Upheld, recommendations

Summary

Miss C complained to us about the care and treatment provided to her partner (Mr A) at Hairmyres Hospital before his death. Mr A had been admitted to hospital because of increasing breathlessness. He was diagnosed with heart failure and subsequently discharged from hospital. However, he was readmitted to hospital two days later. It was initially thought that his heart failure had worsened, but when scans were carried out, it was identified that he had pulmonary fibrosis (a rare condition causing scarring of the lungs).

Miss C complained about the delay in diagnosing that Mr A had pulmonary fibrosis. We took independent advice on this aspect of Miss C's complaint from a medical adviser, who is a consultant in general medicine. We found that the findings from the scans and tests carried out when Mr A was initially admitted to hospital were not in keeping with a diagnosis of heart failure. We considered that Mr A should have remained in hospital and undergone further investigations to determine the cause of his symptoms and we upheld this aspect of Miss C's complaint.

Miss C complained that the board had failed to provide Mr A with appropriate medication when he was discharged from the hospital for a second time. We took independent advice on this complaint from a medical adviser, who is a consultant respiratory physician. We found that home oxygen therapy and other palliative options to alleviate Mr A's symptoms of breathlessness and lethargy should have been considered before he was discharged from hospital. We upheld this aspect of Miss C's complaint. That said, Mr A was suffering with severe pulmonary fibrosis, which was rapidly progressing when he was initially admitted to hospital and this would not have altered his prognosis. We also upheld Miss C's complaints that staff had failed to discuss the seriousness of Mr A's condition with him and his family and that he had been transferred between wards on an excessive number of occasions.

Recommendations

We recommended that the board:

• issue a written apology for the failings identified during our investigation;
• make the medical staff involved in Mr A's care and treatment aware of our decisions on Miss C's complaints; and
• remind the medical staff of the importance of communicating effectively in cases that involve severe life-threatening disease and of the importance of recording this communication in the medical records.

Summary

Miss C's young daughter (Miss A) has suffered gastrointestinal problems for most of her life and has had many hospital admissions. Miss C complained that she was treated unprofessionally and made to feel uncomfortable and inadequate by staff at Raigmore Hospital. She said that meetings were held behind her back and she was given very little notice about a multi-disciplinary meeting held to discuss her daughter's care. Miss C complained that the board failed to communicate with her appropriately about her daughter and that her daughter had not been provided with appropriate clinical treatment.

The board apologised if Miss C had been made to feel uncomfortable and said that this had not been their intention. They also said that meetings held to discuss Miss A had been routine and in her best interest; they said that she had been treated appropriately.

We took independent advice from a consultant paediatrician and we found that while Miss A's initial care was reasonable, given her longstanding problems, her admission to hospital to consider her symptoms should have taken place earlier than it did. Also, by the time a specialist dietician became involved in her care, Miss A had dietary deficiencies which had been likely to have been present for some time. We were also critical that some of the dietician notes were not available when we asked for Miss A's full medical record, so we made a recommendation to address this issue.

In relation to the way the board communicated with Miss C, the evidence showed that Miss C was given very little notice of a multi-disciplinary meeting held to discuss her daughter's care. There appeared to have been no effort to arrange a suitable date and time with her and she was put under unreasonable pressure to attend. We also found that she had not been given an explanation for meeting to discuss a child plan for her daughter. We therefore upheld Miss C's complaints.

Recommendations

We recommended that the board:

• make a formal apology to recognise the shortcomings in Miss A's care;
• ensure that the findings of this complaint are fed back to staff;
• take steps to ensure that they are complying with 'Records Management: NHS Code of Practice (Scotland)';
• make a formal apology for what happened in connection with the multi-disciplinary meeting, and also for failing to provide reasons why it was intended to hold a child plan meeting; and
• ensure that where discussions take place between professionals, an appropriate record is kept on file.

Summary

Mr C complained that his former GP practice unfairly refused a repeat prescription and removed him from their practice list after he complained about the matter.

