Upheld, recommendations

Summary

C complained about the care and treatment provided by the board to their child (A) during a consultation with an orthoptist (specialist in the diagnosis and treatment of eye movement disorders) and optometrist (healthcare professional who provides primary vision care) in relation to the management of A’s strabismus (a squint) and wide-angled esotropia (inward turning of the eye). C made several complaints, including the board's failure to assess the size of the squint, failure to adequately dilate A’s irides using cycloplegic drops (drugs used to paralyse muscles in the eye), issuing a prescription for glasses based on an inaccurate refraction test result, displaying poor clinical knowledge about A’s condition and poor record-keeping. C also complained about how their complaint had been handled by the board, particularly in relation to a meeting that had taken place to discuss the complaint.

In response, the board stated that, while A’s refraction test indicated a greater amount of myopia (short-sightedness) than previous tests, differences could occur for a variety of reasons, such as the amount of dilation of the irides. In patients with dark irides, such as A, dilation could be difficult but this had been recognised by the clinicians and drops to dilate were appropriately re-instilled, with the prescription issued in accordance with the test results. The board accepted, however, that there had been communication issues between the orthoptist and optometrist but measures had been put in place to improve this. The board also agreed to amend A’s notes to reflect more accurately what had been discussed at the consultation and arrange a further review of A much sooner than had been agreed.

We took independent advice from a consultant in paediatric ophthalmology. We found that A’s refraction test results were inaccurate and should have caused the optometrist to question whether A’s irides had been adequately dilated rather than issuing an incorrect prescription. We also found that the records showed that the drops instilled by the clinicians had been administered at inappropriate intervals, which had likely resulted in A’s irides being inadequately dilated. We were critical of the board’s handling of the complaint, particularly in relation to the board taking advice from an optometrist who had insufficient clinical experience of the issues under consideration. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A’s care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Where the outcome of a refraction test indicates that a significant increase to a prescription is required, clinicians should (i) question whether the patient’s irides have been sufficiently dilated, particularly in patients with darkly pigmented irides; and (ii) consider whether it is necessary to repeat the refraction at a follow-up appointment rather than proceed to issue the increased prescription.
• Where different types of eye drops require to be administered in order to achieve dilation of irides before carrying out a refraction test, clinicians should administer each set of drops at intervals of at least five minutes.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C and their pregnant partner (A) attended a local hospital as A was experiencing abdominal discomfort. A was examined and recommended to attend the main regional hospital, advising C to drive them there. The journey time was approximately 3 hours and on arrival A was examined and advised that labour may be starting. A was later told that labour was unlikely to be starting but remained in hospital overnight and discharged the following day.

The following week, A suffered vaginal leakage and attended the local hospital where they were examined by a clinician and advised that they suspected A’s waters had broken. A was advised to go to the main regional hospital and they were told that an ambulance was not needed. C therefore drove A to the main regional hospital.

An examination at the main regional hospital revealed that A’s waters had broken and in the early hours of the following day they went into labour. Later that afternoon clinicians gave A and C a number of options: continue with natural labour, attempt a process of augmentation (helping along a labour that's not progressing as it should), or an immediate caesarean delivery (an operation to deliver a baby that involves cutting the front of the abdomen and womb). A and C both agreed to a caesarean. The procedure was carried out and the baby (B) was delivered. However, clinicians had to resuscitate B.

A scan of B’s brain three days after birth revealed a likely injury which was later confirmed as periventricular leukomalacia (PVL, a softening of white brain tissue near the ventricles which often causes problems later with muscle control and thinking or learning problems). Following repeated scans over several weeks as the cysts continued to form, this was eventually categorised as grade three level of severity.

C raised concerns with the board regarding the care and treatment that A and B had received. C met various clinicians but remained dissatisfied. The board offered to have the events subjected to an external review but terms could not be agreed and the review was not carried out.

We took independent advice from a neonatal consultant. We found that, during both admissions, the board failed to provide reasonable care to A and their unborn child and that the board failed to fulfil their obligations under duty of candour. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to provide optimal care, for failing to carry out adequate assessment, for failing to complete suitable documentation and for failing to make safe transport arrangements. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and A for failing to provide reasonable care by omitting to timeously administer prophylactic antibiotics to A on arrival at the regional hospital and apologise for the board failing to fulfil their duty of candour obligations when the antibiotic incident was identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should offer C a final opportunity to address their outstanding questions in relation to the care of A and B in a format agreeable to both parties.

