Upheld, recommendations

Summary

Mr C complained that the practice unreasonably removed him from the patient list. Mr C had been in correspondence with the practice about matters not connected with his NHS treatment. Mr C received a letter from the practice in which the suggestion was made that perhaps it would be for the benefit of all concerned that he should move to another GP practice. Mr C was dissatisfied with the practice letter and wrote back to them asking for more clarification. He then received a further letter from the practice advising him that they had requested that the health board remove him from their patient list due to a breakdown in the relationship between himself and the practice. Mr C complained about his removal from the list and the fact that he was not given any specific information about why he was removed.

We took into account the contractual regulations and relevant guidance regarding the removal of patients from the practice list. This sets out that, other than in cases involving violence or aggression, a patient whose behaviour is giving cause for concern should be given a written warning informing them that they will be removed from the practice list if they do not alter their behaviour. The warning should last for 12 months. While the practice did have concerns about Mr C's correspondence, staff did not formally bring them to Mr C's attention in line with the regulations and guidance and, therefore, he was unaware of the practice's concerns. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably removing him from the patient list. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of and comply with the guidance and regulations where there are concerns about patient behaviour.

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

Miss C complained about the antenatal care and treatment she received when she was pregnant with her child (Baby A). Miss C also complained that the board did not communicate reasonably with her about her antenatal care and treatment. At Miss C's 20 week anomaly scan it was identified that Baby A was measuring larger than expected. Baby A was born prematurely with severe and complex needs and died a few days later.

We took independent advice from a midwifery adviser and a sonography (the medical diagnostic imaging technique used to see internal organs, muscles, etc) adviser. We found that

No alternative arrangements were made for bloods to be obtained as requested by Miss C's GP during one of her antenatal appointments.

There were no records of:

one of Miss C's antenatal appointments

discussions that the midwife had with the sonographer and the consultant obstetrician (a doctor who specialises in pregnancy and childbirth)

the management plan, reason for changing the management plan and the details of what was communicated to Miss C.

The reason for not repeating the anomaly scan and requesting a growth scan instead was not explained to Miss C.

The sonographer did not seek medical advice regarding Baby A's measurements at the time of Miss C's 20 week scan or as soon as reasonably practicable.

The board identified that inappropriate comments were made to Miss C about Baby A's size.

The sonographer did not communicate Baby A's measurements to Miss C at the time of her 20 week anomaly scan.

Therefore, we upheld Miss C's complaints. We noted that the board had already apologised for some of these failings and had taken action to prevent these reoccurring. We asked the board for evidence of these actions and made further recommendations.

Miss C also complained that the board failed to handle her complaint reasonably. We found that the board did not inform Miss C at the earliest opportunity that a Significant Adverse Events Review would result in a delay in responding to her complaint or keep her updated as the review was progressing. We also found that the board failed to let Miss C know the outcome of the complaint investigation in writing. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failure to provide her with reasonable antenatal care and treatment, the failure to communicate reasonably with her and the failure to handle her complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Bloods should be obtained as requested by GPs.
• Midwives should keep clear and accurate records in accordance with the Nursing and Midwifery Code: professional standards of practice and behaviour for nurses and midwives.
• Clear explanations should be given to expectant mothers about decisions to change the care they will be receiving.

In relation to complaints handling, we recommended:

• The board should ensure that they are adhering to the NHS Scotland Model Complaints Handling Procedure.

Summary

Mrs C complained about the out-of-hours care provided to her father (Mr A). Mr  A was seen at home by out-of-hours GPs and had been undergoing treatment for constipation in the days prior to this. The GPs considered that Mr A's reported symptoms were related to constipation. Mr A was later admitted to hospital where a catheter was fitted to drain retained urine from his bladder. Mrs C complained that the out-of-hours GPs had missed Mr A's urinary retention and prescribed inappropriate treatment as a result. The board acknowledged that an enema (a  procedure in which liquid or gas is injected into the rectum) that Mr A was prescribed was not appropriate and was unlikely to have been of any benefit in his case. This matter had been taken forwards with staff for reflection and learning.

We took independent advice from a GP. We found that there had been no indication that Mr A was suffering from urinary retention at the time he was seen and that the approach taken at the second out-of-hours visit was reasonable. However, we found that an enema had been inappropriate in Mr A's case and that a rectal examination should have been carried out during the first visit. On balance, we upheld Mrs C's complaint.

Recommendations

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

• Rectal examinations should be carried out when clinically indicated in patients presenting with unresolving constipation.

