Upheld, recommendations

Summary

C complained about the care and treatment provided to their late spouse (A). C complained that A had an infected toe which remained unresolved despite undergoing several months of treatment. A was diagnosed with oesophageal cancer but was unable to start chemotherapy treatment because of the ongoing infection. C said that A experienced significant pain during this time and that there was a failure to reasonably coordinate A’s care needs.

We took independent advice from a consultant orthopaedic surgeon (specialist in treatment of diseases and injuries of the musculoskeletal system) and a consultant clinical oncologist (specialist in the diagnosis and treatment of cancer). We found that the board had provided reasonable care and treatment to A over several admissions when each one was considered in isolation.

However, on one occasion, we found that an MRI scan result was not correctly reported at the time. This resulted in A receiving lesser surgery than they would otherwise have received.

We also found that the board had failed to report the incident in line with Duty of Candour legislation, or undertake an internal review process to learn from the event. We found that a more coordinated approach to A’s care may have provided a proper overview of their care needs (including pain) which were known to be complex given the number of specialties involved in A’s care. Therefore, we upheld this part of C’s complaint.

C complained that the board’s handling of their complaint was unreasonable. We found that the board kept C reasonably informed of delays.However, they did not accurately describe the failing with the MRI scan or acknowledge the impact this had on A’s surgery and treatment plan. There was also a failure during the complaint process to initiate relevant reporting and investigation processes in relation to the MRI scan reporting when this became known. Therefore, we upheld this part of C’s 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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• When an incident or harm occurs, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.
• The board should reflect on whether A’s care could have been managed differently.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with  HYPERLINK "https://www.spso.org.uk/the-model-complaints-handling-procedures" The Model Complaints Handling Procedures | SPSO .

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 treatment that their sibling (A) received from the practice. In responding to C, the practice accepted that a diagnosis had been missed. The practice also conducted a Significant Event Analysis (SEA) which resulted in learning around consideration of A’s symptoms and consideration of blood testing.

C was dissatisfied and raised their complaints with SPSO. We found that while there were aspects of the treatment provided to A that were appropriate, a number of aspects were not, including taking a blood sample before all concerns had been explored, poor recording of symptoms and examination findings, and the undertaking of a telephone consultation. Additionally we found that the refusal to undertake further blood tests in the circumstances, lack of recording of reasons for, or makers of, decisions and the failure of the SEA to explore significant decisions were also aspects of treatment that were not appropriate. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and their family 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:

• Any Significant Event Analysis undertaken by the practice fully explores all relevant decisions.
• Doctors should undertake reasonable consultations with patients and fully consider what the appropriate blood tests would be for patients.
• The standard of record keeping at the practice meets General Medical Council “Good Medical Practice” standards.

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 process followed by the board in commissioning and completing a Level 1 Significant Adverse Event Review (SAER) with respect to the care provided to their partner (A), after they had been diagnosed with Barrett’s oesophagus (a condition where some of the cells in the oesophagus grow abnormally). The SAER was commissioned following the death of A.

C complained to the board about their lack of inclusion and involvement in the SAER process. In response to the complaint, the board concluded that whilst the SAER was carried out appropriately and C had been involved in the process, they failed to adhere to their own and published national guidelines in a number of ways. The lack of an appropriate Family Liaison contact had negatively impacted communication with C during the process.

C was dissatisfied with the board’s complaints response and brought their complaint to our office. We took independent advice from a consultant hepatologist (medical doctor who specialises in diagnosing and treating liver disease) and gastroenterologist (a medical doctor who specialises in conditions affecting your digestive system)

We found that in conducting the SAER, the board had acted in the spirt of national policy and guidance with respect to including C in the SAER process. However, the board’s own policy sets more concrete standards about how communication should be managed. We found that overall C’s level of involvement with the SAER process was reasonable, but that there was issues with respect to miscommunication and managing C’s expectations in this regard. Whilst the board responded to C’s requests to meet relevant members of the SAER team, again the communications were not always consistently responded to by the board.

Issues with communication were impacted by the board’s failure to follow process and appoint an appropriate point of contact to assist C and provide them with support. Given the failure to follow process, and issues with respect to communication, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should provide the complainant with confirmation that the apologies highlighted in Recommendations 2 and 3 of the SAER will be provided.

