Upheld, recommendations

Summary

Mr C complained about a delay in being referred for psychology treatment. He was referred to the community mental health team and was seen initially by a consultant psychiatrist and a community psychiatric nurse (CPN). He continued to see the CPN over the following months but it was deemed that no psychiatric follow-up was necessary. However, the CPN subsequently discussed Mr C with the psychiatrist when the Mr C had reported experiencing vivid dreams, and the psychiatrist recommended a referral to psychology. Mr C raised concerns that he was not seen by a psychologist until several months later, when he considered that he should have been referred directly after his initial appointment.

We obtained independent advice from a senior mental health nurse, who did not consider that there was any indication for a psychology referral initially and deemed it reasonable for this to have been proposed when it was. However, the adviser noted that the CPN did not make the referral until almost three months later, despite having indicated that she would progress this. While Mr C was seen by a psychologist within the national 18 week waiting target from referral to treatment, the adviser considered that the delay in making the referral was unreasonable. We were critical that the board did not identify the delay when investigating this complaint and their response inaccurately indicated that the referral had been made around the time it was first proposed. We upheld this complaint.

Mr C also raised concerns about the contribution of a medical secretary at a meeting he attended with the psychiatrist and clinical director to discuss his complaint. He complained that the secretary inappropriately intervened to speak on the psychiatrist's behalf. The minutes of the meeting and the board's response to the complaint confirmed that this happened, although not to the extent described by Mr C. Nonetheless, the adviser considered that the secretary's documented input was inappropriate, noting that she was at the meeting solely as minute taker and should have left any explanations and/or apologies about care and treatment to the professional clinicians in attendance. We also upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in referring him to psychology;
• ask the staff involved in Mr C's care to reflect on the findings of this investigation and take steps to ensure that psychology referrals, once deemed appropriate, are progressed without any avoidable delay;
• highlight to complaints handling staff the importance of establishing the facts and accurately reflecting them in complaint responses;
• apologise to Mr C for the psychiatry secretary's inappropriate contributions at his complaint review meeting; and
• ensure clear directions are given to administrative staff taking on the role of minute takers at meetings, setting out the limitations of their role in this regard.

Summary

Mr C complained about the care and treatment he received from the medical practice. In particular, he raised concerns about a specific consultation where he felt that he should have been referred to a psychiatrist due to him suffering from severe depression. He was not referred to psychiatry until around a year later and he considered this to have been to the detriment of his mental health in the interim period. He also complained that the practice had increased his dosage of antidepressant medication to what he considered to be an unsafe level.

We obtained independent medical advice from a GP. They noted that details of the consultation in question had not been recorded and they were, therefore, unable to assess whether a referral to psychiatry was indicated at that time. While they did not consider that there was any indication for a referral at subsequent consultations six and eight months later, due to the fluctuating nature of Mr C's mental health difficulties we could not conclude that the same applied at the time of the relevant consultation. With regard to Mr C's medication, the adviser noted that it was prescribed at dosages within recommended levels and they could find no evidence of unsafe prescribing.

In light of the identified record-keeping failure, we were unable to evidence that Mr C had been appropriately assessed and, in turn, whether the decision not to refer him to psychiatry was reasonable. Therefore, on balance, we upheld the complaint and made some recommendations to the practice relating to record-keeping.

Recommendations

We recommended that the practice:

• apologise to Mr C for the identified record-keeping failure; and
• reflect on the identified record-keeping failure and seek to ensure compliance with the relevant General Medical Council guidance at all times.

Summary

Mr C complained about the time he had to wait for a gastroscopy procedure (a procedure where a thin, flexible telescope called an endoscope is used to look inside the gullet and stomach) at Raigmore Hospital. Mr C was referred for the procedure by his GP after he complained of symptoms of indigestion. Mr C was offered an appointment 16 weeks after referral, but when he attended the appointment the procedure could not go ahead as the endoscopy department did not have the required equipment available. Mr C complained to the board about the delay and expressed concern that the anticoagulation medication he was taking (treatment with drugs that reduce the body's ability to form clots in the blood) could have posed a risk to his health in the period while he waited for the procedure. The board apologised to Mr C and noted that the equipment was not available at the previous appointment because of a delay in the return of endoscopes following decontamination.

