Upheld, recommendations

Summary

C complained about the board's decision to discharge their late parent (A) from University Hospital Monklands. A had metastatic cancer (cancer that has spread from the part of the body where it started) and had been admitted to hospital with blood in their urine. A was treated with antibiotics and antifungals, however, their infection markers remained elevated. As A showed no other signs of infection, their elevated infection markers were attributed to their cancer and they were discharged home. A was readmitted to hospital the following day with a deep vein thrombosis (DVT, blood clot in a vein). Their condition deteriorated and they died eight days later.

C complained that A had been discharged from the hospital before they were fit to return home. C also raised concerns about the hospital staff's communication regarding A's condition and discharge. C considered that failings by the board meant that A endured unnecessary suffering which distressed family members.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We were satisfied that the hospital staff communicated clearly and regularly with C throughout A's admission to the extent that C was kept informed as to how A was fairing on the ward. We were also satisfied that nursing and clinical staff appropriately monitored and recorded changes in A's mobility and attempted to provide physiotherapy when A was willing and able to participate.

We found that, in the days before A's discharge, C had raised concerns with the nursing staff regarding A's foot being swollen. We noted that this should have raised the suspicion of a DVT specifically and that investigations should have been carried out prior to A being discharged. Whilst the nursing staff advised C that their concerns would be passed on to the medical team, we found no evidence of this happening and concluded that an opportunity was missed to investigate and diagnose A's DVT prior to their discharge. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards setout 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 developed an infection following a wisdom tooth extraction, which was not diagnosed and subsequently spread to their brain. C was reviewed in hospital on several occasions, including out-patient reviews by oral and maxillofacial (OMF) surgeons (specialists in treating diseases and injuries of the mouth and face) and an in-patient admission to Victoria Hospital. C questioned how the infection was missed on so many different occasions by so many different people.

The board indicated in their response that there were no clinical signs which led them to suspect bacterial infection, and jaw joint problems were being considered as the cause of C's symptoms. C was then suspected, during their in-patient admission, to have viral encephalitis (inflammation of the brain). A plan to carry out an MRI wasn't pursued due to noted improvement in C's condition. The responsible consultant reflected that an MRI should have been performed during the admission, and that not doing so may have delayed the identification and treatment of the infection in C's brain.

We took independent medical advice from a consultant OMF surgeon and a consultant physician. While it was noted that C's infection presented atypically and was difficult to diagnose, their C-reactive protein (CRP, inflammation marker) was raised when they initially presented and this wasn't acted upon. A CT scan also showed subtle signs of infection but this wasn't picked up at the time. An urgent out-patient MRI was requested to look for joint problems and not to exclude infection, otherwise it may have been carried out sooner. We also found that the subsequent in-patient assessment didn't give due care and attention to C's recent wisdom tooth extraction and hospital attendances. It was agreed that the failure to pursue an in-patient MRI contributed to the failure to correctly diagnose and appropriately treat C's infection. We considered that the decision to discharge C with a persistent headache was unreasonable. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to diagnose and treat their infection earlier. 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:

• This case should have joint Mortality & Morbidity review. The findings of this investigation should be presented, to ensure relevant learning for staff from the OMF service, radiology and medicine.

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 did not take reasonable action in response to their late spouse (A)'s symptoms and condition. A had a long history of degenerative disc disease affecting their spine (when normal changes that take place in the discs of your spine cause pain) and a history of stomach cancer. A visited or contacted the practice several times over three months regarding pain in the neck and shoulder, numbness in the right hand and jerking of the right leg. Tests were undertaken, medication and therapies prescribed and a referral to an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was made. Following a fall at home, A was admitted to hospital where a spread of cancer to A's spine was diagnosed.

A died shortly after C submitted a complaint to the practice about their response to A's symptoms and condition over the previous few months. In response, the practice recounted the actions they had taken in response to A's visits and contacts in their final months, highlighted blood tests whose results did not indicate any significant abnormality or spread of cancer and explained that A's symptoms were relatable to their ongoing diagnosis of degenerative cervical disc and spinal stenosis (a condition where the space around the spinal cord narrows, compressing a section of nerve tissue). The practice advised that a significant case review had been carried out. This had highlighted that A's orthopaedic referral could have been upgraded to urgent when it was clear A's symptoms were not being controlled, but stated that it was doubtful this would have had any impact on the outcome. C was unhappy with this response and brought their complaint to this office.

