Upheld, recommendations

Summary

Mrs C complained about the care and treatment given to her late mother (Mrs A) in hospital over a two day period. Mrs A was elderly, had been unwell and was deteriorating. Mrs C said she had spoken to her mother by phone late on the afternoon of the first day, and she had sounded well. However, Mrs C received a call the next morning to say that Mrs A had deteriorated rapidly and that she should come to the hospital. Mrs C then spoke over the phone with an out-of-hours GP who was treating Mrs A. The GP advised Mrs A that he felt it would not be appropriate to transfer Mrs A to an acute unit, and that ensuring her comfort and dignity was the priority at that stage. Mrs C complained to us that she felt an opportunity to provide Mrs A with further treatment was missed. She said that though she understood Mrs A was nearing the end of her life, she was concerned that there was a lack of appropriate care and treatment over the two days.

We obtained independent medical, nursing and GP advice from our medical advisers in order to reach a decision on Mrs C's complaint. We found that, although it may have been reasonable to reduce the number of observations carried out on Mrs A due to the type of care she was receiving, this was not recorded in her care plan, nor was there evidence of this having been discussed with Mrs A or her family. We noted that clinical observations taken a couple of days before were inappropriately recorded as 'low', and there was then a

60-hour period during which no observations were made. We took the view that the Modified Early Warning Score (MEWS - a guide used to quickly determine the degree of illness of a patient) had not been used correctly and, although there was no suggestion that the eventual outcome for Mrs A would have been different, we found that her care in this regard was not reasonable.

We did find that the care provided by the GP following the discovery of Mrs A in an unresponsive state was appropriate, reasonable and patient-centred. Mrs C had felt it was inappropriate and distressing that he had discussed these matters over the phone, although the board said that they had phoned Mrs A earlier to advise her to attend the hospital immediately. Mrs C disputed this. We could not reach a definitive conclusion about this, although we noted that in the circumstances there did not appear to have been any alternative and that the GP handled a difficult situation well. On balance, however, giving regard to our findings in relation to the lack of observations, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C in writing for the failures identified in Mrs A's care; and
• consider adopting a weighted scoring system to identify patient deterioration in place of the 'as required' use of the MEWS system, as detailed in National Early Warning Score (NEWS): Standardising the assessment of acute illness severity in the NHS.

Summary

Mr C complained that there was a delay in the board carrying out bariatric (weight-loss) surgery to help control his weight. In August 2009, Mr C's GP referred him to the board's weight management service - a service that was in place between December 2008 and July 2012. The referral paperwork was lost so Mr C's GP sent a further referral in February 2010. The board told Mr C that he would receive a psychological assessment within a couple of months, but the appointment did not take place until a year later. The board did not tell Mr C or his GP that there were no psychological assessment clinics running during this period. In October 2011, the psychologist confirmed that Mr C met the criteria to be further assessed for bariatric surgery and that he would be referred to another board's obesity service, which was the procedure in place at this time. In November 2011, the GP referred Mr C through the appropriate channel but the board failed to advise the GP or Mr C that no referrals to the other board were being accepted, due to the demand on the service. In July 2012 a new national weight management criteria was implemented and in October 2012, Mr C was advised that he was no longer eligible to be referred for surgery because he did not meet new age criteria.

Our investigation found that, had Mr C's referral paperwork in 2009 not been lost, and had there not been a significantly long delay of a year in his psychological assessment going ahead, he would have been assessed under the criteria in place before July 2012. In addition, Mr C appeared to have been misled about the boards weight management service. We concluded that the board should have followed through on their agreement to further assess Mr C's suitability for bariatric surgery.

Recommendations

We recommended that the board:

• consider prioritising Mr C's assessment for surgery under section 3 of the national obesity treatment best practice guide (July 2012); and
• apologise to Mr C for the delay in his psychological pre-assessment being carried out and for the lack of information given to him about his referral to the other board.

Summary

Ms A was removed from the practice's treatment list. She believed this was inappropriate, and complained to the practice. She remained dissatisfied when she received their response and her partner (Mr C) complained to us on her behalf.

When we investigated, we found that the practice had not met the requirements of the relevant regulations for the removal of a patient from a treatment list. We upheld Mr C's complaint that Ms A's removal from the practice list had been inappropriate, and made recommendations to address this.

Recommendations

We recommended that the practice:

• apologise directly to Ms A that she was inappropriately removed from their treatment list; and
• review their procedures on the removal of patients from their treatment list to ensure that they comply with the relevant regulations, guidelines and guidance.

Summary

Mrs A was an 87-year-old nursing home resident. She had Alzheimer's disease and a history of breast cancer and heart disease.