What we said should change to put things right in future:

• Establish record keeping systems that prompt midwives to detail a full assessment and ensure there is cross checking with the consultant unit at the regional hospital.
• Establish a protocol for managing premature rupture of membranes in remote locations and commence treatment where appropriate, prior to transfer.
• Establish standard documentation and standard operating procedures for risk assessing pregnant women in remote locations, to determine the most appropriate mode of transfer to the obstetric units.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about various aspects of the treatment provided by the board to their late parent (A) who was initially admitted to Glasgow Royal Infirmary with a fractured hip following a fall. A was subsequently discharged after surgery and received care at home from district nurses. However, A developed an infection at the site of their surgical wound and was readmitted to hospital, where they underwent several further surgeries to control the infection. A went on to develop further infections and subsequently died.

C complained that there had been a delay in carrying out surgical repair of the hip, that A had been discharged without appropriate physiotherapy follow-up, that an out-of-hours GP had failed to readmit A to hospital sooner and that nursing staff were unaware of a surgical procedure A had undergone. C also complained that there had been a delay in referring A to psychiatry, that A developed further infections, that A’s skin had not been correctly looked after, that there had been poor communication about the decision to withdraw care and that there had been errors on A’s death certificate.

We took independent advice from specialists in orthopaedic surgery, general practice community nursing and hospital nursing. We found that reasonable care had been given in relation to the choice of surgical procedures A underwent. We also found that reasonable care had been given to the management of A's infections whilst in hospital, the level of community nursing care, the management of A’s skin, PICC line (a thin flexible tube inserted through a vein to give medicine directly into the bloodstream), referral to psychiatry and end of life care. However, we found that there had been unreasonable care provided in relation to a delay in carrying out A’s initial surgery. We also found failures by an out-of-hours GP to record sufficient detail about A’s condition and ensure A was provided with prompt antibiotic treatment, requiring A to complete two consent forms for the same surgical procedure. We further found that there was a failure to discuss with A’s family a decision taken by clinicians not to perform cardio-pulmonary resuscitation (where the heart and/or breathing is re-started if it stops) of A were it to be required. We also found instances of poor record-keeping by nursing staff and errors contained within A’s death certificate. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Do not attempt cardiopulmonary resuscitation (DNACPR) decisions should be discussed with the patient or their power of attorney/next of kin and the DNACPR form should be completed appropriately.
• Patients' death certification should be completed accurately.
• Patients' nursing care should be clearly and accurately recorded. Entries should be legible, signed and dated and the use of abbreviations should be minimised.
• Patients should be given appropriately and timely treatment by out-of-hours GPs, which is clearly recorded.
• Patients should be given clear information during the surgical consent process to ensure that they are fully informed.
• Patients with a suspected hip fracture should be appropriately investigated within a reasonable timeframe.
• The nursing staff caring for a patient should have appropriate knowledge of their medical history including their care and treatment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received from the board for their right sided hearing loss. They complained that they had been misdiagnosed and wrongly advised that a hearing aid would improve their situation, and that no surgery would help them. C later accepted a second opinion and was referred to a hospital outwith the board area where they received a different diagnosis and treatment (a bone anchored hearing aid) which they said improved their quality of life.

We took independent advice from an ear, nose and throat consultant. We found that C’s audiogram (hearing test results graph) had been unreasonably misinterpreted and C was misdiagnosed. We found that the treatment that was given (a standard hearing aid) was not suitable for C’s actual condition. We found that C should have been offered a Crosaid (a device worn behind the ear which routes sound from the affected ear to the unaffected ear), or the surgical option (a bone anchored hearing aid) which was eventually provided when C obtained a second opinion.

We also considered that C was not provided with reasonable advice regarding the use of a hearing aid, that there was a failure to take a careful history for C and pick up on the clues in the referral letter from C’s GP as to the nature of the onset of C’s hearing loss, and a failure to arrange appropriate investigations for C. We also found that there had been failures in the way in which the board had communicated with C about their hearing loss, and we were critical of the way the board investigated and responded to C’s complaint. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably advising them that they had otosclerosis (a disorder, sometimes hereditary, in which there is formation of new bone around the base of the bone of the middle ear, resulting in progressive hearing loss), when they had sensorineural hearing loss (resulting from damaged hair cells in the inner ear), failing to provide C with appropriate treatment for their hearing condition and failing to provide appropriate advice on the use of hearing aids. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informan-leaflets.

