Upheld, recommendations

Summary

C's spouse (A) suffered from chronic pancreatitis (inflammation of the pancreas) and was receiving care and treatment from the board. A attended hospital multiple times over several months. A was discharged home but the following day they were admitted again with significant pain and died.

C complained to the board, raising a number of specific questions about the treatment provided to A and was of the view that more could have been done to help A.

We took independent advice from a consultant general surgeon. We found that while during the majority of A's admissions, the treatment provided by the board was reasonable, there was a significant failing in relation to A's discharge the day before their death. At the time A was discharged, their observations were still abnormal, A's pain score remained high and there was no evidence that the blood test results had been reviewed prior to discharge. We concluded that to discharge A at that time 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 provide A with reasonable treatment. 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 there is a clear policy in place on discharging patients with abnormal observations from A&E.

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 relative (A) received at Wishaw General Hospital. A had been admitted to hospital in relation to an infection. They developed hospital acquired pneumonia and died days later. C was concerned that the Hospital Emergency Care Team (HECT) did not respond appropriately to A's deteriorating condition, and that that there had been a failure to contact the family when A's condition deteriorated.

In response to the complaint the board acknowledged, in hindsight, that HECT should have reviewed A in person rather than a telephone discussion having taken place between HECT staff and ward staff. The board said that they were unable to say whether or not A's management would have changed, had they been seen by HECT. The board accepted that the family should have been contacted and they apologised for this. Action was also taken to remind staff of the importance of contacting relatives.

We took independent advice from a consultant in geriatric (elderly) and general medicine. We found that when A deteriorated overnight, they should have been seen by HECT. We also considered that A should also have been examined the following morning. A had delayed recognition and treatment of the infection as a result. This reduced A's chances of surviving the infection, but we could not say with certainty that this would have significantly improved the chance of survival. We were also critical that the record-keeping by HECT was not in line with the Nursing and Midwifery Code.

We agreed that the family should have been contacted and recommended further action to be taken by the board for further learning and improvement. We concluded that A did not receive a reasonable level of care in keeping with local and national standards and, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings by HECT and for not examining A within a reasonable time. 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:

• Deteriorating patients should be reviewed in accordance with local and national guidance and this should be appropriately recorded in line with the Nursing and Midwifery Code.

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

Ms C complained on behalf of her child (Child A) that the care and treatment Child A received from the board was unreasonable. Ms C complained that there was an unreasonable delay in diagnosing Child A's hip dysplasia (when the hip socket doesn't fully cover the ball portion of the upper thighbone) and dislocated hip.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that it was unreasonable that Child A's legs and hips were not examined during a consultation. We considered that had Child A's hips and legs been examined and concerns noted, this should have prompted further investigations to be arranged, such as x-rays, and there was a high likelihood of an x-ray at this time indicating hip dysplasia. Therefore, we upheld this aspect of Ms C's complaint.

Ms C also complained that the board's handling of her complaint was unreasonable. We found that there were delays in the board's response to Ms C's complaint and the board did not provide proactive updates about the status of Ms C's complaint. We found that the board's handling of the complaint was not in line with the NHS Model Complaints Handling Procedure (MCHP) and, therefore, upheld this aspect of Ms C's complaint.

We noted that the board had already taken action to improve their complaints handling. We made no further recommendations but did provide feedback on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in the care and treatment provided to Child A and for the failures identified in the board's complaints 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:

• Patients should be fully examined when presenting at an orthopaedic clinic and further investigations organised as appropriate.

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

Mr C complained about the board's actions regarding his access to overnight accommodation at a facility provided by them, whilst Mr C was attending New Craig Psychiatric Hospital for treatment. Mr C said that the board unreasonably failed to provide him with overnight accommodation when he attended the hospital. He said that when he questioned this, he was initially advised that the accommodation was fully booked, but was subsequently informed that he would not be provided with accommodation as there had also been complaints about his behaviour there on a previous occasion. Mr C also complained that the board failed to investigate the complaints made about his conduct at the accommodation appropriately.

