Upheld, recommendations

Summary

C, a support and advocacy worker, complained on behalf of their client (A) about the board's failure to share confidential patient information with A. C said that information was unreasonably withheld and should have been shared as their safety was at risk. C also complained that the board wrongly treated A's complaint as a 'concern' and they took an unreasonable length of time to respond.

The board said that they were not in a position to share the information A had requested, however they recognised there was some learning for the clinical team and they took steps to address this. The board also said they did not treat C's initial email as a complaint as it clearly stated A wanted to “discuss their experience and concerns”. The board recognised their written response was not issued within a reasonable timescale.

We took independent advice from a mental health nurse. We found that it would have likely been reasonable and legally justifiable for some of the information A requested to be shared with them. We identified that staff were not fully familiar with the national guidance on consent, confidentiality and information sharing. We upheld the complaint.

In relation to complaint handling, we concluded that it was reasonable to treat A's initial email as a concern and a request for a meeting. However, matters became confused when the board's written response following the meeting included SPSO referral details, which inferred it was a complaint response. When C submitted a formal complaint, we noted that the board did not meet the required timescales. On that basis, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to consider whether the disclosure to A of confidential patient information was justifiable. 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, an advice and support worker, complained to the board on behalf of their client (A) who had attended A&E at University Hospital Wishaw. A had sustained severe pain and swelling behind their right eye and was concerned that they may have suffered a stroke. A was seen by the stroke team who confirmed that A had not suffered a stroke and A was discharged home with a diagnosis of severe migraine. A began to have the same problems with their left eye two weeks later and by that time still had not regained sight in the right eye. A reattended the hospital. After initially being told it was another migraine incident, which they did not accept, A was referred to another hospital and then to ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) for further treatment including eye drops and laser surgery. A has regained sight in the left eye but will not regain sight in the right eye. A had concerns about the lack of treatment provided at their first attendance at A&E.

We took independent advice from a consultant in emergency medicine. We found that the A&E doctor, although reaching a reasonable diagnosis based on some of A's reported symptoms, failed to conduct appropriate investigations on A's specific eye symptoms which had been recorded by a nurse and a paramedic at the time. This should have resulted in a referral to ophthalmology. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failure to refer them for an ophthalmology review. 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 A&E doctor should be aware of the relevant recorded findings of other health professionals when conducting a medical review of patients.

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, an advice worker, complained on behalf of their client (B) about the treatment B's spouse (A) received from the board. A had a rare form of dementia and their condition deteriorated to the point where they become a potential risk to themselves. A was admitted to hospital so their medication could be monitored and altered more effectively but they died a few days after being admitted.

B was concerned about the pain relief medication A was given in the final days of their life. In B's view, the pain medication was not administered consistently and A did not receive sufficient medication to alleviate their pain. B felt that a syringe driver should have been used to administer morphine, as they did not feel nursing staff provided pain relief medication as required.

We took independent advice on this complaint from a nursing specialist. We found evidence of good nursing care being provided and confirmed that it was reasonable for a syringe driver not to be used in this instance. However, we also noted a significant gap in the nursing records where there was no evidence of A's level of comfort being monitored. While acknowledging that there was evidence of good care being provide to A, the significant gap in some of the records and the inconsistency in the record-keeping meant we could not conclusively say what happened during this period and what condition A was in. This led us to conclude that the board failed to adequately evidence that A was monitored appropriately and provided with appropriate pain relief during this period. In light of this, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the fact that they were unable to evidence that A was monitored appropriately and provided with appropriate pain relief. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Appropriate tools should be in place to allow staff to effectively record pain experienced by patients with cognitive impairment.
• Nursing staff should comply with required aspects of record-keeping at all times.

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 spouse (A). A was admitted to University Hospital Wishaw (the hospital) with severe pancreatitis (inflammation of the pancreas). At that time, this was attributed to recent alcohol intake. They developed multi-organ dysfunction (respiratory, cardiovascular and renal) over the ensuing 24 hours, but subsequently made a slow but full recovery.

Three years later, A developed abdominal pain whilst on holiday abroad. They were again diagnosed with severe necrotic pancreatitis, which was attributed to raised triglycerides (a fatty substance similar to bad cholesterol), rather than alcohol. It was subsequently documented that they had not drunk alcohol since the earlier episode of pancreatitis. They were admitted to an intensive care unit, intubated and ventilated and managed with conservative supportive therapy. An ultrasound scan during this admission did not show that they had any gallstones. Once A was sufficiently well to travel, they were transferred to the hospital, where they remained until discharge.

