Upheld, recommendations

Summary

Mrs C complained on behalf of her brother (Mr A), that staff at the Royal Infirmary of Edinburgh failed to ensure he was safely transferred to a trolley. In addition, Mrs C raised concern that the incident was not properly investigated, that Mr A was not reviewed following the incident, and that the complaints handling by the board was poor.

We took independent medical advice. We found that Mr A was not transferred to the trolley in accordance with the moving and handling plan that had been put in place following his mobility assessment. Furthermore, when the incident was reported to a nurse later that evening, we were critical that the nurse did not take appropriate steps to formally record the incident on the hospital's system for reporting adverse events. We considered this would likely have resulted in the incident being investigated in a timely manner, and that Mr A would have been reviewed by a doctor sooner. We were also critical of the board's handling of the complaint. Specifically, that they had inaccurately said that a nurse had been present at the time of the trolley transfer for which they apologised. We also found that the board had not acknowledged that the porter's recollection of the transfer was contrary to the manual handling plan documented in Mr A's clinical records. We therefore upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the delay in reviewing him after the incident was reported to the nurse;
• share these additional findings with the nurse involved;
• take steps to ensure that porter staff are made fully aware of patients' mobility limitations and needs prior to carrying out inter-departmental transfers; and ensure that nursing staff are available to provide the necessary support indicated in mobility assessments;
• apologise to Mrs C for the additional failings in the complaints handling identified in this investigation; and
• provide evidence of the steps taken to address the issue related to the complaints handling.

Summary

Mrs C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). She said that an orthopaedic consultant at Hairmyres Hospital should not have referred Mrs A for a Magnetic Resonance Imaging (MRI) scan because she had metal clips in her head from surgery performed in the past.

We took independent medical advice and found that MRI scanning should not be used in patients with metal clips as this can lead to movement of the clips in the strong magnetic field.

We considered that the orthopaedic consultant had not taken an adequate previous medical history when deciding to refer Mrs A for an urgent MRI scan. However, we noted that further safety checks by radiology staff prevented the scan from going ahead. We acknowledged that the board had apologised for the distress caused to Mrs A in relation to the referral but made two further recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failure to obtain her previous medical history at the time of the consultation and for inaccurately completing the MRI request form; and
• draw these findings to the attention of the orthopaedic consultant for future learning.

Summary

Mrs C complained that the dental practice failed to deal with her complaints in a reasonable manner. We found that the practice had failed to establish in the first instance what Mrs C's complaint involved and that this resulted in a missed opportunity to resolve the complaint at an early stage. We also found that Mrs C's complaint was not acknowledged by the practice within the three working day timescale set out in the Scottish Government's 'Can I help you?' guidance for handling healthcare complaints, and that the practice did not communicate with Mrs C by her preferred method. Finally, we found that the practice's response to Mrs C's complaint was not sent to her within the 20 working day timescale that is set out in the Scottish Government's 'Can I help you?' guidance. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings identified by this investigation;
• ensure all staff are familiar with the 'Can I help you?' guidance for handling healthcare complaints;
• ensure their complaints policy is in line with the 'Can I help you?' guidance; and
• ensure that their complaint response letters comply with the 'Can I help you?' guidance, and in particular give details for contacting our office.

Summary

Mr C was referred to a urologist at Raigmore Hospital to have his history of erectile dysfunction and low testosterone investigated. Mr C raised a complaint nine months later as he had not received an appointment and was distressed by his ongoing symptoms.

The board informed Mr C that there was a long waiting list. Mr C raised further concerns that he had not received an appointment, 13 months after his original referral. It took until 19 months after his referral for Mr C to be seen by a urologist.

We took independent medical advice. We found that Mr C's wait to see a urologist was entirely unreasonable and significantly exceeded the Scottish Government's waiting time of 12 weeks for a new out-patient appointment. We were also concerned that the board had not provided evidence to show whether steps had been taken to reduce the waiting time of the urology clinic.

