Upheld, recommendations

Summary

C complained about the care and treatment their late relative (A) received at Glasgow Royal Infirmary. A was admitted to hospital for an elective keyhole procedure (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin) to remove part of their bowel due to cancer. Shortly after, their condition began to deteriorate due to what was later found to be a bowel obstruction and they died. C said that clinicians failed to diagnose A's bowel obstruction within a reasonable time and that their communication with the family was not reasonable in light of A's deteriorating condition and their treatment decisions.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found a number of failings in the diagnostic process that meant clinicians failed to diagnose and treat A's condition (including kidney function) in a reasonable way. These failings included: lack of CT scan; not recognising symptoms indicated a bowel obstruction; continuing treatment unreasonably based on early x-ray findings of constipation; lack of clear evidence in medical records that the importance of the nasogastric tube (a tube passed through your nose and down into your stomach) was discussed with A. We also found that communication between the relevant healthcare professionals and A's family was not reasonable given the potentially catastrophic consequences of A's refusal of a relatively straightforward and potentially lifesaving intervention. We upheld both of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of medical care and treatment and for failing to ensure medical staff communicated with A's family in a reasonable way. 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:

• Review the clinical failings to ascertain: how and why the failings occurred; any training needs; and what actions will be taken (or since then have been taken) to prevent a future recurrence. Before doing so, the board should consider why a previous review failed to identify the failings.
• Ensure record-keeping by healthcare professionals is of a reasonable standard.
• Ensure timely and appropriate communication between clinicians and family members when there is a threat to life.

In relation to complaints handling, we recommended:

• Ensure board investigations identify and address incidents covered by the duty of candour with the relevant Scottish Government guidance.

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 the board provided to their parent (A) after they stepped on a rusty nail and it penetrated their foot. A was initially seen at their GP practice and was then referred to the board. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system).

C said that the board failed to provide A with appropriate care and treatment at Woodend Hospital for their painful toe. We found that A should have been seen in hospital within 12 weeks of referral, but was not seen until nearly eight months later, and after a second referral was sent by A's GP. C also said that the surgeon planned to amputate A's fifth toe during surgery, when it should have been their fourth toe. While the decision to amputate the fourth toe was reasonable, we noted that there was nothing in the medical records recording the misunderstanding about which toe was to be amputated. We also found that the specific risks of the amputation surgery were not mentioned to A at the clinic appointment at which the proposed surgery was discussed. Therefore, we upheld this part of the complaint.

C also complained that the board failed to provide A with appropriate care and treatment after their toe surgery. They said that, when A's surgical wound was not healing, the consultant failed to carry out a pulse test (test of the peripheral vascular system) on A and failed to refer them to the vascular surgeons (specialists in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) sooner. We found that A's pulses should have been assessed at the clinic appointment at which amputation surgery was discussed, and this should then have led to investigations and vascular input prior to surgery, if an abnormality had been detected. We considered that the failure to carry out this assessment was unreasonable and we, therefore, upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to deal with the referral from A's GP in a reasonable manner and see A within 12 weeks of that date; mention the specific risks of the surgery to A at the clinic appointment; record the misunderstanding about which toe was to be amputated in A's medical records; and assess A's pulses at the clinic appointment. 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' pulses should be assessed and recorded at clinic appointments, in cases where foot and ankle surgery is being considered.
• Patients should be informed of the specific risks of surgery at clinic appointments where surgery is discussed and this should be documented.
• Relevant details, including where appropriate, misunderstandings about surgery should be recorded in patients' medical records.
• The board should have appropriate systems in place to assess GP referrals in cases such as this and ensure that patients are seen within an appropriate timescale.

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 us about the care and treatment provided to their late parent (A). A was admitted to Forth Valley Royal Hospital. A few weeks later, A was transferred to Stirling Community Hospital. A developed pneumonia (a chest infection) and was transferred back to Forth Valley Royal Hospital a few days later. A's condition deteriorated and they died.

C complained about A's medical treatment; in particular, that there was a delay in responding to A's chest infection. We took independent advice from a geriatric (medicine of the elderly) adviser. We found that when A's condition worsened at Stirling Community Hospital, A should have been urgently reviewed by medical staff in case A had sepsis (a severe complication of infection). We found that when A's condition worsened significantly at Forth Valley Royal Hospital, A was not given prompt and appropriate antibiotic treatment for possible sepsis. We found that A was not reviewed by medical staff within reasonable timeframes. We also found that anticipatory care planning had not taken place with A and their family, given it was likely A had been nearing the end of their life before they had developed pneumonia. We upheld this complaint.