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

• Problems identified in the management of the adverse event review will be collated and used to create a Shared Learning Notice to ensure learning is board wide.
• Work following this complaint will include that family members must be involved at the earliest point to agree the TOR and are provided with ongoing support for any review, in accordance with the board’s procedures. They must support those identified to take on the role of Family Liaison Manager to have adequate time to carry out this role to a high standard. All staff involved in the adverse event review process will be reminded, via a Shared Learning Notice, of the need to be vigilant and accurate in recording communications in relation to adverse event review management.
• A flowchart had been developed to assist staff with the management of Level 1 adverse events.

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 their attendance at the A&E after their child (A) had a seizure. C said that A’s observations (to measure vital signs like heart rate, blood pressure, and temperature) had not been taken, but that the nurse had told C that they were. C also raised concerns about attitude and behaviour.

The board’s complaint response said that the nurse had intended to reflect to C that observations had been taken by the ambulance crew, and that the nurse had triaged A and determined that A was able to wait for a doctor. C was dissatisfied with the explanations provided. The board told us that a further review of the records showed that the nurse had taken observations, but staff present concluded that there was no physical evidence of the nurse taking observations at any point at triage.

We took independent advice from a qualified nurse. The evidence suggested that observations were not carried out, and that there were failings during the triage of A to act on their abnormal heart and pulse rate promptly. Appropriate repeat observations and a Glasgow Coma Scale score were not taken. There was also a lack of clarity as to whether A was assessed as an adult or paediatric patient. We upheld this complaint.

We found that there had been record keeping failings, including records which did not match the accounts provided by the nurse, paediatric assessment tools not being completed, incorrect oxygen saturation levels having been recorded, and nursing and medical entries not being time stamped. There was also a lack of explanation for the discrepancies in the board’s accounts of observations being taken. We upheld this complaint.

We found that C and SPSO have, at times, been provided with inaccurate and inconsistent information in relation to whether A’s observations were taken. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failings in care and treatment, record keeping, communication, and complaint handling. 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:

• All documentation should be in line with GMC and NMC guidance (all records accurate, dated and signed and attributable to the person who entered the data).
• If a child is admitted then the documentation should reflect that paediatric tools and assessments have been used.
• Patients should be appropriately triaged on arrival to A&E, observations carried out promptly and accurately, findings acted upon, and GCS scoring carried out where appropriate. Observations should be appropriately recorded in the patient record.
• Reflection by staff, whether for complaint processes or revalidation, should be accurate and take into account what is reflected in the medical records. If it differs from what is in the medical records there should be an explanation provided for this.

In relation to complaints handling, we recommended:

• Complaint investigations should be thorough and identify any inaccuracies in record keeping to ensure a full and accurate complaint response is provided. Information provided to SPSO should be accurate, complete and on time. All relevant records in relation to an SPSO investigation should be provided from the outset of our enquiries. The failure to do so in this case led to delays in the investigation.

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 provide them with reasonable care and treatment. C was involved in a road traffic accident after they momentarily lost consciousness while driving. C had a phone and then a face-to-face consultation with a physician associate (PA, a healthcare professional who support doctors in the diagnosis and management of patients) who referred them to respiratory medicine to investigate possible sleep apnoea caused by hypersomnia (excessive daytime sleepiness). Another telephone consultation was held, during which the PA indicated their intention to refer C to the DVLA due to concerns that C was continuing to drive despite their advice to stop.

C was unhappy with their level of care. C disputed having been told that they must not drive, and complained that the referral was made on the basis of a suspected rather than confirmed diagnosis. They also said that they had not received fair warning of the consequences. C complained that it had not been made apparent that they were being seen by a PA rather than a GP. Lastly, C complained about the practice’s complaints handling, and the accuracy of their responses.

We took independent advice from a GP. We found that the questionnaire used to assess hypersomnia had been incorrectly completed by the PA which provided misleading results. C’s prescribed medication had not been followed up as a contributing factor in the accident and C’s significantly low pulse rate had not been identified or acted upon. We found that the PA appeared to have been acting without sufficient supervision from a GP, particularly once the complex nature of C’s situation became apparent. It would have been reasonable for C’s case to be transferred to a GP.