Summary

Mr C complained that the board failed to ensure their mental health service for children and young people (CAMHS) provided a reasonable standard of care and treatment. Mr C said that he had a diagnosis of autistic spectrum disorder (a  developmental disability that affects how a person communicates with, and relates to, other people) from CAMHS but that they failed to explore potential mental health conditions during the period in question or provide appropriate treatment.

We took independent advice from a specialist in the services provided by CAMHS practitioners. We found that in many respects the CAMHS practitioners who assessed Mr C provided a reasonable standard of care and treatment in relation to diagnosis, management and referrals. We also took into account that it appeared Mr C refused to meet with senior staff to discuss his concerns. However, we found that Mr C's case was complex and he experienced considerable difficulties which had a significant impact on him. We also found that there were missed opportunities to engage with Mr C and to consider further referrals to ensure his mental health needs were met. Therefore, we upheld Mr  C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the missed opportunities to engage with him and to consider further referrals to ensure his mental health needs were met. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

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

• Relevant CAMHS practitoners should reflect on this complaint and its findings.

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) when he was admitted to Hairmyres Hospital with a suspected chest infection. Mr A was fed via a Percutaneous Endoscopic Gastrostomy (PEG, a tube into the patients's stomach through the abdominal wall) and early in the morning, on the day after his admission, Mr A's PEG became detached. While it appeared that nurses noticed this, it was not reported until a ward round later that day. By then, the entry tract had closed and the feeding tube was unable to be reinserted.

Subsequently, there were difficulties in ensuring Mr A's nutrition and there were numerous failed attempts to re-establish his feeding. After ten days, Mr A's family requested that he be transferred to another hospital to have a PEG surgically inserted but the procedure had to be stopped. Mr A died shortly afterwards. Mr  C complained that staff failed to act when the PEG had become detached.

We took independent advice from a consultant in general medicine. We found that the board's guidance stated that if a gastronomy feeding tube fell out, it should be replaced as soon as practicable, preferably within two hours. However, this did not happen and staff were initially unaware of the need to reinstate the PEG within a particular time frame. We also found that there was a lack of coordination and planning around the repeated failure to obtain a consistent route of feeding and there was a lack of communication about how unwell Mr A was. Although the outcome for Mr A may have been the same, we considered that his recovery was compromised by a level of care that fell below what could have been expected. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to provide Mr A with a reasonable level of care in that his PEG tube was not quickly replaced and that there was a failure to initiate alternative methods of feeding. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of and adhere to the board's policy on Enteral Tube Feeding, Best Practice Statement for Adults. Patients in a similar situation should receive a timely and feeding regime commenced and timely consideration of transfer. Record-keeping by doctors should meet General Medical Council standards.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's daughter (Ms  A) at Glasgow Royal Infirmary. Ms A was admitted to the hospital on two occasions due to complications from her gastric band (a band placed around the stomach to give a feeling of fullness with less food). Ms A died at home, a month after she was discharged from hospital on the second occasion.

When Ms A was discharged the first time, she waited all day for an ambulance to come to transport her home. Ms C complained that nursing staff did not allow Ms  A back to bed while she waited, even though she was very uncomfortable. We took independent advice from a nurse. We found that there was no record of Ms A's nursing care needs being assessed or met while she waited for the ambulance. We upheld this aspect of the complaint.

Ms C explained that during her second admission, Ms A began to experience difficulties with her hands. Ms C complained that Ms A was not given appropriate help with eating. We found that there was a failure to assess, plan and review Ms A's nutritional care needs, with Ms A's involvement as appropriate. We upheld this aspect of the complaint.

Ms C also complained that Ms A was unreasonably discharged home without appropriate communication, particularly with her GP, about her malnutrition. We took independent advice from a consultant surgeon. We found that it was reasonable Ms A was discharged home. However, we also found that the concerns about Ms A's nutritional status and difficulties with eating should have been communicated to her GP in her discharge letter. In light of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for the failings identified in appropriately assessing, planning, reviewing and recording Ms A's nutritional care needs, and for failing to include all relevant clinical information in Ms A's discharge letter. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The needs of patients who are waiting to be discharged from hospital should be appropriately met while they remain on the ward.
• There should be patient-centred nutritional care assessment, planning and review.
• Clinical issues of concern should be included in discharge letters so GPs are aware of the need to keep them under review.

Summary

Mr C complained on behalf of his late uncle (Mr A) about a delay in the diagnosis and treatment of bowel cancer.

In response to Mr C's complaint, the board acknowledged that there was an initial lack of diagnosis, but explained it was necessary to establish the diagnosis before embarking on a course of treatment. While the board considered that the time taken was reasonable overall, they acknowledged there had been an administrative error causing a delay in a biopsy procedure, and apologised for this.