We found that the board had failed to make a written record of the complaints made about Mr C during a previous stay at the accommodation; did not notify Mr C about the complaints; failed to give Mr C an opportunity to respond to the complaints; and failed to make a written record of their assessment of the situation and their decision to no longer offer Mr C accommodation. As the board decided to act based on the complaints they received about Mr C, we considered that the board should have carried out some form of investigation. Therefore, we upheld these aspects of Mr C's complaint.

Mr C also said that the board failed to respond appropriately to his concerns and complaint about their handling of the complaints. We found that when MSPs first contacted the board on Mr C's behalf, the board failed to classify this as a first stage complaint under the NHS Model Complaints Handing Procedure (MCHP) and that the board failed to look into matters for Mr C and respond to him, as agreed in an email to him. We found that it was unreasonable for the member of staff to investigate Mr C's complaint to the board, when they were the subject (in part) of the complaint. We also found that the board failed to address all of the issues raised in Mr C's complaint to them and failed to demonstrate that each element had been fully investigated, in accordance with the NHS MCHP. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to deal appropriately with the accommodation complaints and the complaints made by him and MSPs about this. 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:

• Complaints about residents at the residential accommodation should be appropriately investigated and recorded by the board's staff.

In relation to complaints handling, we recommended:

• Complaints from patients should be appropriately recognised, investigated and responded to in accordance with the NHS MCHP and the SPSO guidance on MCHPs.

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 a globe perforation (small hole in the eyeball) which occurred during retrobulbar injection (an anaesthetic injection given into the eye) for a left trabeculectomy (a surgical operation to lower pressure inside the eye). C reported the injection being extremely painful and felt that this should have alerted the doctor to the perforation.

We took independent advice from an ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We found that there is a debate as to whether retrobulbar injections have been outmoded by alternative methods of local anaesthetic. Though we did not consider it a failing that the board used this method of anaesthetic, we suggested that they may wish to reflect upon whether the methods of local anaesthesia should be reviewed in light of the outcome of this case.

We also found that the globe perforation that C experienced should have been suspected at an earlier point. We found that whilst the pain C experienced did not indicate a definite perforation, this should have raised suspicion of perforation. We also considered that had the perforation not been suspected/identified at the time of the injection, it should have been the following day when C experienced a leakage of blood in the eye. We upheld C's complaint on this basis.

The board had already discussed the case with doctors involved in C's care, presented the case at a teaching session, and discussed the case at a clinical governance meeting. However, we made further recommendations on the basis that the board had not identified that the perforation could have been suspected at an earlier point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not suspect/identify the globe perforation at an earlier point. 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:

• Where a patient experiences marked pain at the time of retrobulbar injection; or vitreous haemorrhage following retrobulbar injection, clinicians should be alert to the possibility of a globe perforation.

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

Mr C complained about the care and treatment his late brother (Mr A) received at Queen Elizabeth University Hospital (QEUH). Mr A had a number of complex medical conditions; he had previously undergone liver transplantation and suffered a brain aneurysm. Mr A was admitted to QEUH for treatment associated with an unusual resistant form of cytomegalovirus (CMV, a virus). Mr A's health deteriorated during his admission and he died in hospital.

Mr C complained that the board failed to provide Mr A with reasonable clinical care and treatment. Mr C also raised concerns that there was a lack of reasonable communication with him and his family about Mr A's care and treatment.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines); a consultant in critical care and anaesthesia with experience in transplant services and a senior nurse.

We found that there were aspects of Mr A's care and treatment that were reasonable. In particular, in relation to the management of Mr A's blood pressure and the fall in his platelets. When Mr A's condition deteriorated, there was no unreasonable delay in escalating him to the intensive care unit (ICU). In relation to the staff caring for Mr A, there was clear evidence of regular reviews and consultation and liaison between a large number of different specialists at QEUH and the transplant unit.

However, we identified the following failings in Mr A's clinical care and treatment:

For a period of time it was not noticed that there was an unintentional co-adminstration of two medications. While, on balance, any impact was limited and was not a significant contribution to Mr A's eventual outcome, this should not have occurred and was an omission in care. This was acknowledged by the board and appropriate action was taken.