We also found that the referral to the DVLA had not been made in line with either DVLA or GMC guidance. Furthermore, the practice had failed to take appropriate steps to ensure that it was clear to C that they were receiving care from a PA and not a GP. Lastly, we found that there had been a failure to proactively update C on the progress of their complaint and that there were inaccuracies in the complaint responses. Therefore, we upheld C’s complaints.

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:

• A PA should be working within a defined scope of practice as determined by their employer. There should also be appropriate supervision and oversight from GPs when care and treatment is being provided by a PA. Supervision needs to take place in a timely fashion to ensure that complex cases are identified.
• The practice should ensure that all paperwork and IT systems are set up to allow for staff members to appropriately identify their job role.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS complaints handling procedure and all efforts should be made to ensure the accuracy of complaints responses. Complainants should be kept updated on their complaints and clearly signposted to the SPSO in all stage 2 complaints responses.

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.

Correction 4/3/2025

When this case was originally published on 22 January 2025, it incorrectly stated the organisation as 'A GP Practice in the Lanarkshire NHS Board area'. This was due to human error. The GP practice is based in the Forth Valley NHS Board area. We apologise for any inconvenience this may have caused.

Summary

C complained about the standard of medical care and treatment provided by the practice. C attended the practice with a lesion on their back which was diagnosed as a seborrhoeic wart (a harmless growth on the skin). C underwent cryotherapy treatment (the use of extreme cold to freeze and remove abnormal tissue) but this was unsuccessful. Therefore, the practice made a a routine referral for an outpatient hospital appointment to have the lesion removed surgically. C opted to be see a private consultant dermatologist (skin specialist) and was diagnosed with cancer. C felt that the practice misdiagnosed their skin cancer which led to a delay in receiving appropriate treatment.

We took independent advice from a GP. We found that the care and treatment C received when they first attended the practice was reasonable. However, the practice failed to record a clear description of the lesion in the medical records. This is essential to ensure that subsequent viewers of the lesion can assess whether there has been any significant change. Therefore, we could not say that subsequent care and treatment had been reasonable and upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing 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:

• When managing and treating skin lesions, the medical records should contain all relevant information to ensure that subsequent viewers of the lesion can assess whether there has been any significant change in the lesion.

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 child (A) received from a dentist. A injured their front tooth and attended their dental practice for an emergency appointment. The dentist noted there was a 1mm extrusion (tooth displacement) but decided that no treatment was needed. C complained that the tooth wasn’t treated with a splint.

The dentist said that dentists are able to use their own clinical judgement to decide whether or not to follow the guidelines in each case. In this case, the dentist decided that the tooth would recover on its own and made the decision not to splint the tooth.

We took independent advice from a dentist. We noted that there are standards a dentist should follow. This includes providing patients with treatment that is in their best interests and keeping up-to-date with current evidence and best practices. If a dentist chooses to deviate from established practice and guidance, the reason why should be recorded. We found that the dentist did not record the reasons why they decided not to follow the guidelines and they did not inform C that there were guidelines that applied in this case. We also considered that the decision not to follow the guidelines in this case was unreasonable. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform them that the treatment recommended was not in line with the trauma guidelines, failing to inform them of the reasons why the guidelines were not followed, including the decision not to splint the tooth, and failing to appropriately record the reasons why in the clinical records. 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 dentist should be aware of and familiar with the guidelines on how to manage traumatic dental injuries (https://iadt-dentaltrauma.org/guidelines-and-resources/guidelines). Dentists should follow the guidelines when managing traumatic dental injuries unless there is a specific reason to take a different approach. Dentists should be aware of how and when to record their reasoning should treatment offered deviate from the approach recommended in the guidelines.
• The dentist should be familiar, and act in line with the Standards for Dental Team (particularly standards 1.4.2, 7.1.1, and 7.1.2) as well as, the Professional Duty of Candour.

