Upheld, recommendations

Summary

C complained about the care and treatment provided to their late parent (A). A was experiencing shooting back pain, tingling sensations, abdominal swelling, weight loss, poor balance and constipation. A contacted the practice on four occasions with deteriorating symptoms. By the last contact, A was incontinent and unable to mobilise. After some delay, the practice organised (seated) ambulance transport to hospital. A was diagnosed with malignant spinal cord compression (MSCC) caused by metastatic renal cancer. A was paralysed and incontinent until they died a few months later.

C complained that the practice failed to spot red flag symptoms for MSCC and cancer, missed opportunities to send A to hospital earlier and failed to appropriately manage A’s transfer to hospital. C said that when A was discharged from hospital their pain, nutrition, appetite loss and low oxygen levels were not effectively managed. They also complained that a GP inappropriately discussed A’s terminal prognosis and do not attempt cardiopulmonary resuscitation (DNCPR) decision at a home visit.

The practice said that, in previous appointments, they had examined A, conducted blood tests, inquired about symptoms of cord compression, and provided advice on what to do if the condition worsened. They recommended going to the hospital only after symptoms deteriorated. They advised that on discharge, the GP had considered it important to discuss prognosis and DNCPR at the earliest opportunity and had made every effort to do so sensitively. They said that they had adjusted A’s pain medication and referred to palliative care nurses. The practice also said that they had referred to a dietician and it would not be standard practice to check oxygen levels as it would not change the overall palliative care.

We found that it had been unreasonable not to arrange a stretcher transfer to hospital at an earlier date. We also considered that it was unreasonable that changes to pain medication had not been timeously reviewed. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for not referring A to hospital sooner, for not timeously organising appropriate ambulance transport on a stretcher, for not contacting a specialist to expedite review on arrival at hospital, and for not appropriately reviewing A’s pain medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All medical staff employed by the practice are familiar with the referral guidelines for possible malignant back pain and cord compression, such as the West of Scotland Guidance and Recommendations| Spinal metastases and metastatic spinal cord compression | Guidance | NICE.

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 board failed to provide their late partner (A) with reasonable treatment for bladder incontinence. A was admitted to hospital following a fall in which they fractured their hip. A was catheterised after undergoing surgery. C complained that when A’s catheter was removed, they developed a bladder problem, and that hospital staff did nothing to rectify A’s inability to control their bladder or investigate what was causing this. C believed if A’s bladder problem had been addressed they may have made a full recovery. A’s condition deteriorated after discharge and they died within a few weeks.

When the board originally responded to C’s complaint they said that it was documented in the nursing notes that A was incontinent on three occasions. The board said a urine specimen was taken which returned a positive result for a urinary tract infection and A was treated with oral antibiotic medication. The board said that prior to discharge, A was mobilising to the toilet and there was no mention of incontinence thereafter.

C highlighted a number of entries in A’s records which referred to incontinence/use of pads. We asked the board to comment on this, noting this contradicted their position in the complaint response. The board confirmed that if all this information had been considered by the multi-disciplinary team, this may have prompted additional continence support and follow-up being arranged on A’s discharge from hospital. The board confirmed that they were taking forward learning points including an action plan for improvement.

We took independent nursing advice. We found that despite a number of references within the multidisciplinary notes to A’s incontinence, there appeared to have been no attempts to explore this further and to provide appropriate support during A’s admission and/or follow-up after discharge from hospital. Although the board missed an opportunity to address these issues, it was not possible to determine the extent of the impact on A, who had a number of significant health concerns. We upheld C’s complaint and made a recommendation for apology. We considered that the action plan appropriately addressed failings so made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable treatment for A’s incontinence and for failing to appropriately identify concerns about A’s bladder issues in their investigation of C’s complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

C complained about the care and treatment that they received when they attended the board’s urgent care centre with sudden hearing loss in their right ear. C’s hearing loss became permanent and they felt that this could have been avoided.

We took independent advice from a consultant in emergency medicine. We found that the board’s assessment of C was unreasonable. While a clinical assessment was undertaken, a clinical hearing assessment was not, which meant that the cause of C’s acute hearing loss was not ascertained. This could have led to alternate treatment options. The board also failed to provide reasonable advice on what to do if C’s symptoms should continue after five days. The board’s response did not reasonably reflect the records available, and their investigation did not identify the failings in C’s care. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably assess C’s hearing loss and provide appropriate 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.

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

• Guidance is available to staff which provides a localised and helpful pathway as to the action to take when a patient presents with sudden hearing loss.
• Practitioners delivering the out-of-hours/primary care emergency centre service have an appropriate level of training to assess patients presenting with sudden acute hearing loss.

In relation to complaints handling, we recommended:

• Responses to complaints are accurate, identify failings when they occur and seek to take learning from what happened to make similar failings less likely to occur.

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 nursing care provided to their late parent (A) in hospital. A had been transferred from another health board for rehabilitation having suffered a stroke. C said that there was infrequent care rounding and that the provision of and monitoring of A’s diet, nutrition and fluid intake was poor. C also complained about communication, catheter care and pain management.