Mrs A was admitted to hospital after being found in the early hours of the morning on her bedroom floor after a fall. She was found to have fractured her hip. She had surgery in hospital the next day, and was discharged back to the nursing home two days later. Mrs A fell again in hospital on the morning of her discharge, but was medically assessed as uninjured.

Mrs A's daughter (Mrs C) believed that, despite providing one-to-one nursing to the best of their ability, staff at the nursing home struggled to manage her mother's care after her discharge because of her medical condition, impaired mobility and deteriorating cognitive function (the ability to think, concentrate, formulate ideas, reason and remember).

Mrs A fell again, from a chair, six days after being discharged from hospital. She had fractured her arm and was readmitted to hospital. Several days later, she was transferred to another hospital for palliative care (care to prevent or relieve suffering) and died shortly after.

Mrs C said that hospital staff failed to assess her mother's cognitive impairment and individualise her care and treatment, particularly in relation to falls prevention.

Mrs C held welfare power of attorney for her mother and believed that staff failed to communicate with her as they should have, about Mrs A's discharge. As a result of this, Mrs C said that Mrs A was improperly discharged and the board failed to ensure that adequate arrangements for later support were in place. Mrs C also said that they failed to implement an effective falls care plan for her mother, and failed to fully take into account her high falls risk on discharge. As a result, Mrs C believed that Mrs A's fall from the chair, which caused her severe suffering and proved fatal, was avoidable. Finally, Mrs C believed that the board misrepresented the findings of a visit by the Healthcare Inspectorate, a regulatory body. In responding to her complaint, the board said that it was found that ‘a high standard of care was being delivered to elderly patients with cognitive impairment’.

After taking independent advice from a medical adviser, who specialises in mental health issues, we upheld all of Mrs C's complaints. We found that the board's communication with Mrs A's family was unreasonable both in relation to the Adults with Incapacity (Scotland) Act 2000 and to discharge. We considered that a lack of meaningful consultation with Mrs C and the nursing home led to a significant personal injustice to Mrs A, as her discharge was ineffectively planned and coordinated and failed to ensure that her needs were met. We were also extremely concerned about the overall failures in communication, given the importance of meeting the needs of patients with dementia in every aspect of care, treatment and clinical management.

We found that the board failed to comply with their falls prevention policy in a number of important respects. This was unacceptable. The risks of falling cannot be completely eliminated, but can be minimised by careful assessment and clinical management. Some measures were implemented for Mrs A, but additional measures should have been taken to further reduce the risks, given the potentially significant and severe consequences of a fall injury to an elderly person with dementia.

We found that there were a number of significant failures by the board in addressing Mrs A's mental health care needs. We were particularly concerned that Mrs A’s cognitive function was not formally tested during her stay in hospital. Finally, we drew to the board’s attention our finding that the Healthcare Inspectorate report had in fact highlighted the need for improvements in the areas of assessment and care-planning.

Recommendations

We recommended that the board:

• audit staff awareness of the board's policy on falls prevention and the knowledge and skills of staff relevant to its effective implementation, and take action to address any knowledge and skill gaps identified by the audit;
• review the fractured neck of femur care pathway to ensure it meets the needs of patients with dementia, in particular around assessment of cognitive functioning, pain assessment and communication under the Adults with Incapacity Act; and
• inform the Ombudsman of progress in implementing the action plan arising from the Healthcare Inspectorate report and how related clinical practice will be monitored and assessed.

Summary

Mr C complained that the board unreasonably delayed in diagnosing that his late wife (Mrs C) had mesenteric ischemia (reduced blood flow to the intestines). He also complained that they delayed in operating on Mrs C following her diagnosis and that this caused her death.

We took independent advice from one of our medical advisers, who explained that mesenteric ischemia is a very difficult condition to diagnose. It is usually diagnosed by excluding other causes and this can take some time. We were satisfied that the board carried out appropriate assessment and investigations to exclude other causes to diagnose Mrs C's condition. However, we found that the diagnosis of mesenteric ischemia should have been considered sooner in view of the fact that Mrs C was known to have vascular disease.

The board decided that operating on Mrs C would be very high-risk, and referred her to another board for advice. Although we found that this was in itself reasonable, there were delays in obtaining the advice. It was then decided that Mrs C required a major surgical operation, which would carry some significant risks to her health. The surgeon who had been managing Mrs C's care was due to leave the board at that time. He referred Mrs C to another board and asked that they take over her management. Again, given the circumstances, we found that this was reasonable. However, we found that the referral should have been more urgent and the board should have pursued this when no response was received from the other board.

Mrs C's condition deteriorated further before she was seen by the other board. She underwent an emergency surgical procedure and was admitted to intensive care. A second procedure was carried out to review her bowel. It was decided that the surgical options were limited, and the surgeon could not carry out a bowel resection (partial surgical removal). Mrs C subsequently passed away.