C also complained about A's nursing care at Forth Valley Royal Hospital; in particular, that A was not given appropriate falls care, and, that A was not given enough help with personal care. We took independent advice from an acute nursing adviser. We found that nursing staff should have formed and recorded a specific plan to address A's risk of falls at night/overnight, as that was when A was at highest risk of falling. We also found that there was a lack of evidence of regular and appropriate care rounding to meet A's personal care needs. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's medical and nursing 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:

• If a patient is particularly at risk of falls at night or overnight, a clear plan should be put in place to address this and it should be recorded appropriately.
• If a patient or their relatives/carers raise concerns about the patient's medical care, this should be escalated to the senior medical staff overseeing their care; and concerns about nursing care should be escalated to senior nursing staff.
• If a patient's condition has worsened and it could be due to sepsis, this should be recognised and treated appropriately, in line with the board's antibiotic protocol.
• Patients should be given timely and appropriate nursing care.
• Senior medical staff should be updated if their patient's condition materially changes.
• There should be safe and effective medical handover between medical teams so patients are re-assessed within appropriate timeframes.
• Where appropriate, there should be sensitive and timely discussions with patients and their relatives/carers about anticipatory care planning.

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 they received at Victoria Hospital for their broken wrist. C had surgery on their wrist but developed swelling and pain two months later. C's GP referred them back to the board but C felt that they could not wait for 12 or more weeks to see an orthopaedic doctor (a specialist in the treatment of diseases and injuries of the musculoskeletal system) on the NHS, so obtained private treatment.

We took independent advice on this complaint from a consultant in emergency medicine and a consultant orthopaedic surgeon.

C said that they were not given adequate pain relief when they first attended the hospital. We found that the timing and type of pain relief given to C appeared reasonable, but the board failed to record pain scores for C and this was unreasonable. As there was no record of C's level of pain, we were unable to conclude with certainty that C's pain was adequately controlled.

C complained that the board failed to contact them about surgery after they were sent home and advised to wait to be contacted. We found that the board failed to contact C in a timely way to advise them when their surgery would take place.

C also complained that there was a delay in the surgery taking place. We concluded that the ten day delay in C's surgery taking place was unreasonable. However, whilst acknowledging the significant pain and uncertainty experienced by patients in such cases, we found no evidence that the delay had been ultimately detrimental to C's clinical outcome.

C said that they felt they could not wait for 12 or more weeks to see an orthopaedic doctor on the NHS, so had to obtain private treatment. We did not conclude that C had no choice but to obtain private treatment, as it could not be assumed that C would have been back to driving and other manual tasks more quickly, if they had been seen sooner. However, we noted that C's GP referral should have resulted in C being reviewed within four weeks at the fracture clinic or its equivalent, with contact being made with the patient by approximately 12 days of receipt of the referral to advise them of the review.

We also found that in their stage 2 complaint response, the board failed to address the issues C raised in their complaint regarding communication about the surgery, delay in the surgery taking place and C considering they had to obtain private healthcare.

We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to record a pain score for them; contact them in a timely way to advise them when their surgery would take place; carry out C's surgery within a reasonable time; evidence that C's GP referral was assessed appropriately; and address all the issues C raised in 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 board should carry out surgery in cases such as this within a reasonable time.
• The board should have a reliable mechanism in place whereby out-patient trauma is queued appropriately and patients informed of their status timeously, particularly as some of them might be fasting.
• The board should have appropriate systems in place to assess GP referrals in cases such as this and ensure the action taken is appropriately documented in the medical records.
• The board should record pain scores for patients when they present at the emergency department.

In relation to complaints handling, we recommended:

• The board's stage 2 responses to complainants should address all the issues raised and demonstrate that each element has been fully and fairly investigated, in accordance with the NHS Model 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 told us that their spouse (A) had been under the care of a cardiologist (a specialist that deals with diseases and abnormalities of the heart) who saw them at least once a year for review appointments following surgery, until their death twenty years later. A scan taken six years before their death showed a chronic dissection of the descending thoracic aorta (a serious condition in which there is a tear in the wall of the major artery carrying blood out of the heart). Clinicians decided to manage A's condition conservatively, but C told us neither they nor A were aware of this or the findings of the scan. C was also concerned that clinicians failed to carry out regular scans to monitor A's condition until shortly before their death and that communication between different specialists had been poor.