We took independent advice from a GP adviser and found evidence to show that the repeat prescription had been lost or mislaid by the practice and this had not been explained by the reception staff to the GP who had been asked to reissue it. It was only at Mr C's persistence that he managed to receive his medication a few days later after attending the practice on several occasions. We also considered that the practice had not investigated and responded appropriately to this aspect of Mr C's complaint.

We identified that the practice had not followed General Medical Services (GMS) contractual guidance, nor their own policy, when they removed Mr C from the practice list without issuing a warning. We concluded that the practice failed to address Mr C's concerns in a professional manner and that they resorted to unreasonably removing him from the practice list causing him unnecessary distress and inconvenience.

Recommendations

We recommended that the practice:

• review their process for recording missing prescriptions and ensure that information is shared with the appropriate GP who has been asked to re-issue a prescription;
• share these findings with the staff involved and remind them of the importance of providing full and accurate responses to complaints;
• apologise to Mr C for the failings identified with his prescription;
• apologise for failing to issue Mr C with a warning prior to removing him from their practice list in accordance with GMS contractual guidance; and
• ensure all relevant staff are fully aware of the GMS contractual guidance and their own policy before removing a patient from the practice list.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A). Mrs C raised concerns that hospital staff at Dr Gray's Hospital unreasonably arranged to transfer Mrs A to Turner Memorial Hospital. Prior to the transfer, Mrs C had been treated in Dr Gray's Hospital for her existing chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). Mrs C said Mrs A had suffered diarrhoea on the day of the transfer and looked unwell.

The board said Mrs A's transfer had been reasonable. They said there was no evidence of diarrhoea prior to transfer, and Mrs A had been appropriately transferred.

After receiving independent advice from a geriatrician, we upheld Mrs C's complaints. We found that staff had unreasonably transferred Mrs A. In particular, we considered that Mrs A's condition was unstable, and her transfer was not subject to an appropriate level of consideration. We also considered that the board did not comply with the 'Can I help you?' guidance in answering Mrs C's complaint. We made a number of recommendations to address these concerns.

Recommendations

We recommended that the board:

• apologise to the family for the failings identified;
• confirm that the staff responsible will discuss this issue as part of their annual appraisal;
• remind staff of the importance of adequate record-keeping; and
• remind relevant staff of the complaints handling requirements under the 'Can I help you?' guidance.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received at Aberdeen Royal Infirmary. Mr C accepted an apology and explanations from the board for a number of his concerns, but Mr C was not satisfied with the board's response to his concern relating to his wife's DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) status. Mr C was not satisfied that the hospital staff in the gastroenterology department had followed the DNACPR policy and disputed the accuracy of a record which stated that a doctor had discussed the decision with him and his wife. We took independent advice from a consultant physician who was critical of the failure to complete a DNACPR form and the low level of detail in the medical notes surrounding the decision. We upheld this part of Mr C's complaint.

Mr C also complained that the board had taken a number of months to provide him with a written response to his complaint and had exceeded their target response time. Mr C was also concerned that the board had not sufficiently investigated his complaint and he was not satisfied with the response that the board had given him. We acknowledged that, in investigating Mr C's complaint, the board had met with him on two occasions and that this had contributed to the delay in providing a response. However, we remained critical about the individual delays that contributed to the time it took the board to respond, and found that the board had failed to keep Mr C updated on the progress of their investigation into his complaint. We also upheld this part of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to adhere to the DNACPR policy;
• provide evidence that staff in the gastroenterology department have been reminded of the importance of completing DNACPR forms where appropriate;
• provide evidence of any audit or quality improvement work which has monitored the completion of DNACPR forms in the gastroenterology department since staff were reminded to complete the forms;
• apologise for the failure to keep Mr C updated on the progress of their investigation into his complaint and failure to respond to his emails; and
• advise staff responsible for investigating complaints to update complainants in line with 'Can I Help You?' guidance.