We took independent medical advice from a consultant physician who was critical that the time between referral and the procedure exceeded the target waiting time set by the Scottish Government. The adviser also noted that the appointment booking process should not have required two interventions from Mr C's GP. The adviser concluded that because of the delay in the procedure, Mr C suffered from his symptoms longer than was necessary, which was unreasonable. In view of this, we upheld this complaint and made two recommendations.

Mr C also complained that the board did not fully address the concerns he raised in his complaint and had exceeded their complaint response time target. The board acknowledged that a letter explaining the delay was not sent in this instance, and stated that staff have since been reminded about the requirement to send holding letters when appropriate. We were critical that, once they had received Mr C's complaint, the board failed to quickly offer Mr C an appointment, and therefore an opportunity was missed to reduced Mr C's waiting time for the procedure. We therefore also upheld this complaint and made four recommendations.

Recommendations

We recommended that the board:

• advise us of the action taken to address the waiting time delays for the endoscopy procedure identified in this case;
• provide evidence that quality improvement work regarding increasing turnaround time for decontamination has taken place;
• feed back our findings in relation to the handling of Mr C's complaint to relevant staff; and
• provide Mr C with an apology for the failings identified in this investigation.

Summary

Ms C, a voluntary agency worker, complained on behalf of Mr A that the dental treatment he had received was inadequate. Ms C said Mr A believed the treatment he had received had contributed to tooth decay in his mouth. Mr A asked for compensation for the treatment he said he received.

We took independent dental advice, which stated that Mr A had not received the appropriate dental treatment. The advice noted that Mr A had been fitted with a bridge which had only been partially attached, as it had been supported by only one tooth, rather than two, as would normally be the case. The advice said the bridge was, therefore, always likely to fail. The advice noted, however, that Mr A had not maintained the appropriate level of oral hygiene or attended review appointments which were essential for preventing tooth decay following the fitting of bridge work. The advice stated that on balance, Mr A's dental treatment had been unreasonable, since a bridge should only have been fitted if it could be fully attached.

We found that Mr A's treatment was unreasonable, and he should, therefore, have the cost of his dental treatment refunded.

Recommendations

We recommended that the dentist:

• refund Mr A the cost of the dental treatment;
• provide evidence that the dentist has reflected on the failures in Mr A's care identified in the investigation; and
• apologise for the failings identified in this report.

Summary

Mr C complained about the mental health care and treatment of his late wife (Mrs C) in the weeks prior to her suicide. Mrs C had a history of mental illness, and was referred urgently to psychiatry by her GP due to returning symptoms. Mrs C was assessed and a plan was made to treat her at home with support from the Intensive Home Treatment Team (IHTT). After four weeks, the IHTT referred Mrs C to her local team (Rehabilitation and Enablement Services Mental Health Team (RES MHT)) for further care. However, due to problems with the referral process there was a delay in transferring care and a ten day gap between appointments. Mrs C completed suicide the day after her first RES MHT appointment.

The board conducted a Significant Clinical Incident investigation into Mrs C's death. While the review team concluded the care was appropriate, they identified problems with the transfer process, and a lack of documentation about the role Mrs C's family had in her care planning. In response to Mr C's complaint, the board acknowledged failings in involving Mrs C's family in her care planning and in the referral process. The board apologised to Mr C and provided information on a number of actions underway to improve the RES MHT service.

After taking independent mental health and psychiatry advice, we upheld Mr C's complaint. We agreed with the board's findings that there was a lack of involvement of Mrs C's family in her care planning, and failings in the referral process. We also found that, while a comprehensive risk assessment was carried out, the management plan did not include a summary formulation of risk (as required by the local policy). While we considered the board had already taken appropriate action to address the issues found in relation to the RES MHT, we asked that they provide details of action taken in relation to the IHTT.

Recommendations

We recommended that the board:

• remind staff of the requirement to implement a summary formulation of risk (as well as a risk management plan) under the Clinical Risk Screening and Management Policy; and
• demonstrate that action has been taken to improve documentation of carer involvement (and patient consent to this) by IHTT staff in care planning and risk management.

