dentist of his need to lip read in order to fully understand what was being said to him. However, during the procedure, the dentist had continued to speak to him with a mask on.

We took independent advice from our dental adviser, who said that the treatment Mr C received was reasonable and appropriate and that, while the extractions had taken some time, this was reasonable in this case. Our adviser explained that guidance issued by Health Protection Scotland requires dentists to wear full personal protection equipment (PPE), including a mask, during any operative procedure. As such, he considered that it would not have been reasonable to expect the dentist to repeatedly stop the procedure and remove his mask to speak to the patient. This would have required the dentist to remove his PPE, undertake hand hygiene and put on new PPE on each occasion that he stopped to speak to the patient. However, we were mindful of Fife NHS Board's advice that requires staff to respect disabilities. We considered that, in the circumstances, consideration should have been given to offering Mr C the services of an advocate/translator/interpreter or similar. This would have ensured that he fully understood what was being said to him during the procedure.

Recommendations

We recommended that the dentist:

• reflect on this case to guide future practice to ensure that a patient's communication needs are being met. In particular, that in a similar situation consideration should be given to offering a patient the services of an advocate/translator/interpreter or similar who could speak to the patient without wearing a mask.

Summary

Mr C complained that his university unreasonably required him to re-attend for a whole academic year, after he failed to submit a piece of coursework for a module. Mr C was also unhappy with the university's handling of his complaint.

We found that Mr C assumed he could re-sit the coursework at the end of the academic year. However, university regulations said that, in the circumstances, Mr C was required to re-attend. Mr C, as an enrolled student, was bound by university regulations and had confirmed his acceptance of them. Therefore, he had to re-attend. We did not uphold this part of Mr C's complaint.

We found some failings in the adminstration of Mr C's complaint, where the university had not followed their complaints procedure in respect of stage one of the process. We upheld this part of Mr C's complaint.

Recommendations

We recommended that the university:

• remind relevant staff of the stage one process in their complaints handling procedure.