Upheld, recommendations

Summary

Mr C complained that staff at the Royal Alexandra Hospital, Paisley failed to adequately assess his symptoms following a jarring injury to his neck from a fall in his garden. Mr C raised a number of concerns, including that the doctor who saw him failed to take adequate account of his dystonia (a movement disorder that causes muscle spasms and contractions), failed to arrange an x-ray and failed to ensure he had adequate pain relief. Mr C said it was later identified that his neck was fractured, but said that by then it was too late for it to be treated.

We took independent medical advice from a consultant in emergency medicine. The board indicated that the doctor's assessment of Mr C was appropriate. However, as the board could not locate Mr C's medical records, we could not clearly determine that this was the case. We were very critical of the board's management of Mr C's records.

Our adviser said that in general Mr C's dystonia would have played no part in his assessment and the determination of the treatment he required. However, he said that the doctor who saw Mr C should have considered the impact of his dystonia on his ability to swallow when determining appropriate pain relief. In the absence of a pain score, it was difficult to determine exactly what level of pain relief should have been provided. However, the board acknowledged that their understanding of the medication available to Mr C at home was incorrect and it would appear that Mr C was, therefore, sent home without adequate pain relief.

Further, given Mr C's swallowing problems caused by his dystonia, our adviser said that he would have expected senior involvement in deciding if Mr C should have been admitted for pain relief and we were critical of the board for failing to arrange this.

In terms of the need for an x-ray, the adviser was clear that, given the absence of any direct blow to Mr C's head, an x-ray was not indicated.

Recommendations

We recommended that the board:

• review their practice on the storage of patients' medical records to ensure that records are stored securely in future.

Summary

Mrs C complained to us that the board had given her terminally ill child (child A) a large dose of a muscle relaxant before they were taken off a ventilator. Child A had been receiving a muscle relaxant to improve ventilation (breathing), but was approaching the end of life and care was being withdrawn. We took independent advice from one of our medical advisers, and found that it had been unnecessary to give Mrs C's child a large dose of relaxant immediately before being taken off the ventilator. Our adviser said that this might in fact have hastened child A's death by a short time. The board had also continued to give child A the muscle relaxant after they were taken off the ventilator. This was not in line with the relevant guidance, which said that this should not be done.

Mrs C also complained that staff did not discuss this with her. Although the large dose of muscle relaxant should not have been given, any significant changes that affect the care provided to a child should be discussed with the family/carers. There was a clear failure to do so in this case.

Mrs C made a further complaint that the consultant treating child A did not tell her about this, when she asked him several months later why her child had passed away so quickly. Our adviser found no evidence in the record of the meeting that the consultant told her about the large dose of muscle relaxant. It is imperative that parents are given full and complete information about the care and treatment provided to a child when they request this. There was no evidence that the consultant did so in this case. We upheld all of Mrs C's complaints.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for unnecessarily giving her child a muscle relaxant before they were taken off the ventilator and for continuing the muscle relaxant after ventilation had been withdrawn; and
• take steps to ensure that their guidance on end of life care for children reflects guidance on muscle relaxants from the Royal College of Paediatrics and Child Health.

Summary

Mr C submitted a request to see a prison dentist, saying that he had severe dental pain. Seven days later, Mr C had not received an appointment and he complained to the board. The next day, Mr C had a triage appointment with a nurse, who arranged an urgent dental appointment three days later. At this appointment the dentist found that the nerve in Mr C's tooth had died, and root canal treatment was required.

The board did not uphold Mr C's complaint, as he had received an appointment by the time this was considered and they found the delay was reasonable for a 'routine referral'. Mr C was dissatisfied with this response, and complained to us about the delay in his dental treatment.

We asked the board why Mr C's referral was classified as 'routine', given that Mr C was not seen by any healthcare professional until his triage appointment a week later. They explained that requests for appointments were reviewed by healthcare staff, and any requests which were considered urgent were seen by a healthcare professional within 24 hours.