Summary

About six weeks after the birth of her child, Mrs C attended her GP practice with bleeding and abdominal pain. She was treated with antibiotics. She was reviewed several times over the next few months, and a urine test and vaginal swab were carried out, with further antibiotics prescribed. Mrs C was then referred to gynaecology as a private patient, and subsequent investigations showed there were retained products of conception (pieces of placenta) left after the birth. Mrs C complained about the delay in referring her, and said she was only referred after telling the GPs she had private medical insurance.

The practice explained that the cause of Mrs C's bleeding had been unclear. Mrs C had had a CT scan (a scan which uses x-rays and a computer to create detailed images of the inside of the body) after the birth which had returned a normal result (suggesting there were no retained products of conception). In relation to the delay, the practice noted that on one occasion the GP asked Mrs C to come back in one to two weeks, but Mrs C did not return until six weeks later. Mrs C said this was the first available appointment, but the practice said there were a number of earlier appointments available with the same or different GPs. The practice gave us a copy of their audit records, which showed the appointment was booked only a few days before the date of the appointment.

After taking independent medical advice from a GP, we upheld Mrs C's complaint. The adviser said that the GPs should have arranged an ultrasound in view of Mrs C's symptoms of unexplained bleeding for six weeks after birth, and they should have referred Mrs C to gynaecology earlier. However, we agreed that part of the delay was caused by Mrs C returning in six weeks, rather than two (which may have been due to a misunderstanding or miscommunication).

Recommendations

We recommended that the GPs concerned:

• apologise to Mrs C for the failings our investigation found;
• familiarise themselves with postpartum complications and consider identifying this as a learning aim; and
• reflect on our findings as part of their next annual appraisals.

Summary

Mr C, who works for an advice agency, complained on behalf of Mr A who was concerned about the care and treatment given to his late wife (Mrs A). In particular, he was concerned that there was an avoidable delay by staff at Forth Valley Royal Hospital in establishing that Mrs A was suffering from breast cancer. While the board accepted that there had been a delay and apologised, they said that Mrs A had suffered from a rare form of cancer which had been difficult to diagnose.

We took independent advice from a consultant breast surgeon. We found that while Mrs A's form of cancer was a very rare variant, opportunities had been missed to diagnose her sooner. There had also been an initial delay in Mrs A being seen and her cytology (examination of tissue samples under a microscope) results had been incorrectly reported. We therefore upheld the complaint and made recommendations.

Recommendations

We recommended that the board:

• make a formal apology recognising the shortcomings we identified; and
• check that the changes they outlined to Mr A are now in place and that all excision biopsies, as well as cytology aspirates and needle biopsies, are formally discussed at multi-disciplinary team meetings.

Summary

Mrs C's mother (Mrs A) was admitted to the Medical Assessment Unit (MAU) at Dumfries and Galloway Royal Infirmary via A&E after showing signs of a stroke. Whilst in hospital, Mrs A suffered a major stroke. Mrs C raised a number of complaints about the board, including that they unreasonably failed to give Mrs A a clot buster rtPA (an injection to break down blood clots) and that nursing staff failed to monitor Mrs A appropriately.

We obtained independent medical advice from a consultant physician and a nurse. The medical adviser said that the board unreasonably failed to give Mrs A a clot buster rtPA, although they said that the decision would have been a difficult one and would have had to have been made by a specialist.

In addition, the medical adviser said that when Mrs A was in A&E, the board should have carried out a specific risk categorisation using the ABCD2 score (a risk assessment tool designed to improve the prediction of short-term stroke risk after a 'mini stroke'). Had they done so, this would have shown that Mrs A was at very high risk of progression to acute stroke. The medical adviser also said that Mrs A should have been admitted to an acute stroke unit and given a carotid Doppler (a scan to detect a narrowed artery in the neck, which may cause a stroke). She should also have been monitored continuously by experienced staff, rather than being admitted to the MAU. The medical adviser also said that a plan should have been made for Mrs A's care in the event of a deterioration, which should also have been explicit about what to do if new stroke deficits were detected.