We found that there was a lack of recording of Mr A's titres (level of virus). In addition, insufficient consideration was given to carrying out further investigations in order to confirm a diagnosis of Mr A having posterior reversible encephalopathy syndrome (PRES, a rare condition in which parts of the brain are affected by swelling) rather than CMV encephalitis as a possible alternative diagnosis.

Mr A had infected CMV that was known to be resistant to valganciclovir (antiviral medication) and the decision to restart Mr A on this medication was unreasonable. As this treatment was ineffectual, an alternative treatment should have been considered. Whilst it was wrong to use valganciclovir, on balance, taking account of the evidence any impact was limited and was not a significant contribution to Mr A's eventual outcome.

We found that communication with Mr A's family was reasonable while he was in ICU. However, prior to this communication with Mr A's family could have been better and their concerns about aspects of his care and treatment did not appear to have been reasonably addressed.

Mr C further complained that the board's investigation of and response to his complaint was inadequate. The board acknowledged that their complaint response letter was not issued within 20 working days in terms of the relevant guidance. Given the complexity of the complaint, we considered that the delay in providing a response was reasonable in the circumstances. However, we identified an error in the board's calculation of when the 20 day working period for providing a response to Mr C's complaint started. Following the issue of the board's response to the complaint, Mr C had contacted the board making further comment. We considered that the board should have informed Mr C when he could reasonably have expected to receive a response to his further correspondence and if there was going to be a delay in providing this. However, this had not happened.

We upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family that insufficient consideration was given to carrying out further investigations in order to confirm a diagnosis of PRES; about the decision to restart valganciclovir and not to have considered an alternative treatment for resistant CMV; for the failure to record Mr A's titres; for the lack of reasonable communication with Mr C and his family about Mr A's care and treatment; and for the failings identified in 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:

• Patients should receive appropriate investigation prior to confirming a diagnosis of PRES. Decisions about medication should be reached after careful consideration of the effectiveness of the medication and potential side effects. There should be appropriate recording and monitoring of a patient's condition and this should be documented.
• Communicating significant news, especially bad news, to a patient and/or their family should be carried out in a clear and sensitive manner and without any unreasonable delay.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and in accordance with the board's Complaints Handling Procedure. The board should aim, whenever possible, to inform a complainant about when they should expect to receive a response to their communication and if there is going to be a delay in providing this.

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 provided by the board during their admission to Woodend Hospital. C said that the board unreasonably administered an overdose of an opioid drug. We took independent advice from an appropriately qualified adviser. We found that the board failed to follow local protocol and unreasonably administered an opioid drug to C. We upheld this part of C's complaint.

C also complained that the board failed to reasonably monitor them after they underwent an operation. C was being monitored using National Early Warning Score (NEWS). NEWS is a guide used by medical services to quickly determine the degree of illness of a patient. We found that when C triggered a NEWS score of one, they should have been observed every four hours, however C was next observed 11 hours later. This was unreasonable and we upheld this part of C's complaint.

C complained that their spouse (B) was unreasonably communicated with after their condition deteriorated. We found that while it was identified in the morning of that day that B should have been contacted, B was not made aware of C's condition until they entered the ward almost eight hours later. This was unreasonable and we upheld this part of C's complaint.

The board said that they had already taken action in response to these failings. We asked them to provide evidence of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for failing to communicate with them in a timely manner.
• Apologise to C for the failings as identified by the board and from our investigation. The apologies 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 that their partner (A) was prematurely discharged from the Golden Jubilee National Hospital following cardiac surgery. The surgery was successfully performed with no reported complications. A was discharged home from hospital as staff deemed they were clinically fit for discharge. C was concerned that A had been discharged as they had severely swollen feet. A's health deteriorated, and days after discharge an ambulance was called as A had severe shortness of breath and a high temperature. A was then admitted to another hospital where they were an in-patient for several weeks.