After taking independent advice from our dental adviser, we upheld Mr C's complaint. We found that the board did not follow their guidance on referrals, as Mr C's referral should have been classified as 'urgent' and he should have been seen within 24 hours. We also found that it was unreasonable for the board to classify the referral as routine without actually reviewing Mr C, given that the symptoms he described were in the 'urgent' category.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to properly classify his dental request and the delay in issuing him a dental appointment;
• review their procedures for classifying dental referrals, to ensure that all dental cases are reviewed by a healthcare professional within the time-frames required under the Prison Care Pathway guidance; and
• consider clarifying their guidance on the 'Urgent Care' pathway to make it clear that the 24 hour time-frame refers to the patient seeing a healthcare professional, rather than dental treatment being provided.

Summary

Mr C had an elective arthroscopy procedure (a type of keyhole surgery) on his right knee at Forth Valley Royal Hospital. The surgery took longer than anticipated. Mr C was discharged home the following day but was readmitted with an infection in his knee several days later. He had to undergo two washouts of the knee (a technique that involves flushing the joint with fluid) and was prescribed antibiotics to treat the infection, although Mr C said that hospital staff did not give him several doses of the antibiotics. The board agreed that this had happened. Mr C then complained that the care and treatment he received during and after his knee surgery was unreasonable.

We took independent advice from a consultant in orthopaedic and trauma surgery, who explained that Mr C had suffered a severe complication of a joint infection after surgery, which is a recognised risk but is a rare complication. The adviser said that overall Mr C's care and treatment was appropriate and the failure to provide him with antibiotics on a number of occasions did not significantly alter the eventual outcome of the infection he acquired. Nevertheless, the adviser considered the failure to administer antibiotics was either due to failure by staff to be aware of the potential complications of this, or an indifference to 'getting it right' and was, therefore, a failing by the board in their duty of care to Mr C. We were, therefore, satisfied there was a failure in Mr C's care and treatment.

We noted that a senior charge nurse had apologised to Mr C for the failure to give him antibiotics and that other nursing staff had been spoken to, to ensure that this was addressed. However, we thought that the board should apologise to Mr C as well. The adviser had further commented that although the board's explanation about the duration of Mr C's surgery was reasonable, the operation notes did not mention any particular problems or difficulties. We would have expected the reasons for the length of Mr C's surgery to have been noted, and we made a recommendation about this as well.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to administer antibiotics;
• provide us with evidence of the action they have taken to address the failure to administer antibiotics; and
• ensure that our adviser's comments in relation to the operation notes are brought to the attention of the relevant staff.

Summary

Mrs C complained about the standard of medical care she received when she reported a cough to the medical practice. She said that she reported a persistent cough on two occasions but was not referred for a chest x-ray. At a third consultation, seven months after Mrs C first reported her cough, a locum GP referred her for a chest x-ray and, after further tests, Mrs C was diagnosed with lung cancer.

We took independent medical advice from one of our GP advisers. We found that the practice missed two opportunities to arrange for Mrs C to have a chest x-ray as part of their routine investigations into a persistent cough. We found that the practice failed to reasonably follow the national referral guidance for suspected cancer which all GPs should be aware of and which clarify the significance of a cough in the diagnosis of lung cancer and state that a time-frame of three weeks should be considered a persistent cough.

When Mrs C first reported the cough it had been present for eight weeks, and when she next mentioned the cough it had been present for 13 weeks. The criteria for referral for suspected cancer had been met on both occasions. We found that Mrs C should have been sent for a chest x-ray earlier than she was, so we upheld her complaint, and made a number of recommendations.

Recommendations

We recommended that the practice:

• apologise to Mrs C and her family for the distress caused by the late arrangement of investigations into the cause of her cough;
• notify the board's clinical support group and ask them to consider whether to undertake a random review of patient consultation records for quality assurance purposes; and
• carry out a reflective significant event analysis with support from the board's clinical support group and provide us with a copy.

Summary

Mrs C complained about a number of aspects of the care and treatment she received in A&E at Dumfries and Galloway Royal Infirmary. These included concerns about the examinations and investigations carried out and whether doctors should have identified that she had a pulmonary embolism or embolus (a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream), which was discovered when she attended hospital again ten days later.

We obtained independent medical advice on the case from a consultant in general medicine. Our adviser explained that the level of investigation during Mrs C's attendance at A&E was not sufficiently detailed to justify the exclusion of the diagnosis of pulmonary embolus and that in this regard, Mrs C's care fell below the level that she could have expected.