We took independent advice from a nurse. We found that record keeping was not to the standard required in areas such as care rounding, fluid balance and food charts, and pain assessment documentation. The lack of accurate records of A’s nutritional assessment and needs suggested that A’s nutritional intake was not delivered to a reasonable standard and that they were at risk of malnutrition. Additionally, the absence of pain assessments on A’s observation and care rounding charts indicated a failure to properly evaluate A’s pain levels, making it difficult to determine if the pain medication provided was effectively relieving their pain. We determined that there had been a lack of assessment, evaluation, and implementation of A’s care needs and lengthy gaps between care interventions. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Nursing staff should be aware of and achieve the required standards of the Nursing and Midwifery Council: The Code in relation to record keeping. A patient’s pain should be appropriately assessed and documented in their patient 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 medical and nursing care and treatment provided to their late parent (A). A was admitted to hospital after repeated falls at home. A’s behaviour changed significantly during their admission which suggested that their mental state was deteriorating. C said that they were not directly informed of this, and that A was not referred to the mental health team. A had also been refusing to eat and began to vomit blood. C was not contacted at this point, and was not informed of A’s deterioration until later that day.

We took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that A had been prescribed medication, which combined with existing health conditions, should have required additional medication to protect their stomach. This was exacerbated by A’s refusal to eat. We found that nursing records of A’s nutritional intake were not completed. Additionally, A’s mental state was not properly assessed. We also found that the board had told C that they would make a change to improve the electronic prescription system. However, this change was not possible and the board had not informed C of this. We considered that A’s nursing and medical care fell below a reasonable standard and upheld these parts of C’s complaints.

C also complained about the board’s complaint handling. We found that the board’s response to C was inaccurate. 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 failure in medical and nursing care, as well as the complaint handling failures 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:

• Patients should receive the relevant assessments and care planning that reflects their needs. All relevant patient documentation should be completed and recorded in the nursing records in accordance with the NMC Code.
• Patients receiving corticosteroid medication at risk of gastritis or other gastric injury, should receive proton-pump inhibitor (PPI) medication as well.
• Patients should be appropriately assessed when there are changes in their behaviour.
• Person centred care plans should be followed for each patient and weight loss should be recognised and responded to.
• Staff are aware of the importance of prescribing and monitoring a patient’s medication appropriately.
• The board should develop clear guidance to ensure patients with mental health issues can have timely access to nursing staff trained in mental health care.

In relation to complaints handling, we recommended:

• Complaints should be investigated in line with the Model Complaints Handling Procedure. Actions and improvements should only be included in complaint responses when the board is able to carry them out.

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

Summary

C complained that the practice failed to reasonably respond to their complaint. C had made a complaint to the practice about communication and the service provided by them, particularly in relation to their appointment services, phone lines, and frontline staff. C was concerned by the content and tone of the practice’s complaint response.

We found that the practice’s handling of C’s complaint was unreasonable, including the tone and language of their response and a failure to signpost to the SPSO. We considered some of the language used in their response came across as overly defensive and failed to maintain an appropriately conciliatory tone. The practice also failed to have an appropriate two-stage complaint procedure in place that follows the NHS Scotland Model Complaints Handling Procedure, as they were unaware this applied to them. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to respond to the complaint reasonably. 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:

• Complaint responses should acknowledge the complainant’s experience and, in presenting the facts, should use appropriate conciliatory language and tone with the intention of maintaining positive relationships wherever possible.
• The practice should have a complaint procedure that is in line with the NHS Scotland 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 complained on behalf of their parent (A). A had a long history of contact with mental health services at the board. They had a diagnosis of paranoid and antisocial personality disorder for several years before it was changed to paranoid schizophrenia. A later received an occupational therapy assessment but did not receive support and was referred to social work. A few months later, A was referred to mental health services by their GP due to confusion. A failed to attend two appointments and was discharged. The following year, A was admitted to hospital with confusion and left side weakness. A CT head scan showed an established infarct (an area of necrosis (tissue death) due to blood vessel blockage, often caused by a stroke). A was discharged from hospital and mental health services two months later. A did not receive a psychiatric assessment prior to, or following, discharge and did not receive any community support. C complained that A had not received appropriate support, had not received a psychiatric assessment for several years, and was unsure of their diagnosis. C requested a second opinion but this was refused.

The board said that A had received consultant psychiatric assessments, including two prior to their discharge. They advised that the diagnosis was paranoid and antisocial personality disorder and refused to offer a second opinion.

We took independent advice from a consultant psychiatrist. We found that the board’s response could not be verified by the records and seemed to contradict the diagnosis of paranoid schizophrenia that was given previously. The records did not offer a clear clinical rationale for changing the diagnosis to paranoid schizophrenia and it was not clear that the A had been informed. Given the confusion around A’s diagnosis and lack of psychiatric assessment, we considered that it was unreasonable not to offer a second opinion. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the inconsistencies and contradictions in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the lack of clear diagnosis, the lack of psychiatric assessment, the lack of rationale in not offering mental health input following A’s stroke and the refusal to offer a second opinion. 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:

• Assurance that diagnostic rationale and patient symptoms including clearly documented Mental State Examination are clearly and consistently recorded.
• Assurance that all staff are aware of and follow the policy “Mental Health and Learning Disability Services Standard operating Procedure – Managing Second Opinions”.

