Upheld, recommendations

Summary

C complained that the board failed to reasonably communicate with their family when their parent (A) was admitted to hospital. A was taken to A&E following a fall at home.

A was moved to a ward following an x-ray and medical review showing that A had broken their hip. A underwent an operation later that day and remained in hospital until their discharge nearly seven weeks later. C also complained about the nursing care that A received.

We took independent advice from a nurse. We found that there was a failure to communicate with the family about the consequences of delirium. We also found that there was a failure to ensure A had access to bread/toast and milk. There was a lack of acknowledgement and details regarding A’s lost dentures, a failure to inform A or C that A had developed a hospital acquired pressure ulcer, poor record keeping and a lack of evidence of appropriate nutritional care interventions being followed. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the specific failings identified in respect of the complaint. 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:

• Where appropriate, there should be discussions with family members in relation to diagnosis, treatment and management. An appropriate record of this should also be made.
• Blankets should be available for patients on wards, particularly those that care for elderly, frail patients. When wards run out of blankets, there should be a process in place to obtain replacements without delay.
• Bread and milk should be made available on the ward in line with the Food in Hospitals specification. Toast should be made available to patients where this has been specifically agreed.
• Patients should be changed into nightwear as appropriate or offered a hospital gown where no personal nightwear is available.
• Patients experiencing delirium should be given additional assistance to help secure or monitor their personal possessions and in particular, dentures.
• Staff should be compliant with the Duty of Candour legislation and inform patients/relatives if they come to harm.
• Patient documentation should be completed to an appropriate standard and in line with the required standards of the Nursing and Midwifery Council: The Code in relation to record keeping.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring and recording. In addition, this should be appropriately documented.

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 adult child (A) received from the practice following their discharge from hospital.

C complained that A had struggled to get an appointment with a GP and that the practice failed to provide a reasonable standard of care in relation to pain management, A’s mental health needs, and follow-up with the health board.

The practice said that they were short-staffed and had been working on an emergency-only basis at the time of the complaint. When A had enquired about seeing a GP, there had been no indication that an emergency appointment was required. A was advised to phone again the next day or to attend A&E.

In respectof A’s pain, the practice said that the discharge medication had been managed in accordance with their policy and in recognition of the nation-wide shortage of the drugs prescribed. A was given an appointment to discuss pain when they reported that the medication was not working and a prescription for nerve pain was given.

In reference to A’s mental health, the practice said that this was discussed during a phone appointment. However, A had breached the practice’s zero tolerance policy during the conversation. A was issued with a warning letter after the incident but was not removed from the practice (as would be policy) in recognition of the mental health difficulties that they were experiencing.

This incident was reviewed as a part of a Significant Event Analysis Review (SEAR) and the practice identified learning to manage this type of occurrence in the future.

In respect of A’s follow-up with the health board, the practice confirmed no post-discharge requests had been made and that it was the responsibility of the hospital to issue clinic appointments.

We took independent advice from a GP. We found that the practice had reasonably managed the discharge prescription for pain medication. While A had been appropriately directed to other services when no appointments were available, we found that the messaging could have been clearer and that reception staff had unreasonably provided advice about pain medication.

We considered A’s appointment with the GP to discuss pain was unreasonable as there was a failure to document any assessment or information to support the nerve pain conclusion reached.

In terms of A’s mental health, we considered that the phone consultation had been reasonably managed, as was the decision to issue a zero tolerance warning letter. The conclusions reached by the SEAR on this matter were also reasonable. We found that the practice’s actions in relation to A’s follow-up with the hospital was reasonable.

On balance, we considered that the care and treatment provided fell below a reasonable standard and 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 report. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Advice relating to medical matters should be given by GPs or appropriately qualified members of staff.
• The practice should keep reasonable records of consultations undertaken with patients that clearly record any assessment undertaken and the basis for the diagnosis.

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 spouse (A) when they attended A&E. A had fallen from a height and injured their shoulder. A was x-rayed and diagnosed with a soft tissue injury to the shoulder and a minor head injury. A was discharged home and advised to use regular simple pain relief for the shoulder injury. A was later diagnosed with a rotator cuff injury which required an operation. C said that A should have been correctly diagnosed by the doctor in A&E and that the delay left A in significant pain and distress.