What we said should change to put things right in future:

• For the board to appropriately interpret scan results, make appropriate diagnoses in cases such as this, take into account all relevant information, including patient history/GP referral information and test results, identify and arrange appropriate investigations and provide appropriate treatment and advice on the use of hearing aid devices.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring and governance system should ensure that concerns raised are appropriately investigated, failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement. There should be a review of complaints by senior staff during the board’s investigative process.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that their late parent (A) received at University Hospital Monklands. A was admitted to hospital to have fluid drained from their abdomen but died in the hospital a few days later. C was concerned that the drain was left in too long and caused A to suffer a perforation of the bowel, and that medical staff delayed and/or failed to investigate whether A had suffered internal damage as a result.

We took independent advice from a consultant hepatologist and gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found that without a post mortem it was impossible to determine the cause of the perforation. We also found that while A's drain had been left in longer than recommended, it was unlikely that the delayed length of time the drain was left in and the subsequent perforation were related, as A did not have any immediate complications nor signs of problems from the drain for a number of days before developing a bowel perforation.

We found that the clinical action taken by the team involved in A's care at this time was reasonable. Once there was a suspicion of a perforation occurring, a chest x-ray had been carried out and this had been good practice. The board acknowledged and identified lessons to be learned and we considered the board's actions to address what occurred were reasonable. However, we found that the delay in removing the drain was unreasonable and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in removing A's drain. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• There should be good communication between the medical team (inserting the drain) and the nursing team with regards to the timing and the removal of a patient's drain.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C's elderly parent (A) was admitted to a care home to recuperate following surgery. C complained to Aberdeen City HSCP (ACHSCP) that the care home discharged A to their family home without knowing the result of their COVID-19 test and that they were not wearing a mask. The family were informed that A had tested positive for COVID-19 the day after they returned home. C also complained that the care home failed to communicate reasonably with the family about A during their admission.

In their response to C's complaint, ACHSCP acknowledged that it was best practice to have the result of the COVID-19 test prior to discharge. They explained that there was no national guidance regarding COVID-19 testing of residents being transferred from a care home to their domestic home. However, Health Protection Scotland guidance was that the risks should be discussed with the resident's family, specifically when there is an ongoing outbreak as there is a risk that the service user may be incubating the virus and could transmit to other household members. ACHSCP acknowledged communication with the family could have been better and that A was not supported to communicate with the family.

We found that there was no national guidance regarding COVID-19 testing of residents being discharged from a care home to their domestic home. However, we also found that it was evident that there was some ambiguity about what the discharge procedures should be and that there was a missed opportunity for ACHSCP and the care home to firm up their policy on safe discharging residents to their domestic home. As a result, A was discharged home having unknowingly tested positive for COVID-19 and the family were prevented from having a discussion to consider the risks.

We noted that it was accepted by all parties that A was not wearing a mask when they were discharged and that this was in breaching of COVID-19 hygiene protocols. In addition to this, we found that the standard of communication with the family fell below the expected standard. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• ACHSCP should apologise to C for the failure to communicate with the family about A's COVID-19 test to allow the family to assess the risks and for discharging A without knowing the result of the COVID-19 test. ACHSCP should also apologise for the failure to communicate with the family about A's wellbeing during their admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to fully consider an allergic reaction to a wasp sting as the cause for their blackout which occurred when driving a HGV (heavy goods vehicle). When C was taken to hospital following the incident, a tryptase test was taken (a test to diagnose anaphylaxis, an acute allergic reaction). An ECG (a test to check the heart's rhythm) showed that C had an irregular and fast heartbeat and an EEG (a recording of brain activity) showed abnormal results with potential epileptic activity. Due to these findings, C was instructed not to drive and the DVLA were informed.

We reviewed the medical records and took independent advice from an acute medicine adviser. We found that while it was reasonable for the board to arrange for further investigations given that there were a number of potential causes for C's blackout, it would have been reasonable to further investigate an anaphylactic cause for the collapse once the tryptase result was available. Instead, C decided to seek private specialist opinion and the board only referred C to an allergy specialist after a significant amount of time and correspondence from C. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to fully consider an allergic reaction as the cause for C's blackout. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Potential causes of blackouts/collapses should be fully investigated.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the care and treatment that their sibling (A) received from the board was unreasonable. A had previously been diagnosed with breast cancer and had a mastectomy (surgical removal of the breast tissue). When A became ill, the symptoms were considered to be related to irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation). A's symptoms persisted and A was admitted to hospital on numerous occasions. A scan showed a tumour attached to their kidney and they died some months later.

C complained that despite A's multiple hospital admissions and concerns that the cancer had returned, the board failed to reasonably respond to A's worsening condition and delayed or failed in carrying out appropriate investigations.

