Upheld, recommendations

When it was originally published on 22 March 2023, this case referred to a Medical Practice in the Ayrshire and Arran NHS Board area. This was incorrect, and should have read a Medical Practice in the Fife NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

C complained about the end of life care their late spouse (A) had received from the practice. A had Lewy body dementia (a progressive dementia that results from protein deposits in nerve cells of the brain which affects movement, thinking skills, mood, memory, and behaviour) and was cared for at home by C. When A’s condition deteriorated, C complained that the GP had not visited them at home to assess their decline. C also complained that there had been a delay in initiating their end of life care plan allowing access to appropriate pain relieving medication and to the community palliative care team for support.

In response, the practice said that although a GP had not visited A at home in their final weeks, a number of GPs had been in constant liaison with the district nursing team about their care and prescribing appropriate medications. They noted that their duty doctor had not been aware of, or could refer into, the palliative care team but following liaison with the district nursing team, this was progressed and A had received assistance thereafter.

We took independent advice from a GP. We found that the practice had not provided a reasonable standard of end of life care to A. We considered they should have carried out an earlier assessment of A’s palliative and end of life needs to inform better care planning, that there was an unreasonable delay in providing A with appropriate pain relieving medication, and noted that staff lacked awareness of the community palliative care team and the referral process. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of end of life 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:

• Patients experiencing a reported deterioration in their condition should be appropriately assessed in accordance with relevant national guidelines.
• Patients receiving end of life care should have their response to pain relieving medication appropriately assessed and any required changes promptly administered.

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 provide reasonable care and treatment to their late parent (A). A was admitted and discharged from hospital on two separate occasions. A died shortly after their third admission to hospital.

We took independent advice from a consultant in geriatric medicine and general medicine (a specialist in care of the elderly).

We found that while some aspects of A’s care were reasonable, particularly in relation to cardiac (heart) care, given the complexity and combination of A’s conditions, age and frailty, A should not have been discharged the day after their first admission. A should have remained in hospital given that a deterioration in their condition was very likely to occur, and as they also required further detailed assessment of their mobility. It was determined that A’s combination of problems would have required inpatient care even for a previously healthy patient and the acute exacerbation of A’s conditions would have been profound and life threatening.

We also found that there was a lack of detailed assessment of A’s mobility difficulties prior to being discharged. We found that the board failed to take account of the evidence in A’s records that they had struggled with their mobility and had needed supervision and support. We noted that an assessment of A’s mobility had been part of the medical plan at the time of their first admission. Given the severity of A’s illness, age, and the difficulty with walking, there should have been a specific and detailed assessment of A’s mobility prior to their discharge. We also found that the board failed to provide a full response to C’s complaint.

Taking account of the evidence and the advice we received, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in discharging A from the hospital the day after their admission, for failing to carry out a full and detailed assessment of A’s mobility prior to their discharge and for the failure to provide C with a full and informed response in relation to their 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:

• In similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and in line with recognised guidelines.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate.

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 provide reasonable care and dental treatment to them over a period of several months. During clinical examinations, C raised concerns about experiencing pain from a particular tooth.

We took independent advice from a dentist. We found that while treatment provided by the dental practice was, in general, reasonable, there were some missed opportunities to further investigate the condition of the tooth in question. Further investigations would have been appropriate to help determine whether the tooth was the actual cause of the pain. We found that further information obtained at subsequent appointments would have helped confirm that C’s pain was the result of a localised infection. The board accepted that in retrospect, the pain was due to the tooth that was ultimately extracted. Given the missed opportunities to further investigate the condition of the tooth in question, develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the missed opportunities to further investigate the condition of the tooth in question, for the failure to develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort. 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:

• Dentists should act in line with the Scottish Dental Clinical Effectiveness Programme's Management of Acute Dental Problems.

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 practice failed to refer them for an x-ray following a fall, which contributed to a delay in diagnosing fractured vertebrae.

C attended A&E following their injury and then attended the practice a few days later (first consultation). C then had a GP telephone appointment the next day due to ongoing pain (second consultation), and subsequently attended the practice again in person some weeks later (third consultation). C complained that their symptoms were not fully investigated and an obvious bend in their neck was overlooked.

We took independent medical advice from a GP. We found that the practice’s actions at the first and second consultations were reasonable in relying on the outcome of the recent A&E assessment, and that an onward referral for x-ray imaging was not indicated at that point. We found, however, that C’s ongoing pain should have been considered persistent by the time of the third consultation, and that their spinal tenderness should have been regarded as significant. We found that these symptoms should have been regarded as ‘red flag’ symptoms (possibly indicative of a more serious pathology), and should have triggered onward referral for imaging assessment.