Recommendations

We recommended that the board:

• apologise to Mr C for the unreasonable delay in his receiving a urology appointment; and
• provide clear evidence showing the steps they are taking to meet the 12-week waiting time target for appointments in the urology department at Raigmore Hospital and what they will do in cases where they are unable to meet the target.

Summary

Mr C was admitted to Queen Elizabeth University Hospital and diagnosed with atrial fibrillation (irregular and often rapid heartbeat). He was advised at this time that he would possibly need cardioversion (treatment to restore the normal heart rhythm) and that referrals would be made for him to have a scan of his heart and an out-patient appointment with a cardiologist. Mr C complained that it took eight months to receive treatment.

We took independent advice from a consultant cardiologist. We found that there were delays in Mr C receiving the scan, an out-patient appointment and treatment. We considered that the delays were unreasonable and failed to meet the Scottish Government's 18-week treatment time target.

Although we upheld Mr C's complaint, we did not consider that the delays would have affected Mr C's overall outcome. However, there would have been additional stress for Mr C in not knowing what was happening with his care.

Recommendations

We recommended that the board:

• apologise to Mr C for the delays that occurred in relation to his treatment plan after the diagnosis of atrial fibrillation; and
• take steps to ensure the problems which caused the delays do not recur and evidence the action they have taken to prevent them from recurring.

Summary

Mr C's father (Mr A) was admitted to the Queen Elizabeth University Hospital. Mr A died there several days later. Mr C complained to us about Mr A's nursing and medical care and treatment during his admission.

We obtained independent advice from a nurse and a consultant in the care of the elderly. The nursing adviser identified failings in relation to the planning, monitoring and recording of Mr A's nutritional care and hydration and his personal care. They also identified that documentation had not been adequately completed. Mr A appeared to have suffered four falls during his admission. We found it was of concern that Mr A's falls risk appeared to have been ineffectively assessed and there was an unreasonable delay in making a referral to a falls prevention specialist. We also considered that communication with Mr A's family was unreasonable.

While we were unable to conclude that any of these failings were significant contributing factors in Mr A's death, we were satisfied that Mr A's nursing care and treatment fell below a reasonable standard and upheld this aspect of Mr C's complaint.

The medical adviser said Mr A was frail, had a history of heart disease and that there was evidence he had chronic kidney disease. While the advice we received was that a number of aspects of Mr A's medical care and treatment were reasonable, the medical adviser identified issues concerning Mr A's medications. The medical adviser also commented that there was a failure to contact Mr A's family when there was a serious deterioration in his condition. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• issue a full written apology to Mr C and Mr A's family for the failings in Mr A's nursing care and treatment and communication this investigation has identified;
• feed back the comments of the nursing adviser and the findings of this complaint to the nursing staff involved for reflection and learning;
• issue a full written apology to Mr C and Mr A's family for the failings in Mr A's medical care and treatment and communication this investigation has identified; and
• feed back the comments of the medical adviser and the findings of our investigation to the medical staff involved for reflection and learning.

Summary

Mrs C complained about the care and treatment provided to her late father (Mr A). Mr A was admitted to Dr Gray's Hospital where staff identified that he had suffered a stroke. Over the course of approximately four months, he had three further admissions. During the course of the admissions, Mr A's condition deteriorated. Mrs C raised concerns about pain Mr A was experiencing in his abdomen and back, and swelling in his leg. During the fourth admission, a scan revealed cancer. Mr A died approximately one week later.

Mrs C complained that the board unreasonably delayed reaching a diagnosis that Mr A was suffering from cancer. She also complained that the board failed to appropriately diagnose a deep vein thrombosis (DVT), which was identified during one of the admissions.

The board apologised and acknowledged that they had been slow to investigate pain Mr A was experiencing in his back and abdomen. They did not consider that earlier identification of the cancer would likely have impacted on Mr A's outcome, and that treatment would have been palliative. The board considered there had not been a delay in identifying the DVT.