We took independent advice from a consultant colorectal and general surgeon adviser. We found that, overall, there was a failure to adequately investigate symptoms, take into account patient history, and appropriately manage A's care, including acting on findings of sclerotic bone lesions (an unusual hardening or thickening of your bone) and a failure to consider an overarching diagnosis. Whilst the board did carry out a Significant Adverse Event Review (SAER) in relation to A's care and treatment, this failed to identify all of the failings highlighted above. As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Appropriate and timely investigations, including radiological investigations, should be considered for patients presenting with abdominal pain, recurrent vomiting and diarrhoea not known to be infective and with no explanation.
• CT KUB findings (scan of the kidneys, ureters and bladder) of sclerotic bone lesion should be investigated appropriately.
• When SAERs are carried out, failings should be identified appropriately and action should be taken to ensure that lessons are learned.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided by the board to their late spouse (A) who was diagnosed with muscle-invasive bladder cancer. C complained about various aspects of the care that A received. These included delay, and ultimate failure, to carry out surgery to remove A's bladder, inappropriately high and missed doses of medication, and initial refusal to offer chemotherapy (a treatment where medicine is used to kill cancerous cells). C also complained about a failure by an out of hours doctor in identifying a deep vein thrombosis (DVT, a blood clot in a vein) that A developed and subsequent provision of insufficient information on medication used to treat the DVT. C further complained about various failures of communication as well as concerns about arrangements for visiting A due to the Covid-19 pandemic and end of life care.

We took independent advice from medical advisers with expertise in oncology (cancer specialist), urology (a specialty in medicine that deals with problems of the urinary system), general practice and community nursing. We found that A's pain medication regimen was reasonable and that the timescale for the scheduling of A's bladder removal surgery had been appropriate. We also found that decisions made about the timing of chemotherapy and communication with A had been reasonable. This included communication about A's end of life care and how rules relating to visiting A during the pandemic had been applied.

However, a number of failings in the treatment provided to A were also identified. We found that A had not been given appropriate information on the extent of their cancer, the prognosis and the potential treatment options. We also found that there had been an unreasonable delay in the discussing of A's case by the board's multi-disciplinary team, which also understated the extent of A's cancer. Furthermore, we found that A missed doses of regular medication when attending for palliative chemotherapy, that the DVT A developed was unreasonably not initially identified and, once diagnosed, insufficient information was given to A about medication given to treat the DVT.

For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients diagnosed with DVT should be given appropriate information on anticoagulants (drugs that reduce the body's ability to form clots in the blood), in line with relevant clinical guidance.
• Patients should be given a comprehensive assessment of their end of life care needs, including support for sleeping, which is then clearly recorded in their nursing records.
• Patients should be given timely, clear and accurate information about the extent of their cancer, prognosis and management options. Patients should also receive appropriate support from clinical nurse specialists, in line with relevant clinical guidance.
• Patients requiring urgent care should be referred to specialists within a reasonable timeframe.
• Patients should be appropriately referred to the multidisciplinary team within a reasonable timeframe.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided by the board to their parent (A), who was admitted to hospital with severe back pain after suffering a suspected fall and later diagnosed with osteoporosis (a condition that affects the bones, causing become fragile and more likely to break). C complained about the physiotherapy and occupational therapy assessments carried out during A's admission, the communication by staff and a lack of recognition of A's cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). C also complained about the lack of written information about osteoporosis/fragility fractures and how they should be managed after A's discharge, and A's follow up care, in particular, the failure to carry out a DEXA scan (a special type of x-ray that measures the density of bones).

In order to investigate C's complaint, we took independent advice from a trauma and orthopaedics (conditions involving the musculoskeletal system) adviser. We found that it was reasonable, in light of cognitive assessments undertaken by A, for staff to have taken the information A provided at face value. It was also reasonable in light of current practice and guidance for the board not to have provided A with written information about the management of osteoporosis upon discharge. We also found that the decision not to offer a DEXA scan was appropriate given the diagnosis, and that the appropriate treatment for this type of injury (osteoporosis/fragility fractures) was conservative management and therefore follow up care was not a requirement.

However, we identified a number of failings including that the board unreasonably delayed in starting A's osteoporosis treatment and that there were also failings in communication. In view of these specific failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the delay in starting A's osteoporosis treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• There should be a clear treatment pathway in place for patients starting osteoporosis treatment which is based on the relevant national guidance so as to avoid unreasonable delay in the start of their treatment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.