The adviser said it was not possible to say that Mrs C's pulmonary embolus would definitely have been diagnosed if more care had been taken during her attendance at hospital. However, he said it was much more likely to have been diagnosed if doctors had carried out a sufficiently detailed assessment and investigation. The adviser also explained that, overall, he considered it likely that Mrs C's pulmonary embolus was present when she first went to A&E, and should have been considered as a diagnosis at that time.

Recommendations

We recommended that the board:

• feed back the failings identified to the staff involved and ask them to complete reflective commentaries for their educational/appraisal portfolios; and
• provide Mrs C with a written apology for failing to perform an adequate assessment of her in A&E.

Summary

Ms C was admitted to Borders General Hospital (hospital 1), then Knoll Hospital (hospital 2) after being involved in an accident. She was given pain relief at the scene of the accident and taken to hospital 1. On arrival, there was a mix-up over patient details and Ms C told us that on that day and the following day, staff tried to give her medication meant for another patient. Ms C told us that this took some time to resolve and, as a result, she said she was not given pain medication in a timely manner or when requested. She also believed she was given an overdose of morphine, which affected her ability to pass urine. She alerted nursing staff who then identified a urine retention issue. Ms C was transferred to hospital 2 the following month. She said that nursing staff there were institutionalised in their attitudes and treated her as if she was an elderly patient. Ms C discharged herself five days later.

We took independent advice on this case from our nursing adviser, who said that pain charts were not fully utilised at hospital 1 to manage Ms C's pain. Although pain was recorded there was no record of any action taken. In addition, Ms C was known to the pain team but they were not alerted until four days after her admission. We also found that although Ms C was already known to have chronic pain, she was not assessed for this in a proactive manner, and that in this instance care was not reasonable. Moreover, we were concerned that her patient details were incorrect. This was rectified and did not result in any medication errors, but could potentially have had more serious consequences. We were satisfied that the nursing care in relation to urine monitoring and that provided by staff at hospital 2 including their attitude was reasonable, and were satisfied Ms C was not given an overdose of morphine. However, in light of the failings identified, we upheld the complaint.

Recommendations

We recommended that the board:

• review how pain is assessed and monitored in Borders General Hospital and how instruments such as early warning system charts are used;
• inform us of the steps taken to ensure patient details are correct; and
• apologise for the failures this investigation identified.

Summary

Mr C complained about care and treatment provided to his late mother (Mrs A) by the board. Mrs A attended the A&E department at University Hospital Ayr and was admitted to the hospital, where she was diagnosed with a urinary tract infection. Mrs A had a number of longstanding conditions including spinal curvature and lymphoma (a type of cancer). An x-ray was taken which showed a large abnormality at the top of the right lung. This was reviewed by a doctor who considered the progression of Mrs A's lymphoma as a possible diagnosis. After being advised that Mrs A's x-ray showed deterioration, Mr C and his family decided to take her home and she was discharged the following day. The doctor's reading of the x-ray was incorrect as the abnormality was caused by Mrs A's head resting against her chest. The family were advised of this after her discharge and she was readmitted two days after returning home. Mrs A died several weeks later.

Mr C complained that Mrs A had not been given appropriate medication for her infection due to the misdiagnosis and that this had hastened her death. Mr C also complained that the response to his complaint was inadequate.

After taking independent advice from our medical adviser, we found that there had been a major error in the doctor's interpretation of the x-ray and that Mr C and his family should not have been advised that there was a deterioration in her condition. Although we did not find any evidence that Mrs A had been given inappropriate medication or that the incident had hastened her death, we upheld Mr C's complaints due to the significance of the error in reading the x-ray. We also found that the board's investigation of Mr C's complaints did not fully address the doctor's error and that the responses provided were inconsistent. We upheld both Mr C's complaints and made a number of recommendations.

Recommendations

We recommended that the board:

• make staff aware of our adviser's comments on the incorrect diagnosis and determine if there are lessons that can be learned from this incident;
• remind staff of the importance of keeping accurate contemporary records in line with the relevant General Medical Council guidance;
• provide a copy of our decision to the doctor to ensure he is fully aware of the outcome of this investigation and allow any learning points to be discussed at his next appraisal; and
• carry out a review to determine if the doctor's misinterpretation of the x-ray was an isolated incident and provide appropriate training if required.