A subsequently had an ultrasound and this demonstrated a thickened gallbladder containing sludge. They then underwent cholecystectomy (gallbladder removal).

C complained on behalf of A that the board unreasonably delayed in performing a test to establish the cause of A's pancreatitis. We found that the board failed to follow national guidelines by not performing ultrasound scanning at the time of A's first admission to hospital with acute pancreatitis. Ultrasound scanning might have resulted in the identification of biliary sludge within the gallbladder at that time and prompted gallbladder removal, thus potentially avoiding the more severe episode of recurrent acute pancreatitis. It should also be stressed, however, that a negative scan at that time would have been unlikely to change A's subsequent clinical course. There was little documentation of discussions with A and their family. In view of these failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to perform ultrasound scanning during A's first admission to hospital and the lack of documentation of discussions with A and their family in relation to the cause of the pancreatitis. 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 cases where the cause of an illness or disease is unclear, or where a diagnosis potentially confers a degree of stigma to the patient, tactful discussions should take place between the medical team and the patient and their relatives with such a discussion being carefully documented afterwards.
• Patients presenting with acute pancreatitis should undergo ultrasound scanning during their admission in order to consider gallstones as the potential cause.

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 was referred to a consultant obstetrician and gynaecologist (specialises in the medicine of the female genital tract and its disorders) regarding a skin lesion they had on their vulva. At the first appointment, the consultant removed the lesion under local anaesthetic. C complained to the board that the consultant decided to remove the lesion without properly examining it, that proper anaesthesia was not applied, and the consultant and nurse demonstrated a lack of preparedness.

The board provided assurances that the consultant did examine the lesion and proceeded with the procedure after discussing the options with C. Additional anaesthesia was applied when C said they could feel the incision. The board also explained that equipment had to be retrieved from the theatre.

We took independent clinical advice and reviewed the medical records. We found that the consultant failed to offer a third treatment option which was to have a smaller biopsy taken for the purpose of making a formal diagnosis and arranging a full excision at a later date. This may or may not have been the best choice, however it would have allowed C to make a more informed decision. There was no evidence to suggest C was not examined properly and we noted the consultant did apply further anaesthesia when C reported feeling pain. Overall, we concluded the General Medical Council principles of decision-making and consent were not fully met and as such the care and treatment provided was unreasonable. We upheld the complaint.

Recommendations

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

• All procedures should be carried out following full discussion and informed consent.
• The board should consider using leaflets to supplement the verbal information given to the patient at the time of biopsy with clear instruction on what to expect and how to obtain advice after going home.

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 support and advocacy worker, complained on behalf of their client (B) in relation to care and treatment provided by the board to B's parent (A). C complained that the board had delayed in performing a CT scan when A presented at Belford Hospital with symptoms associated with a stroke. When a CT scan was performed four days after A's admission, it confirmed that A had suffered a stroke.

C also complained that the board again delayed investigating symptoms suggesting that A had suffered a further stroke when A was re-admitted to Belford Hospital the following month. A CT scan performed three days after A's re-admission showed that A had suffered a new stroke or a worsening of the previous one. C also said that the specialist stroke team based at another hospital had not been contacted for clinical input in A's case.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that, in relation to A's first admission, A was not examined with sufficient care and that the clinicians involved did not act upon symptoms commonly associated with a stroke. As a result, performance of a CT scan had been unreasonably delayed. In relation to A's second admission, we found that A's new symptoms were also inadequately investigated, which led to an unreasonable delay before a further CT scan was performed. We also noted that A's clinical records indicated A's case would be discussed with the specialist stroke team at another hospital but this did not appear to have taken place. We upheld C's complaint but were unable to conclude if A's outcome had been made worse as a result of the shortcomings in the care provided.

When reviewing the complaint, we also found that the board's investigation into C's complaint was unreasonably delayed and that C was not provided with sufficient information about the reasons for the delay or a revised timescale as to when the investigation would be completed.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in performing CT scans following A's admissions to hospital, the failure to fully consider the possible causes of A's stroke and the failure to seek input in A's care from the specialist stroke team. 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 relevant clinicians should reflect on the standard of care and treatment provided to A and give consideration as to where improvements could be made in their practice to ensure that (i) symptoms of stroke are adequately investigated as soon as possible; (ii) once a diagnosis of stroke is made, consideration is given to the possible causes of the stroke in accordance with SIGN and NICE guidelines; and (iii) input from stroke specialists is obtained in clinically appropriate cases.