We took independent advice from a cardiology consultant (doctor who deals with diseases and abnormalities of the heart). We found that insufficient action was taken to establish the extent of A's heart failure and possible wound infection prior to their discharge from the Golden Jubilee National Hospital, which amounted to a failing in the standard of care and treatment required. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failure to ensure their symptoms of severe fluid retention and possible infection were resolving prior to discharge from hospital. 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, where a patient shows symptoms of severe fluid retention and possible infection, appropriate clinical investigations take place to ensure that the symptoms are resolving prior to hospital discharge.

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

Mrs C complained on behalf of her husband (Mr A) about the treatment he received when he attended A&E of Forth Valley Royal Hospital due to experiencing pain that had started in his neck and had travelled to his hands. In particular, Mrs C was concerned that there was a delay in diagnosing Mr A with sepsis (blood infection).

Mr A had been examined and then discharged to the care of his GP on the same day. We found that there was no evidence that Mr A had sepsis at that time. A diagnosis of sepsis requires a source of infection and evidence of abnormal physiology; however, the urinalysis showed no signs of infection. Therefore, there was no failure to identify sepsis at this stage. The following morning Mr A was taken by ambulance to hospital and was admitted again. Mr A was diagnosed with a urinary tract infection and then developed sepsis. While we did not consider there to be a failure to diagnose sepsis, Mr A is a diabetic and we found that there was a failure to carry out a bedside blood glucose finger prick test during his first attendence at hospital given glucose was found in Mr A's urine following the urinalysis. On this basis, we considered that the board failed to provide Mr A with reasonable care and treatment. Therefore, we upheld this complaint.

Mrs C also complained about the response she received to her complaint regarding the content of the discharge letter to Mr A. The response to the complaint correctly stated what was in A&E notes (the GP was to consider referring Mr A to neurology (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system)), but the discharge letter to Mr A's GP did not mention this. We upheld the complaint on the basis that the discharge letter should have contained this information and the complaint response should have identified this discrepancy. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for (a) an unreasonable failure to carry out a bedside finger prick blood glucose test; (b) an unreasonable failure to include within the discharge letter to Mr A's GP information about a possible GP referral to neurology; and (c) a failure to ensure the response to the complaint correctly reflected what was in the discharge letter to the GP regarding a neurology referral. 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:

• To ensure clinical staff are aware of the circumstances in which a bedside fingerprick blood glucose test should be carried out.
• To ensure clinical staff include relevant information in discharge correspondence to GPs.

In relation to complaints handling, we recommended:

• To ensure the facts of an investigation are correctly reported to a complainant.

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

Mrs C complained about the care and treatment provided to her father (Mr A) at Victoria Hospital. Mrs C was also concerned that the investigation of her complaint to the board had been inadequate.

Mr A had been admitted to hospital for treatment of a heart condition. Mrs C believed that his assessment had been inadequate and that he had been prescribed a drug which had caused a severe reaction when combined with the medication Mr A was already taking. Mr A had developed ulcers in his left eye and then contracted cellulitis (an infection of the deeper layers of skin), which had affected both eyes.

Mr A had required surgery to his left eye. Mrs C believed this experience had rapidly increased the onset of Mr A's dementia, leaving him incapable of managing by himself, where as he had previously had a significant degree of independence. Mrs C said that this could have been avoided, had his medication been checked properly before he was prescribed new drugs by the hospital, as ulceration was a known complication.

We took independent advice from an appropriately qualified adviser. We found that Mr A's care and treatment had fallen below a reasonable standard, because his medication had not been properly reconciled prior to the prescription of a new drug. We could not state for certain that Mr A's deterioration was solely attributable to this error, as the side effects he suffered could have been caused by the new drug by itself, rather than in combination with his existing medication. We upheld this aspect of the complaint.

We also found that the board's investigation of the complaint had been inadequate, as it had not identified the failure to reconcile Mr A's medication. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mr A for the inadequate standard of care provided by the board and the failure of the subsequent complaint investigation by the board to identify this. 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 need to comply with the board's procedures for medication reconciliation.

In relation to complaints handling, we recommended:

• Staff should be able to identify accurately the substantive issues contained within a complaint.

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.