Upheld, recommendations

Summary

Mr C complained about the care his father (Mr A) received at the Royal Alexandra Hospital's A&E department after attending there with a severe headache. Specifically, Mr C complained that Mr A was not reviewed by a doctor for several hours and there was a delay in taking a CT scan of his head (computerised tomography scan: a specialised x-ray). Mr A had a subarachnoid haemorrhage (SAH: a bleed on the brain). He was transferred to a hospital with specialised services where he suffered a seizure and died.

The board said that Mr A was seen by a doctor within ten minutes of arriving at A&E and that an immediate CT scan had not been performed as Mr A's neurological examination was normal. However, he was admitted to a medical ward with the intention of carrying out a CT scan. The board considered whether there were any lessons to be learned. Consequently, the department have lowered the threshold for when a CT scan should be arranged if a SAH is suspected when neurological examination is normal.

We took independent advice from two of our medical advisers and found that Mr A was assessed promptly by an emergency doctor who had suspected a SAH. However, we were critical that the board would normally only arrange a scan if there was a neurological decline. We considered a scan should have been arranged as soon as the doctor suspected a SAH in line with national guidance. In any case, when Mr A's condition declined in A&E, a CT scan was not arranged until a further decline happened several hours later on the ward.

We were also critical that there was no record to show that the doctor had discussed the merits of arranging a CT scan with the on-call consultant. This was not in line with the General Medical Council's good practice guidance on record-keeping.

Recommendations

We recommended that the board:

• apologise to the family for failing to arrange a timeous CT scan in line with national guidance;
• review their local protocol on the management of headaches to ensure it is in accordance with national guidance; and
• draw to the attention of the emergency doctor the importance of recording discussions about the management of patients in line with good practice.

Summary

Miss C complained that the board had failed to put in place appropriate treatment for her mental health problems when psychotherapy (a type of therapy used to treat emotional problems and mental health conditions) she had been receiving for a fixed period ended. Whilst receiving psychotherapy, Miss C had been diagnosed with autistic spectrum disorder. She was also sensitive to change and had been concerned that she would receive inadequate support when the psychotherapy ended.

We took independent advice from one of our medical advisers, who is a psychiatrist. We found that the board had tried to take active steps to liaise with relevant services to try to ensure that there was adequate support in place for Miss C. However, when the psychotherapy ended, Miss C's community psychiatric nurse was not available and her consultant in the community mental health team had changed. In addition, an autism support group said that they could not support her. We found that inadequate co-ordination and transfer of Miss C's care left her with inadequate support in place for her identified needs at that time. In view of this, we upheld her complaint.

The board had already apologised to Miss C for their failings and had said that the learning points would be fed back to clinicians, but we made one recommendation.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to try to prevent the problems that arose in Miss C's case from recurring.

Summary

Ms C was a new patient at a dental practice where she presented with a chipped tooth. She saw a dentist who examined her mouth and did an x-ray which revealed some decay. She attended the dentist six times within two months and during this time, root canal treatment was commenced, she had one extraction and four fillings.

Ms C complained about the care and treatment she received. She said that it had been unnecessary and left her with damaged teeth and in pain. However, the dentist said that she had presented with extensively damaged teeth which required attention and that although Ms C had had a difficult time, this was as a consequence of extensive decay. Despite her best efforts, the dentist said that she had been unable to save one of Ms C's teeth.

We took independent dental advice, and found that Ms C's notes were poorly recorded and that while decay was present in some of Ms C's teeth for which treatment was necessary, it appeared that one of Ms C's teeth had been treated in error while a damaged tooth received no treatment. We also found that some of the decay was minimal, not requiring the extensive drilling that was undertaken. While the dentist recorded that she had had to give Ms C extensive treatment, the condition of Ms C's mouth as recorded in her notes suggested that she only required oral hygiene advice. We upheld Ms C's complaint.

Recommendations

We recommended that the dentist:

• make a full apology; and
• undergo additional training in record-keeping and address the concerns raised by the adviser as part of her continuing professional development. She should confirm to us that she has done so.

Summary

Ms C complained about the care and treatment she received during the birth of her son. In particular, she complained that there was a delay in the decision being taken to deliver her baby by caesarean section, that midwives took too long to react to complications, and that she had been left without staff being present for long periods of time. Ms C was also unhappy with the level of information given to her during the birth of her son and complained that the board failed to communicate effectively with her.

We took independent medical advice from one of our advisers. Our investigation found that overall the care and treatment given to Ms C was unreasonable. The advice we received was that her observations should have been taken more frequently, especially following Ms C's raised temperature. We also found that there was a lack of close monitoring of her vital signs and that an obstetric early warning system chart should have been used to record Ms C's vital observations. The advice we received was that these observations are important signs that may suggest serious illness and warrant immediate medical referral. In the circumstances, we upheld the complaint that the board had failed to provide appropriate care and treatment to Ms C during labour.