Instead, C was referred for physiotherapy following the third consultation. C subsequently contacted the practice on a fourth occasion to request that this referral be expedited. A GP received this message and concluded that C did not meet the criteria for an urgent referral. The GP did so without taking a history and/or examining C. We found that it was unreasonable to make this decision without evidence. If an examination had been arranged following this fourth contact by C, it may have given rise to an x-ray referral.

We concluded that the practice unreasonably missed opportunities to refer C for an x-ray at the third consultation, as well as at the time of C’s subsequent contact regarding the physiotherapy referral. On balance, we upheld this complaint. We noted the practice had already reflected extensively on their management of C and identified things they would do differently in future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to refer them for further investigation following the third consultation, and for concluding that they did not meet urgent referral criteria without taking a history or examining C. 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 should be referred on for appropriate investigation when they present with red flag symptoms. The practice should ensure that they follow relevant guidelines and that they are aware of and alert to red flag symptoms.

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 end of life care that their partner (A) received at home from district nursing services during the final weeks of their life.

C complained that the nurses did not listen to their concerns about A’s deteriorating condition, that A’s condition was not adequately assessed and managed, and that they were not included in discussions about A’s care. C considered that there were missed opportunities to admit A for earlier hospice care.

We took independent advice from an advanced nursing practitioner. We found that the care provided to A was generally in line with recognised practice for end of life care, with review and prompt action around pain control and symptom management. However, we found that there were significant gaps in communication and clinical assessment which impacted on the care delivered to A.

While the nurses recorded C’s reported changes in A’s condition, this did not appear to have prompted any specific action or investigations. We found that there was a lack of clinical examination, and a failure to check and act upon C’s reports of excessive fluid in A’s legs. The board acknowledged that there was a failure to monitor A’s baseline observations when they began to deteriorate, and we found it concerning that this did not happen. The board also accepted that communication with A and C could have been better managed and they committed to raising this with staff. As A’s main carer, we noted that C’s views should have been central to care planning and to ensuring that the care being provided remained suitable as A’s condition changed. We found that there was an unreasonable failure to act upon C’s concerns and consider whether a need for hospice care was indicated. We therefore upheld the 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 receiving end of life care at home should be appropriately assessed and monitored in line with their symptoms and any deterioration acted on. Patients and their carers should be communicated with effectively and their views appropriately taken into account.

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 provide appropriate care for their parent (A).

C said that the lack of care resulted in A falling from their bed, while the bedrails were in place. As a result, A fractured their hip. C said that staff had been made aware that A was confused a very disorientated at the time.

We asked the board to provide an explanation as to how A was able to fall from the bed if bedrails were in place. The information provided by the board showed that A had been found trying to get out of bed on two previous occasions. This led us to question what interventions were put in place to try and prevent a fall from happening and why this appears not to have been successful.

We took independent advice from a nursing adviser. We found that the lack of a proper assessment of A’s mental capacity and their previous attempts to climb out of bed contributed to the fall incident and that this was a significant oversight. Additionally, we found that the board failed to maintain accurate and appropriate records, particularly in relation to the 4AT (Rapid Clinical Test for Delirium Detection), on the two occasions that A was found trying to get out of bed, and the fall itself. We therefore upheld the 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:

• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant nursing and midwifery standards.
• Patients should be appropriately reassessed when there is a change in their behaviour and, if bedrails are in use, consideration given to carrying out a reassessment of their use.
• Patients over 65 should be assessed in line with the board’s admission procedures including a 4AT so that a full assessment of the patient risk is achieved.

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, a taxi driver, complained about the way the council had handled their medical examination which they were required to attend to determine their fitness to DVLA Group 2 medical standards (medical standards for driver licencing refer to two groups, with Group 2 licence holders usually requiring substantially higher medical standards).

C had passed the medical examination pending the results of an Exercise Tolerance Test (ETT). However the council did not follow up on the results of this test. As such, C was unaware until their next medical some years later that their ETT had met the threshold for referral to DVLA for further consideration of their fitness to drive. C had continued to work as a taxi driver throughout this time. On recognising this oversight, C’s taxi licence was suspended to be later re-instated after an assessment undertaken by an NHS cardiologist (heart specialist) was reviewed by the council’s occupational health provider and they were considered fit to drive. In complaining to the council, C was advised the matter would be investigated internally and no further response was received, despite their requests for further updates.