Our adviser said that Mrs C was a high-risk candidate for surgery and it was likely that this would have been unsuccessful. It could also have led to other parts of her system being compromised, even if it had been undertaken at an earlier opportunity. It would have been inappropriate to carry out surgery without obtaining advice from the other board. Although we upheld Mr C's complaints, as we found that there had been delays by the board, both before and after Mrs C was diagnosed with mesenteric ischemia, our adviser said that the outcome was unlikely to have been different if these delays had not occurred.

Recommendations

We recommended that the board:

• make the clinical staff involved in Mrs C's treatment aware of our finding on this matter; and
• review the management of Mrs C's case and consider how they can ensure continuity of care when a patient is referred to another board for treatment.

Summary

Mr C visited a hospital accident and emergency department (A&E) with lower back and left leg pain and increasing periods of numbness. He was discharged with an appointment to see a consultant twelve days later. Within a short time of being discharged, however, Mr C returned to hospital as he was experiencing increasing pain and numbness. Examination showed that there had been some loss of sensation and Mr C was admitted. An MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone) was carried out the next day, and showed a central prolapsed disc (when the centre of a disc in the spine pushes out into the spinal column) and Mr C was urgently transferred to a neurological unit at another hospital. The following day, a laminectomy (a surgical procedure to remove a portion of the vertebral bone called the lamina) and a discectomy (surgical removal of disc material that presses on a nerve root or spinal cord) were carried out.

Mr C complained that he should not have been sent home after he first attended A&E. He believed that if he had been kept in hospital the first time, his post-operative problems would have been reduced. We investigated the complaint and all the relevant documentation and clinical records were carefully considered. We obtained independent advice from a clinical adviser, which we also took into account. The adviser said that Mr C's first examination showed a decreased sensation in the area surrounding the anus and genitals and, so the diagnosis of partial or incomplete cauda equine syndrome (a very large disc prolapse that may cause pressure on the nerves supplying the bowel and bladder, leading to incontinence) should have been considered. Unless this is dealt with very quickly, within hours, the chances of recovery are low, and it was not considered. We upheld the complaint, noting that Mr C should have had an immediate MRI scan.

Recommendations

We recommended that the board:

• formally apologise to Mr C for their failure in this matter; and
• review their management pathway for suspected cauda equina syndrome and define the indications for an emergency MRI scan.

Summary
Mr C, who is a prisoner, complained about the prison health centre's complaints handling. Mr C had submitted a formal complaint about the health care and treatment he had received. However, the health centre responded to the complaint under the feedback procedure, not the complaints procedure. The board said that this was in accordance with the approach for all informal complaints, which should be dealt with by local response. They said that any further complaints or feedback forms would be dealt with through the formal complaints procedure. They also commented that, where possible, complaints are addressed at the point of contact, unless the complainant wished to pursue their complaint through the formal complaints procedure.
 

We considered that as Mr C had submitted a formal complaint, it should have dealt with as such. We were concerned that the board were using the feedback procedure as an additional level to the NHS complaints procedure. This is restricting, and over-complicates prisoners' access to the NHS complaints procedure. It is clear that Scottish Government guidance does not require NHS users to complete the feedback procedure before accessing the complaints procedure. This should also apply to people receiving NHS care and treatment whilst in prison.

Mr C went on to make a further formal complaint to the health centre. However, he said that they returned the complaint form to him, and explained that it was not answered, along with several others, due to the fact that they met him to see if the issues could be dealt with. They said that during the meeting, Mr C withdrew the complaint after agreeing that the problems were resolved. However, we found no records to support this in the evidence we received from the board.

Mr C then submitted a further complaint to the health centre, but did not receive a response. The health centre should have sent this complaint to the board for response. Mr C contacted the board, who advised that they had not received it from the health centre. The board could provide no explanation as to why this complaint and the previous complaint were not submitted to them in line with their complaints procedure. In view of these failings, we upheld Mr C's complaint.

Recommendations
We recommended that the board:

• consider our findings and review the handling of prison healthcare complaints to ensure that they are being dealt with in line with the good practice outlined in the Scottish Government Guidance 'Can I help you?'; and
• issue a written apology for the failings identified.

Summary
Ms C is an advocate for the sister of the late Mr A. Ms C complained that the care and treatment that two medical practices provided to Mr A was unreasonable.

Mr A had attended the first practice until March 2010, when he changed his registration to the second practice. At the time of the events complained about, the practices were independent of each other. The second practice has since taken over management of the first practice.