We took independent advice from a GP. We found that the practice took reasonable action in response to A's symptoms and condition until a point. However, when it was clear that A's symptoms were not being controlled and began to worsen, the practice's actions were unreasonable. We found that the potential significance of test results reported to the practice and the potential link with A's symptoms were not reasonably recognised by the practice until they reviewed A's care and treatment as a result of our investigation of the case. Therefore, we upheld C's complaint. However, while we noted that earlier action by the practice may have led to an earlier admission to hospital, it was extremely unlikely to have prevented A's death.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. The apology should make clear mention of each of the failings identified, whether that was identified by the practice or this office. 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 practice should review how it deals with blood samples that are significantly outwith the normal range. This would include consideration about how they are communicated with the patient, how they are highlighted in the notes and how they are followed up.
• The practice should review their current policy on home visiting patients who are too frail or too unwell to attend the practice to ensure there is a clear criteria for accepting or refusing a home visit and that safeguards are in pace when a home visit request is turned down.

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 on behalf of their late spouse (A) who was admitted to Ninewells Hospital. A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR, a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place some time after their admission and they died a week later.

C complained that clinicians failed to discuss the DNACPR with family prior to this being put in place and, when they were consulted, the family were clear that they were not in agreement with it. The family also complained that the DNACPR form was only signed by one clinician, rather than the two required for the form. C considered this was further evidence that the DNACPR decision was taken incorrectly.

In response, the board said that the decision to put a DNACPR in place was made following discussion at the multi-disciplinary team meeting, the records did not show any disagreement by the family at the time and the form was completed by one of the junior medical staff, on the lead consultant’s instruction.

We took independent advice from an appropriately qualified adviser. We found that the board failed to follow appropriate processes and procedures in relation to the implementation of the DNACPR, in as far as they failed to both adequately document conversations with family members, and to complete the required paperwork correctly. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow appropriate processes and procedures in relation to the implementation of the DNACPR, more specifically for failing to adequately document conversations with family members, and also in failing to complete the required paperwork correctly. 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:

• Clinicians involved should reflect on the complaint and identified failures with respect to the implementation of the DNACPR, specifically documenting communications with family and completing the relevant paperwork and forms.
• Medical professionals and clinicians are aware of, and adhere to, relevant professional standards and guidance with respect to maintaining clinical records and recording decision-making.

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 had been treated for chlamydia and gonorrhoea (two types of sexually transmitted infection) by the board. C continued to feel unwell and attended an appointment at the board. C was concerned that they were not physically examined or tested for pelvic inflammatory disease (an infection of the female upper genital tract, including the womb, fallopian tubes and ovaries) and that they were advised to isolate with a possible COVID-19 infection.

We took independent advice from a consultant in sexual and reproductive health with a background in hospital gynaecology (female reproductive system). We found that C reported symptoms which were consistent with pelvic inflammatory disease. In the circumstances, it was unreasonable that a physical assessment was not performed, or as an alternative, empirical antibiotic therapy commenced for possible pelvic inflammatory disease. It was unreasonable that further steps were not taken to assess for and exclude pelvic inflammatory disease as a possible diagnosis in this case, prior to providing the advice regarding self-isolation for possible COVID-19 infection.

In light of the above, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not performing a physical assessment for pelvic inflammatory disease or as an alternative commencing empirical antibiotic therapy. 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 who present with abdominal pain and fever, in the context of a recent sexually transmitted infection, should be physically examined and/or commenced on empirical antibiotic therapy.

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 parent (A). A attended Raigmore Hospital with symptoms including lethargy, bruising and weight loss. A was found to be severely anaemic (a low level of red blood cells) and had a very low platelet count (small cells that help the blood to clot). A was asked to attend Caithness General Hospital for regular platelet treatment and further investigations into their condition.