Summary

Mr C was referred to Glasgow Dental Hospital by his dentist in January 2015. He attended the appointment in March but told the hospital he did not wish to see the same clinician again. Mr C also requested a second opinion following the outcome of this appointment. Mr C's case was passed to hospital management for a new appointment to be made.

In the meantime, Mr C changed dental practitioner. In July 2015, he was referred back to Glasgow Dental Hospital by his new dentist. However, the hospital replied to say they were unable to offer Mr C an appointment because of a previous history of aggressive behaviour and non-attendance. They suggested that future treatment be carried out by Mr C's dental practice.

In December 2015, Mr C complained to the board about not being provided with a second opinion after his March appointment. The board apologised for not carrying out a second opinion, but maintained that they were unable to offer an appointment. Mr C then complained to us.

We took independent advice from a dentist. They said it appeared that a second opinion had not been offered as a result of administrative oversight. They said that this was unacceptable, but noted that the board had acknowledged this and looked into their procedures to prevent such a situation recurring. We asked the board to advise us of the action they have taken.

The adviser also said that the board were entitled to discharge Mr C back to the care of his dentist because of the non-specialist nature of Mr C's treatment, episodes of aggressive behaviour towards clinical staff and multiple non-attendance at appointments. We accepted this advice, although on balance we upheld the complaint because a fuller explanation should have been provided and because of the failure to organise a second opinion.

Recommendations

We recommended that the board:

• advise us of the action taken to prevent a situation occurring whereby a request for a second opinion is not actioned.

Summary

Ms C complained that she had been referred to the Glasgow Dental Hospital for treatment for gum disease. Ms C had concerns about her treatment and, in particular, the failure to treat properly an abscess (a painful swelling caused by a build-up of puss) in her mouth. Ms C visited both the hospital and the board's out-of-hours service, but the problem was not properly diagnosed over several visits.

We took independent dental advice on Ms C's complaint. The adviser said that Ms C was treated correctly for the problem which had led to her referral to the hospital. However, the advice we received was that Ms C should have been x-rayed on her first attendance with an abscess. The failure to do this had prevented her abscess being properly diagnosed or treated. The adviser noted this was contrary to General Dental Council (GDC) guidance.

We therefore found that whilst Ms C's treatment plan was reasonable for her original dental problem, it was unreasonable for the board not to have followed the appropriate diagnostic guidance when she developed an abscess, so we upheld her complaint.

Recommendations

We recommended that the board:

• review its procedures to ensure that patients presenting with abscesses or associated swelling receive x-rays in line with GDC guidance; and
• apologise for the failures identified in this case.

Summary

Ms C complained to us about the care and treatment she was given when she went into the Princess Royal Maternity Unit to give birth to her daughter. When her labour was slow to progress and other alternatives were unsuccessful, her baby was delivered by caesarean section (an operation to deliver a baby which involves cutting the front of the abdomen and womb). However, doctors noted that she was not recovering from surgery as expected. She was taken back into surgery when she collapsed, two hours and twenty minutes after her caesarean section, and was found to have had a major internal bleed. Ms C raised concerns that her caesarean section was not carried out appropriately, and that doctors did not notice her deterioration quickly enough. She said that this resulted in a prolonged recovery time for her, and difficulties relating to her time with her new-born baby.

We sought independent advice from an obstetric adviser. They reviewed Ms C's medical notes in detail and did not raise any concerns about the way Ms C's caesarean section had been carried out. However, they did raise concerns about how medical staff responded to her deteriorating condition in the two hours after her caesarean section. They noted that a blood test had been taken but not followed up. They noted that medical staff did not maintain appropriate records of their decisions and plans. They also considered that Ms C's deterioration was not appropriately escalated to both anaesthetic and obstetric teams. They said that, if all this had been done, it was likely that Ms C's second operation could have been undertaken 45 minutes earlier, before her condition had become so critical.

We noted the obstetric advice on Ms C's care and treatment and upheld her complaint. We made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• review the post-operative escalation policy, to ensure concerns are escalated to both obstetrics and anaesthetics when post-operative concerns persist;
• share these findings with the staff involved, and remind them of the need to record their findings, working diagnoses, plans and timescales for review;
• review mechanisms for receiving blood test results to ensure that results are identified and acted on promptly;
• review staff competencies and potential training needs on the early diagnosis of occult/internal haemorrhage and on scanning an acute surgical abdomen; and
• apologise to Ms C for the failures we identified, and for the distress caused to her and her family.