We took independent advice from a consultant in emergency medicine. We found that A should have been reviewed by a senior doctor before discharge. We also found failings in relation to a lack of follow-up and record keeping. Therefore, we upheld C’s complaint.

We also found that C’s complaint was not handled reasonably as there were clear inaccuracies in the board’s complaint response and no reflection on the failings. We made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of care at the A&E and complaint handling. 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:

• Patients who attend the A&E with a significant soft tissue injury should be provided with a reasonable standard of medical care in relation to the referral process and follow-up.

In relation to complaints handling, we recommended:

• Complaint responses should be clear that failings and their impact are recognised and that any findings from the investigation are supported by the clinical records.

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 was admitted to hospital and received treatment for a chest infection and pleural effusion (a build-up of fluid in the chest). A remained in the hospital awaiting discharge arrangements. During a visit to A, C was told that A's bed was needed for a more acute patient and that A would be transferred to a maternity ward as a boarder. C complained that A was not included in this conversation, and that the family felt pressured to accept an unsuitable move. They were concerned that it would negatively impact A’s care and wellbeing due to noise, disruption and the availability of equipment.

The board stated that A had been identified as a patient suitable for boarding and that ward moves are necessary when there is extreme pressure on capacity. The board also considered that the care provided to A was not affected by the move.

We took independent advice from a consultant specialising in acute medicine. We found that A was not considered suitable for boarding under the board's policy. We also found that there had been a failure to conduct and record a full risk assessment, and to record the reasons for this deviation from policy. There was evidence that the move caused A distress leading to a deterioration in their behaviour and acceptance of treatment. Therefore, we upheld this part of C's complaint.

C also complained that the board’s complaint response focussed on allegations of aggressive behaviour from A’s family towards hospital staff. C did not consider that this accurately represented events.

We found evidence of challenging behaviour documented in the available records. However, the board’s complaint response unreasonably focussed on these events, which were not ongoing. Therefore, we considered that the board failed to handle C's complaint reasonably and upheld this part of their 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:

• All decisions regarding boarding patients should be made following appropriate clinical considerations and a formal risk assessment. These should be clearly documented. Should a situation arise when a decision is made to deviate from the board's policy due to exceptional pressures, a clear rationale should be documented outlining why the decision has been made and how the risks have been weighed.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late spouse (A) for cardiac amyloidosis (the abnormal build-up of a protein (amyloid) in the heart).

C complained about delays in referrals, diagnosis and treatment. The Board did not uphold the complaint and considered that there had been no delay in referring A to an appropriate specialist or in their diagnosis and treatment.

C was unhappy with this response and brought their complaint to this office. C also complained that the board had failed to adequately investigate and/or respond to their complaint.

We took independent advice from a consultant cardiologist (specialist in diseases and abnormalities of the heart) and a consultant haematologist (specialist in blood and bone marrow). We found that A’s cardiology care and treatment was reasonable. However, we also found that there was an unnecessary delay in referring A for specialist haematological treatment and that this treatment was poorly documented. Additionally, we found that the communication with A’s family about A's treatment could have been better. We upheld this part of C’s complaint.

As these failures were not identified by the board, we found that the board had failed to adequately investigate and respond to C's complaint. 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 www.spso.org.uk/information-leaflets.

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

• Patients should receive appropriate and timely care and treatment that is in line with relevant guidance. Where a patient has been referred to the National Amyloidosis Centre (NAC) and advice is awaited, appropriate and timely reviews of the patient should be carried out and where clinically necessary, the patient’s case should be prioritised.
• Communication with a patient and their extended family about their care and treatment should be proactive, clear, and timely.
• Patient records should be accurately completed with the appropriate level of information included, in accordance with the relevant medical and nursing standards.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the relevant complaint handling guidance when investigating and responding to complaints. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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) during an admission to hospital. C complained that the board had failed to manage placement of a nasogastric tube (NG) correctly and did not act timeously on signs of a complication. C said that the board failed to carry out an adverse event review of this event.