Summary

Miss C, who has a condition affecting her mobility, complained of a lack of support from the college. In particular, she raised concerns about a fieldwork residential trip, which she was not allowed to attend due to health and safety concerns. Miss C said she was not involved in decisions made about her ability and, although she was provided with notes and recordings from the trip, these were not of a good standard, and she had to seek help from the lecturer to finish the assessment. She also raised concerns about delays in processing changes to her personal learning support plan (PLSP) and personal emergency egress plan (PEEP) in second year.

Because she felt she was not receiving the support she needed, Miss C applied to transfer to a new course. However, this took some time and she was ultimately not able to transfer. Additionally, when Miss C asked her tutor why he thought the transfer was not an option, he suggested that the physical aspects of the course might be too challenging for her.

In response to Miss C's complaint, the college accepted that the notes from the residential trip were not of a good standard. They also explained that the delays in the PEEP and PLSP were due to the unexpected absence of the additional support coordinator, and apologised for this. However, the college considered that Miss C's request for transfer had been handled reasonably. They said that her tutor had told her within five working days that her transfer request had been refused, and they considered that his comments about the physical aspects of the course being challenging were not intended to make assumptions about Miss C's physical ability. Overall, the college said that they had provided reasonable support to Miss C, and they did not uphold her complaints. Miss C was dissatisfied with their response, and complained to us about the additional support provided, the handling of her transfer, and the college's handling of her complaint.

We investigated Miss C's complaints and found that, although the college had involved her appropriately in discussions about adjustments to the residential trip, the arrangements ultimately made were unreasonable, as the college relied on another student for these. We said that the college should have ensured that the notes were made available in good time, and were of sufficient quality to enable Miss C to complete the assignment. We also found that the college failed to make timely arrangements to update Miss C's PEEP, as her classes were scheduled for a different building and no alternative arrangements were made for her until the third week of term when she raised this herself. However, we found that they did make reasonable attempts to review her PLSP, including offering her an urgent appointment early in the next academic year.

We found that the college unreasonably handled Miss C's request to transfer to another course. While the decision to refuse the transfer was made in a reasonable time-frame, this was not appropriately communicated to Miss C for over two weeks. Although her tutor informally told her that he did not think the transfer was an option, the only reason he gave for this was that the course might be physically challenging, and he did not tell Miss C that the head of curriculum had declined the request. We were critical of the failure to properly communicate the decision to Miss C, and of the tutor’s comment.

Finally, we found that while the college generally handled Miss C's complaints well, they did not comply with their policy, as they failed to provide a written response within 20 working days.

Recommendations

We recommended that the college:

• review their templates and procedures for setting up personal learning support plans (PLSPs) to ensure that additional support required for fieldwork is discussed with students at an early stage and there is a clear process for informing module tutors of students' PLSPs and additional support entitlements;
• review their processes for setting up and reviewing personal emergency egress plans (PEEPs), to ensure that PEEPs covering the relevant building are in place before students are expected to attend classes;
• take steps to clarify the roles of different staff in relation to requests for transfer (including who is responsible for liaising with the student);
• raise the findings of our investigation with staff involved for reflection;
• apologise to Miss C for the failings our investigation found; and
• remind staff of the requirement to provide a written response to all complaints which are considered at the investigation stage.

Summary

Mr C submitted four complaint forms to the prison governor alleging assaults by prison staff and issues related to a strip search. He then submitted four more forms the following month, saying that his concerns had not been investigated.

In response to the complaint, the governor told Mr C that the allegations of assault had been referred to the police for investigation. However, because the police did not take matters further due to insufficient evidence, the prison did not undertake a local investigation.

We upheld Mr C's complaint as our investigation found that, although the police investigation did not find enough evidence to pursue criminal actions, the governor had not clearly demonstrated that the prison had dealt with the complaints. We were critical that despite submitting eight complaint forms directly to the governor, it had not been properly explained to Mr C - or to us - whether staff handled him in accordance with the prison rules, and their control and restraint guidance.

Recommendations

We recommended that Scottish Prison Service:

• investigate whether or not staff handled Mr C in line with the prison rules and their control and restraint manual;
• investigate Mr C's allegations that nursing staff were present during a strip search and whether this was in accordance with the prison rules and their standard operating procedure for conducting searches; and
• draw our findings to the governor's attention to ensure that complaints are fully investigated and responded to.