Around a month later, A became unwell and they attended A&E at Caithness General Hospital. A was discharged home the same morning. Two days later, C became concerned about A as they looked 'black and blue'. C phoned the consultant haematologist (a specialist in diseases of the blood and bone marrow) for advice. They told C to contact A's GP if they were concerned about A's condition. By the next morning, A had become very unwell and they were taken to Caithness General Hospital by ambulance. A was found to have intracranial bleeding (bleeding within the skull). A was airlifted to Aberdeen Royal Infirmary that evening for platelet treatment. A's condition continued to worsen and they died the next day.

We took independent advice from a consultant haematologist. We found that there was no evidence A was told about the possible complications they could develop from their low platelet count, such as the risk of internal bleeding. We found A was unreasonably discharged home from Caithness General Hospital, as they should have been referred for emergency platelet treatment. In relation to C's phone call to the consultant haematologist, we acknowledged a GP should normally be the first point of contact. However, we considered appropriate action was not taken in response to the phone call, given C had described signs of A having internal bleeding. For these reasons, 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:

• If a patient/family member contacts a clinician with information that indicates they are seriously unwell, this should be recognised and appropriate action should be taken.
• Patients at risk of developing serious complications should be given clear information about that, and it should be appropriately documented in their medical records.
• Patients, who are found to have low platelet levels, should be referred for timely and appropriate platelet treatment.
• The board’s complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is 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 about the standard of medical care and treatment provided to their late parent (A) during an admission to Queen Elizabeth University Hospital (QEUH). A was admitted to QEUH with worsening symptoms of a chest infection and a leg ulcer. When A’s condition deteriorated, medical staff decided to transfuse three units of blood. During the transfusion, A went into cardiac arrest and died. C complained that the decision to transfuse A with blood was unreasonable given their condition and symptoms, and that this led directly to their death.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A should have had a thorough clinical review prior to the transfusion being prescribed. The transfusion monitoring protocol was not followed, and the board acknowledged that this may have led to a delay in recognising A’s deterioration. We also noted that when A’s observations and condition indicated a serious concern, nursing staff should have contacted a senior doctor but instead contacted the most junior doctor on duty. We considered all of this unreasonable. We saw no evidence that the severity of A’s condition, and likely poor prognosis, was actively considered or discussed with them or their family. This would have been good practice.

We noted that after A's death the team appropriately discussed the case with the Procurator Fiscal and the death certificate review team, who stated that they would be content for a death certificate to be issued without the need for a post mortem examination. However, when this was then discussed with A’s family, they remained concerned and said they would like things investigated further. With reference to the relevant guidance, we found that the case should have been referred back to the Procurator Fiscal for further consideration. If the Procurator Fiscal had still considered there was no need to investigate, the medical team should have offered the family the option of a hospital post mortem examination. We upheld this complaint. We were satisfied that the learning already implemented by the board was appropriate and satisfactorily addressed what had gone wrong in A’s care. However, we made further recommendations in relation to the reporting of a death to the Procurator Fiscal.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to advise the Procurator Fiscal of the family’s ongoing concerns regarding A’s death, and for failing to offer a hospital post mortem. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Share this decision notice with the Procurator Fiscal for advice as to whether the board should take any further steps.

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

• Medical staff are clear about the procedures for reporting deaths to the Procurator Fiscal. In particular, in the event that nearest relatives of the deceased are concerned that medical treatment may have contributed to the death of a patient this requires discussion with the Procurator Fiscal, even if initial reporting has already been carried out.

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 attended Aberdeen Royal Infirmary after being referred by their GP for left leg pain and swelling behind the knee. Investigations revealed the presence of a Baker’s cyst (fluid-filled swelling at back of knee) and C was discharged home with no further treatment planned. The pain continued to bother C over the weekend and they sought further medical opinion and returned to the hospital six days later. This time a deep vein thrombosis (DVT, blood clot in a vein) was diagnosed and C was discharged home on blood thinning medication. C believed that the DVT must have been present at their initial presentation to hospital and that action should have been taken at that time to address their symptoms and therefore there was a missed diagnosis.