Mr A began to attend his GP at the first practice in July 2009, reporting recurring bouts of diarrhoea. Blood tests suggested that he had an infection of helicobacter pylori (a bacteria commonly found in the stomachs of middle-aged people which has been linked to ulcers and some stomach cancers). Mr A was treated with three different types of antibiotics and was advised to eat a bland diet. He continued to report symptoms of altered bowel habit, and then weight loss, as his food and drink options became more limited.

Mr A was eventually referred to hospital in February 2010, and was diagnosed the following month with Mantle Cell Lymphoma (MCL - a cancer of the white blood cells). He was treated by both his local NHS board and the specialist team at another board. In June 2011, he was told that his test results were clear.

In August 2011, however, Mr A's symptoms returned and he again visited a GP, this time at the second practice. Tests initially suggested that the MCL had returned. However, after a liver biopsy (where a sample of tissue is taken for examination in the laboratory), Mr A was told that he had a second type of cancer, incurable small cell lung cancer. This had already spread to his liver. Mr A died some three weeks later.

As part of our investigation, we took independent advice from a medical adviser. We found that in July 2009 the North East Scotland Cancer Co-ordinating and Advisory Group had issued guidance for GPs on the action to take and when to take it, when patients reported symptoms suspicious of cancer. A symptom that should have triggered an urgent referral to a specialist colorectal surgeon (a specialist in disorders of the stomach and bowel) was where a patient reported altered bowel habit for more than six weeks. Mr A had reported his symptoms for some seven months before he was referred. Even then, he was given only a routine referral to a general surgeon, rather than the urgent specialist referral described in the guidance. We upheld Ms C's complaint and made recommendations to address these failings.

Recommendations
We recommended that the practice:

• apologise for the failings identified;
• review a sample of clinical records from all GPs at both practices to assess the standard of record-keeping in line with General Medical Council guidance, and if deficiencies are found these are to be discussed at the GP(s) annual appraisal(s) and if necessary appropriate training to be undertaken; and
• ensure that all GPs in both practices are aware of and take cognisance of the local guidance on urgent referral of symptoms suspicious of cancer.

Summary

Mr C complained about root canal treatment that he had received. He told us that after it he was left with periodic pain for two years, and that he had to pay for corrective work to be carried out by a new dentist.

After taking independent advice from a dental adviser, we upheld Mr C's complaint. Our investigation found that the standard of treatment he received was inadequate. The adviser said that an x-ray taken after the treatment showed that the dentist had not completely filled the root canal, leaving space that could then act as a possible further source of infection, and that led to Mr C's problems. We also found that there was a lack of information in the dental records and no record of any discussion with Mr C of the options, risks or warnings given in advance of treatment. In addition, there was no evidence that x-rays taken had been graded or that any report on the x-rays was written.

Recommendations
We recommended that the dentist:

• apologise to Mr C for the failings identified in this case;
• refund the cost of treatment required by Mr C from another dental practice;
• ensure that dental records are in accordance with General Dental Council standards; and
• provide the Ombudsman with an undertaking that she would address the concerns raised in this complaint through her continuing professional development.

Summary
Mrs C complained about the care and treatment that her father (Mr A) received from the board during the four months it took to provide a definitive diagnosis of pancreatic cancer (cancer of the pancreas - a gland in the digestive system). Mr A had been attending his medical practice, and they referred him to hospital for a range of tests. When the test results indicated the possibility of pancreatic cancer, Mr A was referred on an urgent suspected cancer pathway (a route into further treatments which are not available to GPs directly) for a scan. Following this, his case was discussed at a team meeting, and he was referred on for another specialist scan. The results of this test were reviewed at further team meetings, which identified a need for a specialist form of endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). Mr A had to wait four weeks for this test, and was given a final diagnosis of pancreatic cancer four months after he first attended his GP. During his hospital visits, he was seen by a clinical nurse specialist three times, but never had a clinic appointment with a consultant.

We obtained independent advice on this complaint from two medical advisers. Their advice indicated that pancreatic cancer is difficult to diagnose, so it took several tests to get a diagnosis. In Mr A's case, there were no significant delays in delivering the tests or results. However, we upheld Mrs C's complaint as our investigation found that the lack of contact with a consultant indicated a lack of good patient care. Mr A's needs and concerns were not kept at the heart of the process, and this made it more difficult for him and his family to accept the apparently slow progress in reaching a diagnosis.

Recommendations
We recommended that the board:

• conduct a significant event analysis around the substance of this complaint, particularly in relation to the conduct and role of doctors and specialist nurse practitioner in the delivery of diagnostic service, taking into account our advisers' concerns on this issue;
• ensure that the findings of this complaint become a significant part of the relevant consultant's next appraisal; and
• issue an apology to Mr A for failing to provide him with appropriate care and attention while he was undergoing diagnostic tests.