In relation to complaints handling, we recommended:

• The board’s complaint responses and responses to SPSO enquiries should be consistent and supported by the medical records available.

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) by the board. A was living independently but fell and injured their knee. A was admitted to hospital and underwent surgery. C believed that A did not receive adequate food or drink and that A was not provided with antibiotics timeously. A died in hospital and C complained about the way that A’s end of life care was managed, as well as a delay in providing C with a death certificate.

We took independent advice from a consultant physician and a registered senior nurse. We found that A’s medical and nursing care fell below a reasonable standard. During the end-of-life period, we also found that A’s nursing care fell below a reasonable standard, although their medical care was reasonable. We also found that there was an unreasonable delay in providing C with A’s death certificate. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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:

• Care for patients receiving end of life care should be planned and their care plan updated to reflect their specific needs. Appropriate end of life care should be provided in particular in relation to repositioning and comfort care and this should be documented.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring, as well as appropriate and regular monitoring of their weight when requested as part of their care plan.
• Patients admitted to hospital should receive reasonable medical care including appropriate and timely medical assessments for feeding and nutrition and delirium and appropriate antibiotic treatment.
• Staff caring for a patient with diabetes should be competent in the monitoring and appropriate recording of blood sugar results and any action taken to address low or high blood sugar.
• Staff involved in wound care should be knowledgeable and competent in wound assessment; wound care and treatment.
• Reporting of deaths and issuing of a death certificate should not be delayed unnecessarily by staff absence.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning.

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 independent advocate, complained on behalf of their client (B). B’s adult child (A) died from an overdose of dihydrocodeine (opioid prescribed for pain or severe shortness of breath). A had been prescribed a number of different medicines by their GP practice including painkillers and benzodiazepines (depressants).

B complained that the practice did not appropriately manage the risks of prescribing A such medication. B questioned why prescriptions were issued to A on a monthly basis, rather than weekly or even daily. B also complained that the practice had insufficient regard to A’s history of overdoses and that A should not have been given additional prescriptions on request, as had happened on multiple occasions. Lastly, B was concerned that A had remained with the practice despite having moved a significant distance away.

In their response to the complaint, the practice stated that weekly or dispensing does not necessarily prevent the hoarding of medication, and that A had been maintained as patient due to their local GP being staffed primarily by locum doctors lacking a familiarity with A’s situation. They said that while they were aware of A’s overdoses these were often also due to alcohol or illegal drugs. The practice said that they felt A’s requests for additional medication had been genuine and that they needed to balance the risk that A would seek illicit drugs or street medication if suffering from withdrawal. The practice also stated that following this incident they had reviewed their approach to such patients and had recently refused a number of requests to keep on patients living remotely.

We took independent advice from a GP. We found that the kinds of medication prescribed to A are implicated in many drug related deaths, often in combination with other substances such as alcohol. Taking into consideration A’s history, their mental health, alcohol misuse and history of multiple drug overdoses, early prescriptions should not have been given to A and instalment dispensing should have been used to reduce risk. We also found that the evidence did not suggest that A remaining as a patient with the practice had kept them safe, and had influenced the decision not to provide weekly dispending. While it was not possible to say whether this decision had contributed to A’s death, overall, the practice had not provided A with reasonable care and treatment with regard to their prescription medication and on this basis, we upheld B’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings identified in A’s care and treatment with respect to the prescription medication issued to A. 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’s parent (A) was admitted to the hospital and diagnosed with a urinary tract infection (UTI) and sepsis. A was transferred to the acute medical unit (AMU) that night and died later the next day. C was concerned about the care and treatment provided to A.

C raised a number of complaints with the board regarding the care and treatment that A received, including the provision of oral care. The board accepted that there had been issues with the prescription and administration of anticipatory medication and the care provided to A, and outlined steps that would be taken to prevent any recurrence. C was dissatisfied with the board’s responses and actions and raised their concerns with SPSO.

We took independent advice from a nursing adviser. We found that the investigation already carried out by the board, and the steps taken to address the areas for improvement identified were reasonable and did not require further investigation by the SPSO. However, we found that the action taken did not address the issue of the provision of oral care to A and investigated this matter further.

In responding to our enquiries, the board accepted and apologised that there had been issues with A’s oral care during their admission. Therefore, we upheld the complaint that the board did not provide A with reasonable oral care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not provide A with reasonable oral 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:

• Training is delivered to all relevant nursing staff in the Acute Medical Unit regarding mouthcare in palliative care. This should include structured educational or awareness sessions covering common mouth problems in such care (dry mouth, painful mouth, infections, bad breath, changes in taste and drooling).

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.