In relation to complaints handling, we recommended:

• Where a response to a complaint cannot be provided within an agreed timescale, the complainant should be provided with adequate information to let them know the reasons why the timescale cannot be met. In such circumstances, complainants should also be provided with an updated timescale as to when they can expect to receive a response. Where an investigating officer is unable to complete an investigation due to absence through long-term sickness, the complaint should be reallocated to a suitable alternative investigating officer to complete 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 about the care and treatment provided to their parent (A). A was reviewed in the A&E department of a GP led community hospital with epigastric pain (pain or discomfort right below the ribs in the area of the upper abdomen). A felt that the pain was coming from their gallbladder. Tests for a urinary tract infection (UTI) were carried out and A was admitted to a ward for fluids and treatment with an antibiotic. A few days later, the decision was taken to transfer A to another hospital. Further tests carried out there revealed A's gallbladder had perforated causing an abscess on their liver. They were then subsequently diagnosed with gallbladder cancer.

C complained about the care and treatment provided to A at the community hospital. The board said that gallbladder pain usually radiates to the shoulder which was why this was considered unlikely in A's case. A was stable but diagnosis was unclear so they were admitted for observation and antibiotics for a UTI, which had been confirmed on testing.

We took independent advice from an appropriately qualified clinical adviser. We found that A did not have specific clinical features of a UTI and urinalysis was not convincing for a bacterial infection. The clinical presentation of nausea, sweating and epigastric pain accompanied by the finding of the right upper quadrant tenderness was more in keeping with gallbladder pain and infection. We also noted that once A's abnormal blood results were known, the decision should have been taken on that same day (the day following admission) to consider transferring A to secondary care, because their clinical condition and abnormal blood results suggested something that could not be managed properly or adequately in a GP led community hospital. We also found that A was given too much IV fluid during their admission. Given A's known history of heart failure, the administering of fluid should have been regularly reviewed. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failure to acknowledge that A did not have specific clinical features of a UTI and recognising that urinalysis did not indicate bacterial infection; failure to appropriately consider gallbladder pain and infection; administering too much IV fluid during A's admission and for not reviewing this regularly; failure to take A's abnormal blood result seriously; and failing to appropriately consider transferring A to an acute hospital once their blood results were known, given their clinical condition. 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 implement clear guidance within the GP led community hospital to make clear who can be admitted along with clarity on the level of care that can be provided. The guidance should include criteria under which transfer to an acute hospital should be considered.
• The board should share this decision with the doctors involved in a supportive manner, and ask that they reflect on A's case.

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 adult child (A). A was admitted to the Royal Alexandra Hospital via A&E after four weeks of diarrhoea and vomiting where they were diagnosed with Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). It was suggested for A to have medical treatment with infliximab (a medication used to treat autoimmune disorders) which might prevent the need for surgery. This was prescribed for A and A was discharged to receive the second dose at an out-patient clinic. When A attended the out-patient clinic for the second dose, the hospital would not administer it as A had an existing infection.

A was re-admitted to hospital and a dose of infliximab was given. A was told that as they had not responded to infliximab, the board would perform a sub total colectomy (a surgical procedure to remove all or part of the colon) which would be reversible after 12 months. A had their surgery and a few days later their condition deteriorated and they required emergency surgery. It was found that A had a duodenal peptic ulcer (an open sore inside the lining of the stomach or small intestine) which had burst and caused sepsis (a serious reaction to infection). C complained about the medical and nursing care that A received.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and a nursing adviser. We found that there was a lack of clarity about whether the first infliximab dose was administered, the second dose was unreasonably delayed, there was miscommunication about A's surgery and concerns about how A's condition was monitored overnight when their condition deteriorated. There also was no evidence that a medical/surgical review had taken place when it should have. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for unreasonable care and treatment provided to A, communication failures and the lack of clarity about whether key medication was administered. 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 staff are aware of how the error in communication occurred and how to prevent a reoccurrence.
• The board should reinforce the national guidelines 'Professional Guidance on the Administration of Medicines' RPS & RCN Jan 2010 and local policy 'Safe and Secure Handling of Medicines in Wards, Theatres and Departments' NHSGGC 2008 (currently under review).

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 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.