We took independent advice from a consultant cardiologist. We found a number of failings that had an impact on the board's ability to monitor A's condition which in turn meant that their treatment plan was not fully informed. These failings included: lack of records relating to A's operation and x-rays which made interpretation of later scans more difficult; lack of follow-up on whether additional imaging and/or cardiac opinion was needed following the scan showing the dissection; results of a CT colonoscopy (a procedure that uses a CT scanner to produce detailed images of the colon and rectum) were not shared or acted upon. We also found that communication between the relevant healthcare professionals was not as effective as it should have been given A's complex clinical condition. We upheld both of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. 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:

• Ensure communication between clinicians from different specialisms is effective.
• Ensure record-keeping by healthcare professionals is of a reasonable standard.
• Ensure that significant test results are followed up appropriately.
• Feedback the findings of our investigation in relation to further tests and referrals to other specialists to relevant staff for them to reflect on.

In relation to complaints handling, we recommended:

• Ensure board investigations identify and address incidents covered by the duty of candour with the relevant Scottish Government guidance.

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 their late relative (A) received at Dumfries and Galloway Royal Infirmary. A reported that they did not feel well, had difficulty pronouncing words and were a little confused. A then had a fall at home before being taken to hospital.

A was treated for a chest infection but died the next morning. C raised a number of concerns regarding the care that was provided and the staff's attitude towards A and C.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that A's initial assessment was reasonable; they were appropriately examined, their medical history taken and their existing medication noted. However, we noted that an x-ray taken to help with diagnosis showed appearances that were more consistent with heart failure than a chest infection. From the available evidence, it appeared that A was incorrectly diagnosed as having a chest infection, commenced on a suboptimal treatment pathway and left without being monitored effectively overnight. The true nature of A's condition was only identified when the consultant attended the next morning. A died shortly afterwards.

Whilst clinically the outcome may not have changed for A, had C had accurate information about their condition, they may have been better placed to support A. We considered that the care and treatment fell below a reasonable standard and upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• That the board share this decision with the staff responsible for A's care to ensure that any points of learning are identified and acted upon.

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 they received from the board was unreasonable. C was added to the general surgery waiting list for gallbladder removal via keyhole surgery. The board determined that C would require an Intensive Care Unit (ICU) bed booked for the time of surgery, in case the operation needed to be converted to open surgery. C waited several months for surgery, and the board stated that this was due to a high level of demand for hospital services, including ICU beds. C eventually underwent surgery but did not improve postoperatively and developed a wound abscess (a painful swelling caused by a build-up of pus) and sepsis (blood infection). The abscess was drained, and C was treated with antibiotics. C raised concerns that there were unreasonable delays to their initial surgery, which allowed their condition to deteriorate. C also complained that there was not enough care taken during their two surgeries and they developed sepsis, which they considered could have been avoided.

We took independent advice from a consultant general surgeon and a nurse. We found that the sequence of events, the management of C's booking for surgery, the preoperative assessment, C's medical state, and the anaesthetic view did not support the board's statement that the delay in C's operation was due to lack of ICU beds. In addition, we found that the board failed to meet the Treatment Time Guarantee in C's case and to properly advise them of this under the relevant regulations. We considered that the delays C experienced were unreasonable.

With regard to C's surgery and postoperative infection, we found that the initial surgery and the surgery to drain their abscess was carried out appropriately. The diagnosis and management of their sepsis postoperatively was also reasonable. However, we found that there was a lack of documentation to demonstrate that medical staff discussed C's condition and management with either C or C's partner and this was unreasonable. As a result, we upheld 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 www.spso.org.uk/information-leaflets.

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

• Patients who have been admitted as an emergency, as in C's case, and require to be seen in an out-patient clinic for clinical assessment prior to surgery should receive a timely appointment.
• The board should take all reasonably practical steps to manage patients scheduled for gallbladder surgery without delay and in line with the Treatment Time Guarantee with appropriate assessment of risk for ICU beds.