Our investigation also found that, while the midwife had communicated with Ms C on some issues, there was no evidence that some of the examinations carried out were explained, or that concerns about her raised temperature or transfer to another ward was discussed with Ms C or that Ms C's ongoing treatment plan was discussed with her. We found that the board had failed to communicate effectively with Ms C and we upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings we identified;
• provide us with an action plan which addresses the failings identified in the assessment, monitoring and evaluation of vital signs, which should include the use of the obstetric early warning system chart and the triggers for referral to an obstetrician; and
• provide us with an action plan which addresses the communication issues identified in this investigation, which should include involving women and their partners in the ongoing plan of care and any concerns about labour and recording information /communication.

Summary

Mrs C was diagnosed with a condition where pressure is exerted on the spinal cord. She said she was told by a consultant neurosurgeon that without surgery she would become bedridden and doubly incontinent possibly within a period of three months and, therefore, she required urgent surgery which would take place within weeks.

Mrs C accepted the board's offer of having her surgery at a private hospital (paid for by the board) to meet treatment time targets. Mrs C said the private hospital then told her no decision had been made to accept her referral and gave her no indication when the surgery might take place. Mrs C paid to have her surgery carried out at a different private hospital shortly thereafter.

We took independent medical advice from a consultant neurosurgeon who said there had been a failure to give Mrs C a realistic prognosis and the board had handled her referral to the private hospital unsatisfactorily. We accepted Mrs C genuinely believed a failure to have urgent surgery would have dire consequences for her and she reasonably did not know for certain whether and when her treatment would take place at the private hospital the board had said they would refer her to. We considered the board had not clearly communicated with Mrs C and explained what was to happen with her treatment. Given the board's failings and as they had agreed to meet the cost of Mrs C's surgery we did not consider it reasonable that she, rather than the board, should be out of pocket.

We also found no evidence Mrs C was informed about her removal from the waiting list or that any clinician had approved her removal from the list.

However, we considered the board had apologised to Mrs C for delay in the handling of her complaint and had reasonably responded to correspondence.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings identified in this complaint in relation to delay and poor communication;
• reimburse Mrs C with the cost of the private surgical treatment undertaken;
• improve communication and record-keeping between them and other external care providers where patients are referred for treatment;
• provide evidence of the action taken to address the lack of availability of access to theatres; and
• apologise to Mrs C for the failure to inform her that her name was removed from the waiting list for surgery.

Summary

Mr C's GP had referred him to the board in November 2014 as he required the removal of his gallbladder. Although Mr C was not a resident in the board area he had received previous treatment there and his daughter lived nearby. The plan was that Mr C would stay with his daughter on his discharge following the surgery and the board had indicated that they were willing to accept him for surgery on this basis. Mr C emailed the board three times in January 2015 as he had heard nothing more. He was then advised that the board could not accommodate the GP's referral, and that the board had referred him to the health board where Mr C was resident. Mr C complained about the delay by the board in responding to his GP referral.

The board apologised for the delay in responding to Mr C's emails and explained that the reason they could not carry out the surgery was due to pressure on their services and that to accept a referral from another health board would put added pressure on an already pressured system. We upheld the complaint and found that between November 2014 and January 2015 there was no action taken regarding the GP referral as two staff members thought the other was dealing with the matter.

Recommendations

We recommended that the board:

• ensure that the staff members who considered whether to action the GP referral reflect on their actions and discuss the complaint at their next appraisal.

Summary

Mrs C complained about the care provided to her late mother (Mrs A) by Forth Valley Royal Hospital. Mrs A had dementia and was admitted to the hospital suffering from a urinary tract infection and increased confusion; she was noted to be generally unwell. One evening, Mrs A fell out of bed just before 21:00 but Mrs C was not told about this until the following morning.

Mrs A had been reviewed by a doctor and her head and shoulder were x-rayed, but despite having pain in her leg this was not x-rayed. Three days later, after Mrs C pointed out to nursing staff that Mrs A's foot was at an odd angle and she was in severe pain, an x-ray was done and it was found that Mrs A had broken her hip. Remedial surgery was considered but due to Mrs A's on-going and recurrent infection and her general frailty, it was agreed with the family that only palliative (end of life) care was appropriate. Mrs A died less than a fortnight after her fall.

Our investigation included taking independent medical advice from two of our advisers, a doctor specialising in care of the elderly and a senior nurse. The advisers found some evidence of reasonable care, especially in Mrs A's initial care - but they were critical of the lack of communication with Mrs C about Mrs A's fall and later about what happens when a patient dies in hospital; the delay in diagnosing Mrs A's broken hip; that at one time Mrs A's notes were missing and later found in another patient's room - resulting in a delay in prescribing pain relief for Mrs A; and that when surgery was still being considered, Mrs A was found to have an incorrect identification wristband on.