We found that the council’s administration of C’s medical examination was unreasonable, noting that the ETT results had not been followed up on as they should have been, and that this oversight had not been noticed until C’s next medical examination some years later. Therefore, we upheld C’s complaint.

We found failings with the council’s complaint handling, noting they had not fulfilled their duties in keeping with the Model Complaint Handling Procedure for local authorities. Therefore, we also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to process their taxi driver licence application reasonably and for failing to reasonably respond to their 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:

• The council should ensure the status of driver licences pending further medical tests are checked to ensure they remain valid.

In relation to complaints handling, we recommended:

• Complaints should be accurately identified and dealt with through the complaints handling procedure.

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 to their late adult child (A). A had been admitted to hospital from police custody due to cellulitis in their hand. A was monitored overnight and discharged the following day. A was readmitted several days later following a cardiac arrest. On resuscitation, a cannula (a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples) was found in A’s arm dated the day of their initial admission. A’s condition deteriorated and they died a few days later.

C was concerned that A’s mental health issues were not taken into consideration and that it had been unreasonable to discharge A without these being assessed. C also believed it was unacceptable for A to have been discharged with a cannula in place given A’s known drug misuse. C believed that these failings led directly to A’s death as they had used the cannula to administer drugs immediately before suffering a cardiac arrest.

The board had carried out an Adverse Event Review (AER) following C’s complaint. This found a number of failings in A’s care. It made recommendations to try and address these.

We took independent medical advice from a consultant in emergency medicine. We found that there had been a full investigation of the case. The key learning points had been identified and actions were being taken to reduce the likelihood of a similar incident occurring in future. There was no evidence of failings which had not been addressed by the AER.

We upheld C’s complaints due to the acknowledged failings in A’s care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in the care and treatment, and discharge processes, in relation to A’s admission to hospital. 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 to the board about the care and treatment provided to their late parent (A) regarding hip problems they suffered.

A was admitted to hospital with worsening mobility having suffered a number of recent falls. Under the care of older people’s services they were reviewed by occupational therapy and received physiotherapy, before being moved to another hospital for rehabilitation. A month after being discharged, A was readmitted and underwent an X-ray CT scan. A was initially diagnosed with a broken femur. A underwent hip replacement surgery and passed away a month later.

C complained that despite being informed by the board that A had sustained a fracture of their right femur, possibly present some years prior, they were later told that A had not sustained a fracture. Nevertheless, A’s death certificate had recorded a fracture of the right femur as one of the causes of death. This confusion caused the family significant anxiety. In their complaints response the board concluded that junior medical staff had been responsible for misdiagnosing A and apologised for the miscommunication. They also apologised for the misdiagnosis having been included on A’s death certificate.

We took independent advice from a medical adviser with expertise in orthopaedics (treatment of diseases and injuries of the musculoskeletal system), and further advice from a radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that while A did not have a broken femur, the board had failed to act upon a CT scan taken some years previously that showed A was suffering from significant arthritis which therefore went untreated over the subsequent years. Additionally, the board had emphasised the role of a junior doctor in misdiagnosing the fractured femur despite the involvement of more senior management in signing off on this diagnosis. In view of these specific failings, we upheld the 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:

• Care should be taken by staff to ensure that patient records are correct and as full as they can be. Where discussions have taken place what was said should be documented. A’s case should have been discussed at the board’s Radiology Events and Learning Meeting (REALM). If this had not happened they should happen in order to highlight the importance of reporting significant osteoarthritis as an incidental finding, if it has not been depicted on prior imaging.
• The board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement.

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 provided their late parent (A) with inadequate care and treatment when they were an in-patient in hospital.

C complained to the board that they had failed to provide A with adequate personal care, nutrition and hydration. C also complained that the board had failed to accommodate A’s disabilities. The board identified failures in A’s care and apologised for these. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that more consideration should have been given to A’s minimal fluid intake, and the impact of this in terms of delirium and escalation to medical staff. In addition, we found that it appeared that more could have been done to support A in relation to their toilet needs.

Therefore, we upheld the complaint.

Additionally, we found that the board did not provide C with sufficient explanations related to the learning and improvement taken from A’s experience. We also found that the board had delayed in providing C with copies of minutes from a meeting and that no appropriate apology had been made for this. We made recommendations in light of these failings.

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:

• Where a meeting with a complainant is held to discuss their concerns, the meeting should try to ensure that full explanations of what occurred and of any learning and improvement action being taken as a result are provided to the complainant at the time. Following up on a meeting with a copy of the minutes of that meeting and the board’s final response letter should be issued to the complainant as soon as possible thereafter.

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.