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 which their late partner (A) received when they attended A&E at University Hospital Ayr. C was concerned about A's colour as they had an alcohol problem, but A was discharged by a doctor who said that an in-patient stay was not required. C felt that A should have been admitted for further assessment or treatment. C took A to their doctor a few days later as A continued to show symptoms, and they said the GP was also concerned that A had not been admitted to hospital. A died ten days after the A&E attendance and C felt that had staff taken appropriate action then A would have been more comfortable in the final stages of their life.

We took independent professional advice from a consultant in emergency medicine. We found that there were a number of failings identified at the A&E attendance which included a failure to establish the cause of A's bleeding and what their blood coagulation (clotting) status was. There were also failings in record-keeping and communication. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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 a full investigation is carried out in regards to a patient's reported symptoms and that record-keeping and communication are completed to the required 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 care and treatment given by the board to their late parent (A). They made a formal complaint to the board to which the board replied two and a half months later. They were unhappy with the reply and wrote again.

A had been admitted to Ayr Hospital where they were diagnosed with sepsis. They had previously had a heart valve replacement and were taking Warfarin (blood-thinning medication) on a long-term basis for which they required regular International Normalised Ratio checks (INR; checks used to monitor the effectiveness of the medication), especially when they were taking antibiotics.

C believed that during A's admission they were not properly cared for, that inadequate tests and investigations were carried out and that their previous medical history was not taken into account. Staff showed no sense of urgency when A's condition deteriorated.

C noted that A was allowed to deteriorate to the extent that they could not be treated and that they died as a result.

The board's view was that on admission, all of A's symptoms and history were taken into account and that they were treated reasonably, promptly and appropriately throughout.

We took independent advice from a consultant physician and cardiologist (specialises in dealing with disorders of the heart), who identified that A's INR levels were not checked in accordance with the board's standard Warfarin prescription, given that A had been prescribed new medication following the diagnosis of sepsis. When A's INR levels were subsequently checked again, they were found to be rapidly rising before being brought under control two days later. However, A's INR levels were again recorded as being too high within days, at which time A began to display symptoms of delirium. A scan of A's brain was arranged and that confirmed A had suffered a cerebral haemorrhage (bleeding from a ruptured blood vessel in the brain). A later died. Whilst it could not be said with certainty when the bleeding started, we found that the INR levels were likely to have contributed to the brain haemorrhage that A suffered prior to their death. We found that the failure to check and closely monitor A's INR levels was unreasonable and therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Formally apologise to C for their failure to follow standard Warfarin prescription guidance. 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:

• Relevant staff should be aware of and apply Standard Warfarin Prescription guidance.

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 spouse (A). A had surgery to remove their gallbladder. A's recovery from surgery was difficult but they were deemed fit enough to be discharged.

However, A had to be readmitted four days later after becoming unwell, and was discharged again two days later. A deteriorated at home and was readmitted two days later and was diagnosed as suffering from a significant bleed. A was taken to the operating theatre but died later that day.

C complained to the board that A's symptoms indicated severe illness, that they were not fit enough to be discharged from hospital and that had treatment been provided sooner, they may have survived.

The board explained to C the complications with the initial surgery, why they considered discharge was appropriate on each occasion and that the source of the bleed could only be identified during the post mortem. The board acknowledged that there had been delays in A being assessed and treated on their final admission. They apologised for the delays and explained they identified learning as a result. The board's view was that given that the type of bleed was very rare, earlier intervention was unlikely to have resulted in a different outcome for A.

We took independent advice from an appropriately qualified clinical adviser. We found that whilst there was complications with the initial surgery, and A's recovery was difficult, the care and treatment provided, including the decisions to discharge A on both accounts, was reasonable.

However, on A's final readmission, there was an unreasonable delay in assessing A, diagnosing that their symptoms were caused by a significant bleed and subsequently moving A to theatre for investigations.

Whilst earlier treatment was unlikely to have altered the outcome for A, this delay was so serious that we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay between A's diagnosis and in A being moved to theatre for further investigations to take place. 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:

• Relevant clinicians and clinical managers should reflect on this case and give consideration as to whether there are aspects of their provision for gastrointestinal bleeds and major haemorrhage pathway which may reduce the likelihood of delays between diagnosis and intervention.

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.