C complained that the board dismissed A’s known diagnosis of myasthenia gravis (a rare long-term condition that causes muscle weakness) too quickly and failed to arrange a neurology (speicalism concerned with the diagnosis and treatment of disorders of the nervous system) review. Finally, C said that the board did not maintain A's privacy or dignity when providing end of life care and communication with the family was poor.

The board apologised for failures in A’s care in respect of the NG tube insertion and for aspects of their communication. The complication which occurred with the NG tube was a rare but known complication of the procedure. The board said that A’s case had been reviewed at a Mortality and Morbidity (M&M) meeting and points of learning had been identified.

We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system), a consultant gastroenterologist (specialist in the diagnosis and treatment of disorders of the stomach and intestines) and a consultant respiratory physician (specialist in conditions affecting the lungs).

We found that there were aspects of A’s care which were reasonably managed including the review by neurology, the decision to site the NG tube, the end of life care provided to A and the review of the admission undertaken by the M&M meeting.

However, we found that the chest x-ray undertaken after insertion of the NG tube was unreasonably delayed. Therefore, we upheld this part of C’s complaint. However, we noted that the board had recognised this failure as part of their own review of C’s complaint.

C complained that the board failed to handle their complaint reasonably. We found that the board took a significantly long time to respond to C’s complaint and failed to provide C with any updates or a revised date of response. 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 in this report. 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 .

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaint Handling Procedure. They should be managed within timescales or updates should be provided to account for delays and to provide a revised timescale for completion. Complaints should be properly investigated and the complaint response should be accurate.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their parent (A) during two admissions to hospital. Both admissions were due to concerns about A's lungs. A was admitted to hospital for a third time and was diagnosed with empyema (pockets of pus) in their left lung. C complained that this was missed during A's first two admissions and that A was unreasonably discharged from hospital on both occasions.

We took independent advice from a consultant who specialises in both respiratory and general medicine. We found that there was no evidence that empyema was present during the two admissions. However, there were missed signs that indicated the potential for empyema to develop. In particular, the presence of high C-reactive protein (CRP, an indicator of inflammation in the body) during the first admission and the recent history of pulmonary and pleural infection at the time of the second admission. We considered that it would have been reasonable for the board to carry out further investigation during A's admissions to hospital. We concluded that the board did not take reasonable steps to establish whether there was an evolving infection or potential for empyema to develop. Therefore, we upheld this part of C's complaint.

In respect of A's first admission, we found that A was clinically well enough to be discharged. However, there was a failure to recognise the significance of the raised CRP in the context of A's presentation, and to consider further assessment on this basis. Therefore, we upheld this part of C's complaint.

In respect of A's second admission, we found that A was clinically well enough to be discharged. In contrast to the first discharge, A's CRP was not as significantly high and was shown to be declining. As such, there was less indication that A would benefit from remaining in hospital. Therefore, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failure to recognise the signs of potentially developing empyema and the unreasonable discharge. C has highlighted the importance to them that the apology acknowledges the impact on A and on A's spouse, who has had to provide care. 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:

• Rising CRP blood test in the context of pleural infection should prompt further assessment and consideration of the potential for empyema to develop.

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 assessed by a junior doctor in A&E who ordered various tests and investigations. A was later moved to the acute assessment unit and diagnosed with a perforated bowel. A underwent emergency surgery and developed sepsis. C complained that there was a delay in identifying A’s condition. They said that the board focussed on potential cardiac issues rather than an abdominal cause. C considered that this delay resulted in a worse outcome for A.

The board acknowledged that a more senior doctor may have identified the cause of A’s symptoms quicker. However, they said that the care provided was reasonable. They also noted that this this complaint had resulted in learning and ongoing development.

We took independent advice from an emergency medicine consultant. We found that there were a number of red flags in A’s presentation that should have raised the possibility of significant abdominal pathology. It did not appear that A was reviewed by a senior clinician.

We also found issues in the documentation. No intimate examination was recorded in the records and there was a lack of documentation around the interpretation of an x-ray. Overall, the initial assessment process led to a delay in the diagnosis of acute bowel perforation which is likely to have had a significant effect of the outcome for A. Therefore, 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 should receive appropriate treatment including assessment, relevant tests and senior review in accordance with their symptoms.
• Case records should include details of any tests / examinations carried out and the rationale for any 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 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.