Both advisers said the nursing staff did not monitor Mrs A appropriately or observe her every two hours, as required. The medical adviser said that the scoring system used by staff to monitor Mrs A (the Glasgow Coma Scale or GCS) was not entirely suitable. The nursing adviser said that not taking Mrs A's vital signs for a period of over five hours was a serious failing. We upheld Mrs C's complaints and made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• feed back the failings identified regarding the clot buster rtPA, the ABCD2 score, carotid Doppler and admission to an acute stroke unit to the staff involved;
• identify and address training needs for staff in A&E and the MAU on guideline 108 of the Scottish Intercollegiate Guidelines Network;
• provide Mrs C and her family with a written apology for the failings identified in the first recommendation;
• feed back the failings identified in Mrs A's nursing care to the staff involved;
• complete their review of the use of the GCS score, taking into consideration the medical adviser's views, and provide us with evidence of the outcome of the review; and
• provide Mrs C and her family with a written apology for the failings identified.

Summary

Mr C complained about the board following the death of his partner (Mrs A). Mrs A had attended A&E at Galloway Community Hospital with abdominal pain. She was recorded to have a high temperature and fast heart rate. The doctor who examined Mrs A diagnosed her as having a urine infection, and he discharged her with antibiotics. The next day, Mrs A was accompanying a friend to a hospital in another board area when she collapsed. She developed signs of sepsis (blood poisoning), originating in the gall bladder, and despite resuscitation and intensive care, she passed away.

In their response to Mr C's complaint, the board accepted that the early signs of sepsis had been missed at Mrs A's initial attendance at A&E and apologised for this. However, Mr C brought his complaint to us as he wanted further assurances that appropriate steps had been taken to avoid similar mistakes in the future.

We took independent advice from a medical adviser, who considered Mrs A's initial diagnosis when she attended A&E to be unreasonable based on her symptoms at the time. We also found Mrs A's elevated heart rate and temperature to be of sufficient concern that further investigation should have been warranted and admission to hospital considered. As such, we upheld the complaint.

In response to our enquiries, the board provided extensive details of procedural changes and training that had taken place in Galloway Community Hospital to aid in the diagnosis and treatment of sepsis, so we did not consider that any recommendations of this kind were necessary. We did, however, make a recommendation regarding the doctor who assessed Mrs A, and we asked the board to apologise to Mr C.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified; and
• confirm that the doctor who assessed Mrs A has discussed the treatment they provided to Mrs A at their annual appraisal.

Summary

Miss C was concerned about the high water charges in her pub, which she had taken over in 2006. She said she queried her charges in 2009 or 2010 and several times since, but Business Stream had no record of contact before 2014.

In 2014, Business Stream wrote to Miss C noting her high consumption, and she asked them to check the meter. They arranged a survey and initially told Miss C the meter was serving both the pub and the two flats above, but then explained the meter was only serving her pub, although it appeared to be faulty (the numbers were jumping back and forth). Business Stream sent the meter for testing, but this showed it was under-reading (so it did not explain the high consumption). However, since installing a new meter in a new location, Miss C's water charges reduced by about two thirds, despite her not having changed anything in the pub. Miss C asked for a refund, saying that the meter must have been faulty, but Business Stream refused on the basis that the meter test had not found an over-reading fault.

After taking independent advice from a water consultant, we upheld Miss C's complaint. We found the high readings were likely caused either by a problem with the meter or with its location on the old pipework (causing air turbulence). However, it was not possible to tell whether the over-reading was caused by the installation of the meter or by a problem with Miss C's pipework. Given the possibility that Miss C's pipework contributed to the problem, and the time taken to raise this matter with Business Stream, we did not consider a full refund was reasonable. We recommended Business Stream pay a full refund from the date they first noted the meter needed to be moved, and consider paying a partial refund for the period before this.

Recommendations

We recommended that Business Stream:

• refund the difference between Miss C's total water charges and her estimated actual consumption (based on her current consumption) for a specified period; and
• consider making an ex gratia payment of 20 percent of the difference between Miss C's charges and estimated consumption for a specified period.