We took independent advice from two clinical advisers: a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant physician. We found that although there was no evidence of a DVT on the original ultrasound scan, staff failed to act in accordance with guidance and arrange a D-dimer test (a blood test that can be used to help rule out the presence of a serious blood clot) and a further ultrasound scan within seven days. Staff gave C advice to seek further medical opinion should their clinical condition deteriorate which C did. There was no delay to the actual diagnosis of DVT and C’s treatment regime would not have altered in the period until the second scan was performed. However, we upheld the complaint on the basis that there was a failure to act in accordance with the guidance.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow the guidance when a negative scan result was obtained. 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:

• Staff should ensure that they are aware of and follow the guidance concerning negative ultrasound findings for DVT.

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 of their late parent (A) at Falkirk Community Hospital (FCH). A had a cognitive impairment and gained access to washing-up detergent that had been mistakenly left out in the staff kitchen area. A subsequently became unwell and advice was sought from the out-of-hours (OOH) GP service prior to eventual transfer to Forth Valley Royal Hospital (FVRH), where their condition deteriorated and they died the following week. C raised a complaint with the board, seeking answers as to what happened, and the board commissioned a Significant Adverse Event Review (SAER). The board were unable to conclude with any certainty whether detergent was ingested and contributed to A’s death.

C complained to us about inaccuracies and inconsistencies in the SAER and clinical records, and also about timescales surrounding the SAER and complaint processes.

We took independent clinical advice from a nursing adviser and a GP adviser. It was not possible from the evidence available and advice obtained for us to confirm whether A ingested detergent. We found that the SAER was open, transparent and evidence-based. The report acknowledged that there were inconsistencies and inadequacies in the records. However, we considered that the SAER did not adequately probe into the contact with, and actions of, the OOH GP. The initial advice given by the GP was to monitor A, when the observations should have prompted medical review. The GP assumed these observations were incorrect. When the GP later advised transfer to hospital, this was left to nursing staff to arrange and clear advice was not provided surrounding the urgency of the ambulance request. We found that the GP deviated from standard practice and failed to provide appropriate care to A.

While the SAER acknowledged that record-keeping standards were not adhered to, we highlighted a further shortcoming in that the transfer from FCH to FVRH was not formally documented. We found that there was delay in staff completing an incident report following the detergent incident, and a delay in completing the SAER. We also found that there were delays in responding to C’s complaint, and some confusion between the SAER and complaint processes. The board acknowledged these delays and apologised that the complaint process was very protracted at such a distressing time for the family.

We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the unreasonable delay in completing an incident report, the unreasonable delays in concluding the SAER and responding to the complaint, and the confusion between the two processes, the failure of the SAER to probe sufficiently into the contact with, and actions of, the OOH GP, and the OOH GP’s deviation from standard practice and failure to provide appropriate care to A. 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 board should ensure there are clear mechanisms in place for investigating both significant adverse events and complaints, and clarity between the two processes, with adherence to the board’s SAER policy and Complaints Handling Procedure. The board’s SAER policy should align with Healthcare Improvement Scotland guidance.
• Documentation needs to improve to support safe, effective quality and person-centred care delivery. The board should ensure protocols exist for documentation of handovers and clinical contacts.
• The board should ensure that SAER investigations comprehensively examine contributory factors, and that where possible these are reviewed by someone with knowledge of the relevant speciality, as per Healthcare Improvement Scotland guidance.
• The board should ensure the OOH service has clear protocols in place for escalations to hospital for medical review, including roles and responsibilities in this regard. GPs should act with due care when receiving second hand clinical information.

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 on behalf of their parent (A) about their care and treatment at University Hospital Ayr. A was admitted to hospital after an episode where they had become unresponsive. C raised concerns that medical staff decided to change A's epilepsy medication without getting specialist input.

We took independent advice from a specialist in geriatric (medicine of the elderly) and general medicine. We found that A had not been properly assessed, that there was no clear reason for changing their epilepsy medication and that there was a lack of communication with their family about the change. We upheld C's complaint. We considered that the board had not appropriately responded to C's complaint, so we also made a complaints handling recommendation to address that.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's care and treatment and for not adequately addressing 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 an emergency setting, patients' medications for specialist conditions should normally only be changed if their diagnosis is clear, the change is unequivocally beneficial and the reasons for the change are discussed with them and/or their families/carers.

In relation to complaints handling, we recommended:

• Complaints should be responded to accurately and as comprehensively as possible, particularly when we have requested that a specific matter is addressed.

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.