After receiving independent advice from a consultant in acute medicine, we upheld Mrs C's complaints. We found that the symptoms Mr A had experienced were unusual, but should have alerted the board to the possibility of cancer at an earlier stage. We noted that the cancer was aggressive in nature and early detection would not have likely altered Mr A's outcome. We found that the board did fail to recognise the DVT in this case. We were critical of the limited records regarding checks for DVT. Finally, we had some concerns about delays in the board's handling of Mrs C's complaints.

Recommendations

We recommended that the board:

• apologise for the failings this investigation has identified;
• feed back the findings of this investigation to the relevant staff;
• remind the relevant staff of the guidance surrounding assessments and checks for venous thromboembolism, including DVT;
• develop an action plan to improve assessments and checks for venous thromboembolism, including DVT; and
• apologise for the failings in complaints handling this investigation has identified.

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) while he was a patient at Aberdeen Royal Infirmary. Mr A had a complex medical history and he was admitted to hospital with ischemia (inadequate blood supply to an organ or part of the body) and sepsis (a blood infection). Several weeks later, he was discharged to a community hospital from where he was discharged home. He died the following day. Mr C complained about aspects of Mr A's discharge to the community hospital including communication.

We took independent medical advice. We found an unreasonable failure by staff to carry out comprehensive multi-disciplinary discharge planning. We also found that Mr A was transferred to a community hospital when he did not have capacity, which was against his family's wishes and without relevant documentation. We also found that there had been a breakdown in communication which meant that medical staff wrongly informed other staff about the family's wishes in relation to discharge. We upheld the complaint.

Recommendations

We recommended that the board:

• review what happened in light of the adviser's comments and reflect on relevant guidelines to ensure that processes in relation to discharge of complex patients are adequate;
• bring the failings identified to the attention of relevant staff; and
• apologise for the failings identified in this investigation.

Summary

Ms C, who works for an advocacy and support service, complained on behalf of Ms A about a health visitor's monitoring of her infant daughter (Miss A). Miss A was diagnosed with hydrocephalus (an abnormal build-up of fluid in the brain) at around four months old. Ms C complained that this should have been picked up sooner.

We took independent medical advice from a health visitor, who considered that there were failures to appropriately record and interpret Miss A's head circumference, resulting in missed opportunities to identify the steep growth rate and make an appropriate referral for further investigation. In particular, it was noted that the measurement at Miss A's six to eight week assessment had crossed over the top centile and, in line with the board's policy, should have prompted referral. We concluded that the health visitor did not take appropriate action to monitor Miss A's development and we upheld the complaint.

Recommendations

We recommended that the board:

• provide training to relevant staff on the guidance in place for monitoring, recording and analysing growth measurements;
• take steps to ensure that health visitors receive adequate clinical supervision and are able to access support in cases such as this; and
• apologise to Ms A for the identified failure to appropriately monitor Miss A's development.

Summary

Mr C complained that the practice failed to appropriately manage pulmonary fibrosis (a lung condition) in his late mother (Mrs A). The condition was first identified in a scan carried out five years prior to Mrs A's death and she regularly attended the practice over the intervening years with symptoms that included breathlessness. We obtained independent medical advice and we identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, we considered that a referral should have been made following the initial scan. We also considered that a referral should have been made a year before Mrs A's death, when an x-ray reported progression of the pulmonary fibrosis.

We found that all tests in between these times were not reported back to the practice in terms that would have prompted referrals. However, we noted that one GP expressed awareness of the condition during this period and made a referral to a geriatric clinic. While we considered it appropriate that further investigation was arranged, we noted that a respiratory referral would have been more appropriate.

We were assured that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. However, we recognised that earlier specialist intervention would have afforded Mrs A and her family the opportunity to better understand the nature of her condition and be assured that her symptoms were being appropriately managed. We upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Mr C and his family for the missed opportunities to refer Mrs A to respiratory medicine; and
• reflect on the failings identified in this investigation and ensure that the GPs are familiar with the relevant guidelines and care pathways for patients with pulmonary fibrosis.