Recommendations

We recommended that the board:

• ensure that all staff involved in this complaint are made aware of our findings and reflect on them to inform their future practice;
• consider the introduction of an information leaflet for relatives explaining the procedure when a patient dies in hospital;
• remind staff involved in this complaint of the requirements of the General Medical Council and Nursing and Midwifery Council guidance on record-keeping, and in particular with regard to protecting patients' confidential information;
• ensure that staff involved in this complaint are reminded of the importance of good, and timely, communication with relatives where patients have sustained a fall and/or injury while in hospital; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C complained about the poor communication by Victoria Hospital in relation to her father (Mr A), who had been receiving dialysis treatment (a form of treatment that replicates many of the kidney's functions). Following a discussion with Mr A's family, the medical team at the hospital decided to stop the treatment, but they did not tell Mr A's GP that they had done so. The GP didn't found out that Mr A required palliative care until a home visit three weeks later.

In response to Mrs C's complaint, the board said the consultant in charge was unable to locate the letter he dictated after meeting with the family. The board apologised for this and said that the consultant would try to ensure that in future information is passed on appropriately. Mrs C was dissatisfied with the response, as the board did not explain whether the letter was in fact dictated or typed, or whether the consultant had any recollection of signing it. Mrs C also considered that the board's response was not robust enough to prevent a reoccurrence of the situation, and she brought her complaint to us.

After taking independent medical advice, we upheld Mrs C's complaint. We found that the consultant had failed in his responsibility to inform the GP of Mr A's discharge (with the most likely explanation being that the letter was never dictated). We were also critical that the consultant did not give a clearer response to Mrs C's complaint, as this could have resolved it at an earlier stage. We noted that the board had already apologised to Mrs C and taken steps to improve their system for signing letters. As the failing in this case appeared to be caused by human error, rather than a system failure, we considered that asking the consultant to reflect on his practice was an appropriate and proportionate response.

Recommendations

We recommended that the board:

• bring the findings of our investigation to the attention of the relevant consultant, for reflection as part of his next annual appraisal.

Summary

Mr C has a history of back problems. He complained that he was only given an x-ray for his back pain and had to arrange for a magnetic resonance imaging (MRI) scan privately because a clinician at Dumfries and Galloway Royal Infirmary refused him one. Unlike an ordinary x-ray, MRI shows the soft structures in the spine such as disc, nerves, ligaments and muscles.

In response to the complaint, the board said that Mr C had an increase in back pain with no new symptoms and there was no indication that an MRI scan would be needed in accordance with national guidance on the early management of persistent non-specific low back pain.

We took independent advice from our medical adviser who said that Mr C's presentation was not straightforward and did not properly fit with the diagnosis of non-specific low back pain or any existing spinal guideline. The medical advice we received was that Mr C should have been assessed for the possibility of spinal cord compression and either have had an MRI scan or his case discussed with a spine specialist given he had a pre-existing deformity of his spine and had several red flags (symptoms that are likely to indicate a particular serious illness). We only found records to show that an orthopaedic specialist had interpreted the x-ray but no evidence to show that the specialist was aware of the red flags and the pre-existing deformity.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• review their local guidance with a view to including information on spinal presentations, such as spinal deformity and myelopathy pathologies;
• ensure the clinician reflects on the shortcomings in their next appraisal; and
• consider reimbursing Mr C for the cost of the private MRI scan on provision of appropriate receipts.

Summary

Mrs C's mother (Mrs A) was admitted to Dumfries and Galloway Royal Infirmary following a fall at home. She had previously been diagnosed with Alzheimer's disease and was noted to be confused upon admission. Staff found no evidence of bone fractures, but kept Mrs A in hospital until her mobility improved. A few days following her admission, Mrs A began vomiting. Medical staff suspected a bleed in her stomach and proposed an endoscopy (a camera inserted into the stomach to find the source of the bleed). Mrs A was fasted for the procedure, but it was delayed on several occasions due to a lack of patient consent.

Mrs C complained that her mother was fasted unnecessarily on a number of occasions in preparation for the procedure. She noted that staff had been informed that she had power of attorney for her mother (a legal document appointing someone to act or make decisions for another person) and complained that she was not asked to provide consent for the procedure. She also complained about Mrs A's hygiene, the monitoring of her fluid intake and poor communication from staff.

We were critical of the board's handling of the consent for Mrs A's procedure. There are clear guidelines for obtaining consent from patients who lack capacity to discuss their own treatment and these were not followed. The record-keeping in Mrs A's case was very poor and suggested a lack of consultant review over a number of days during her admission. We were critical of this, and the lack of discussions with Mrs C regarding Mrs A's treatment plan. We also found the staff's communication to be poor with no proactive plan to discuss Mrs A's care with Mrs C. This led to impromptu discussions in open corridors which we found to be inappropriate.

Recommendations

We recommended that the board:

• conduct an audit of the relevant ward's compliance with malnutrition universal screening tool, falls risk, and adults with incapacity responsibilities;
• review the standard of record-keeping in Mrs A's case and identify any requirements for additional staff training;
• provide us with details of the outcome of the Endoscopy User Group's review and the action taken to prevent further consent issues;
• apologise to Mrs C for the inadequate level of care and treatment Mrs A received during her admission at the hospital; and
• ask senior staff responsible for the relevant ward to review how staff communicate with family members to ensure regular, proactive, communication with particular emphasis on complying with the national standards for care of dementia patients.