Summary

Mrs C complained about the standard of medical and nursing care and treatment her late mother (Mrs A) received as an in-patient at New Victoria Hospital in October and November 2014. Following a hip operation, Mrs A was transferred from another hospital to a rehabilitation ward at the New Victoria Hospital. She had underlying health conditions (including hospital acquired pneumonia, lung disease and heart disease) and contracted clostridium difficile (a common bacteria that infects the colon). Whilst in hospital, her condition deteriorated and she died less than a fortnight after being transferred to the New Victoria Hospital.

We took independent advice from a medical adviser and a nursing adviser. Turning first to medical issues, we found that while appropriate investigations were carried out within a reasonable time and treatment decisions were reasonable, there were shortcomings. These included that senior clinicians should have been more involved in Mrs A's care and medical staff had failed to implement the relevant do not attempt cardiopulmonary resuscitation (DNACPR) policy. We also found that there was a failure to discuss the possibility of Mrs A's death with her family within a reasonable time. Also, the day before Mrs A's death, medical staff should have discussed her condition with an intensive care unit doctor sooner and it would have been reasonable for medical staff to have had a discussion with them the day before. Related to this, it was not clear whether the on-call doctor had followed up contact from a member of nursing staff about Mrs A's condition or whether they had been informed of her condition following the change of oxygen supply.

Turning now to nursing issues, we found that there were shortcomings in relation to infection control and nutrition which the board had addressed. However, we also found shortcomings around the implementation of an early warning system guidance (the National Early Warning Score - NEWS) and that nursing staff failed to monitor and assess Mrs A on the day before her death in line with this guidance. We also found failings in record-keeping.

Recommendations

We recommended that the board:

• consider the issues around end of life care including communication and take steps to ensure no recurrence;
• bring the medical adviser's comments in relation to record-keeping, implementing the DNACPR policy and escalating difficult significant clinical decisions to relevant staff, and take steps to ensure no recurrence;
• bring the nursing adviser's comments about shortcomings in implementing NEWS policy to relevant staff; and
• apologise for the failures this investigation identified.

Summary

Ms C was referred to the former Southern General Hospital in Glasgow by her GP for investigation of secondary infertility. A HyCoSy scan (a procedure to detect whether the fallopian tubes are damaged or blocked) and blood tests were arranged. The board took ten months to arrange the scan. Ms C said that because of the time it was taking to see a consultant gynaecologist to discuss the results of the scan and as the board could not provide her with a timescale of when she would get an appointment and as she was suffering severe abdominal pain, she arranged to be seen privately by a consultant gynaecologist abroad. The private consultant gynaecologist reviewed the results of her HyCoSy scan and carried out an ultrasound scan and, as a result, recommended a laparoscopy to confirm and, if necessary, treat endometriosis. A laparoscopy is surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin.

Ms C said that although she presented this information to the board's consultant gynaecologist, they refused to arrange a laparoscopy. Ms C said she paid for the laparoscopy procedure abroad. It confirmed a diagnosis of endometriosis and she had surgery to treat and cure her symptoms.

We took independent advice from a consultant gynaecologist. We found that there was an unacceptable delay in arranging Ms C's HyCoSy scan, the result of which was not normal and that a laparoscopy should have been arranged for Ms C by the board. Based on the clinical advice we received, we were satisfied that the board should have offered Ms C a laparoscopy to provide the definitive diagnosis. Therefore, we upheld Ms C's complaint.

We were also critical that the board were unable to locate and provide us with Ms C's complete clinical records and we made a recommendation to address this.

Recommendations

We recommended that the board:

• apologise to Ms C for the delay in arranging a HyCoSy scan, the failure to offer her a laparoscopy and for losing her medical records;
• refund to Ms C the invoiced cost of her ultrasound scan, laparoscopy and associated treatment arranged abroad;
• provide evidence that the delay in carrying out the HyCoSy scan has been addressed;
• feed back the comments of the adviser and the findings of this investigation to the consultant gynaecologist for reflection and learning, to include the importance of the management of medical records; and
• take steps to ensure that they are complying with 'Records Management: NHS Code of Practice (Scotland)'.