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 delays in the care and treatment provided to their spouse (A) who was diagnosed with lung cancer following an abnormal chest X-ray. C said that there was a delay in A being provided with a CT scan result by the respiratory consultant, and a further wait to be seen by the oncologist (cancer specialist) following A’s biopsy (a medical procedure that involves taking a small sample of body tissue so it can be examined under a microscope). C asked whether A’s diagnostic pathway influenced their treatment, in that patients with more curable grades of cancer were treated sooner.

We took independent advice from a consultant oncologist. We found that there was no formal pathway for lung cancer patients in place at the time. We also found that the diagnostic pathway being used, was inadequate for all patients, not just for A or other patients with high grade cancer.

We found that due to a shortage of respiratory physicians at the time, there was a delay in arranging a review with the respiratory consultant. This resulted in delays to the biopsy which delayed a treatment plan. The board have accepted that the pathway for A was delayed and have made improvements to enable patients to follow the optimal lung cancer pathway. We found that there was an unreasonable delay in carrying out a respiratory review and that this, and a lack of formal pathway, had a significant impact on A’s overall treatment plan and experience. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. 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 on behalf of their elderly parent (A). A had a known history of high blood pressure and white coat syndrome (when a patient’s blood pressure rises in response to a stressful situation, such as, a doctor’s appointment or visit to the hospital). A had been prescribed a combination of two diuretic medications (types of drug that cause the kidneys to make more urine) to treat this. During an appointment with a locum GP, it was noted that A’s blood pressure was high so they prescribed a third diuretic medication. A became unwell and attended the practice a few days later. They were then admitted to hospital and diagnosed with hyponatraemia (a lower than normal level of sodium in the blood). C was concerned that the practice prescribed an unnecessary third diuretic that led to A’s admission to hospital and that they did not perform checks on A’s bloods before prescribing this medication.

The practice said that the medications were safe to be prescribed together with close blood monitoring. They explained that they have a system in place to monitor patients who are prescribed ‘triple whammy’ drugs (a combination of drugs of different types: non-steriodal inflammatories, diuretic, and ACE inhibitors). They also highlighted that they took bloods during the consultation before A’s admission to hospital.

We took independent advice from a GP. We found that the decision to prescribe the third diuretic was unreasonable and unsafe. The consultation that took place before the admission to hospital was reasonable and bloods were gathered. However, the practice’s procedure to monitor triple whammy drugs does not apply in this case as A was prescribed three diuretics and none of the other drug types. Therefore, A’s case would not be picked up by this monitoring programme. We found that the practice should have carried out a Significant Adverse Event Review and did not acknowledge any failings in their complaint response. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to carry out a reasonable consultation on their first visit, failing to ensure that the medication prescribed was necessary and safe, failing to acknowledge any mistakes and failing to carry out a Significant Adverse Event Review, when they should have done. 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:

• When serious significant adverse events occur that could have caused or did result in harm, reviews should be carried out in line with the national guidance: Learning from adverse events through reporting and review – a national framework for Scotland.
• Clinicians should ensure that medication prescribed is required and is safe to be prescribed in combination with other medications before a new medication is issued. If required, blood monitoring should be carried out before commencing a patient on new medication.
• Temporary staff such as locum GPs should be aware of relevant practice procedures and working practices so that they may act in line with them.

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) spent two months in hospital due to extensive bruising on their arms and legs with no obvious cause. A suffered acute hip pain while in hospital and became dependent on oxygen. C complained about concerns that they had regarding many aspects of A’s experiences, including A’s discharge after a few weeks and readmission just over a week later. On the day of readmission, A had been visited by district nurses who had administered morphine to A. A died on readmission.

We took independent advice from an adviser specialising in medicine for the elderly. C complained that A was unreasonably discharged. We found that steps had not been taken to ensure that A and C had been provided with reasonable information about the medication that A had been prescribed. Therefore we upheld this aspect of the complaint. Additionally, C complained that district nurses unreasonably failed to administer an appropriate amount of morphine to A. We found that the district nurses’ should have administered an additional dose after the initial dose of morphine did not take effect. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failures in this case. 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 reflective reviews undertaken to reduce the risk of similar issues emerging in future should have included specific discussion of information about medication being provided to patients and, where appropriate, their carers/families or other support.

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.