We took independent advice from a consultant general surgeon, who explained that Mr A had a locally advanced recurrent cancer and a complicated pathway. We found that some of the investigations were performed promptly, such as the imaging and arranging of a TRUS biopsy (transrectal ultrasound guided biopsy). However, we also found that there were some delays by the board that could have been avoided, such as an administrative error causing cancellation of a procedure and issues with scheduling of treatment. We found that whilst these factors caused some delay in Mr A's management, the clinical effects of the delay would not have had any impact on his outcome. We considered that there were aspects of unreasonable delay in the diagnosis and treatment of Mr A's bowel cancer. On balance, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the instances of unreasonable delay in the diagnosis and treatment of bowel cancer. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients on similar care pathways should receive co-ordinated and planned care.
• As far as possible, patient appointments for investigations and treatment should be processed without administrative error.

Summary

Ms C complained about the care and treatment her late mother (Mrs A) received at Aberdeen Royal Infirmary. Mrs A had a history of a number of health issues and was admitted to the cardiology unit (the branch of medicine that deals with diseases and abnormalities of the heart) with a diagnosis of atrial fibrillation (a  heart condition that causes an irregular and often abnormally fast heart rate) and congestive heart failure. While she was in hospital, Mrs A had a heart attack but Ms C said that she was not told about this. She also said that Mrs A was not properly monitored nor given dialysis to reduce the fluid she retained. Mrs A's condition deteriorated and she later died.

We took independent advice from a consultant cardiologist. We found that Mrs  A's symptoms should have alerted staff to the possibility of internal bleeding and that neither the additional diagnosis of unstable angina (chest pain caused by reduced blood flow to the heart muscles) nor a management plan were documented. Therefore, Mrs A's emergency management plan could have been affected, however, it is unlikely to have changed her immediate outcome. There was also no evidence that Mrs A's deteriorating condition had been communicated to her family. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to consider internal bleeding, to document the additional diagnosis of unstable angina and its management, and no evidence of deterioration being communicated to the family. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• All potentially important admission diagnoses should be clearly documented and updated in the light of investigation results and clinical review. A clear management plan should be written for each admission diagnosis especially where it may involve a change in medication or withholding of therapy, an invasive procedure or potential risk to a patient as in the case of acute coronary syndrome. Treatment options and discussions should be recorded.
• Changes in a patient's condition such as a deterioration as in this case should be appropriately communicated to relatives. Serial investigation results should be reviewed (and documented) against previous ones and against admission results.

Summary

Mr C complained that the practice failed to discuss the risk of testosterone replacement when it was prescribed to him.

We took independent advice from a GP. We found that at the start of his prescription, there was no evidence in Mr C's medical records to show that the risks and benefits of the treatment had been discussed with him as required by General Medical Council guidance. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to discuss the risks of testosterone therapy with him. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

Summary

Mr C complained about delays in the care and treatment he received for his eye at Dr Gray's Hospital and Aberdeen Royal Infirmary (ARI). Mr C had developed diabetic retinopathy (a complication of diabetes, caused by high blood sugar levels damaging the back of the eye, which can cause blindness if left undiagnosed and untreated). He also complained about the impact the delays had on his sight, which he said left him almost blind, and about the delay in his treatment following routine diabetic screening by the board at a local health centre.

We took independent advice from a senior consultant 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 were delays in Mr C being seen following his initial appointment at Dr Gray's Hospital and following his original laser treatment at the hospital. It appeared that due to a failure in the booking system, the board failed to arrange a follow-up appointment for Mr C at ARI after his original laser treatment. The board accepted and apologised for this failing, and indicated that remedial action has been taken. However, we considered that further action should be taken by the board in this area and we addressed this in our recommendations. We upheld this part of Mr C's complaint.

In relation to the follow-up appointment's, we found that the delay contributed to him developing more severe diabetic retinopathy and the subsequent need for surgery. Although the surgery was successful, the poor clarity of vision that finally occurred was possibly not related to the delay and may have been due to other elements of diabetic retinopathy.

We also found that there was a long delay of over three months from Mr C's diabetic screening at the health centre to his laser treatment at ARI. This was outwith the timescales recommended and we considered that Mr C should have been seen within a shorter timescale. We noted it was difficult to determine whether the deterioration in Mr C's sight occurred as a consequence of the previous problems with diabetic retinopathy or whether this was a secondary event. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in his treatment following his initial appointment at Dr Gray's Hospital and following his diabetic screening at the health centre. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance .

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

• The board should have a follow-up system that ensures patients are seen within an appropriate time frame; and appropriately followed up across different sites. The system put in place should also take into account relevant standards/guidelines.