Upheld, recommendations

Summary

Ms C complained about the way her son (Mr A)'s psychiatrist dealt with communication from Mr A's father (Mr B). Mr A is estranged from Mr B, and the psychiatrist had been in contact with Mr B regarding some communication from Mr A to Mr B's work. Ms C and Mr A subsequently met the psychiatrist whose' contact with Mr B was discussed. Ms C said that the psychiatrist failed to deal with the matter in a reasonable way.

We took independent advice from a medical adviser. We found that the quality of record-keeping in relation to clinical decisions made and the rationale for these in relation to the communication was poor. We also found that the relevant guidelines in relation to consent was not followed. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for how communication with Mr B was handled. 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:

• Relevant staff should follow the General Medical Council guidance in relation to consent.
• Clinical records should be audited regularly.

Summary

Mr C complained that there was an unreasonable delay in being offered an ophthalmology (the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) appointment at Hairmyres Hospital following a referral by his optician with possible glaucoma (a common eye condition where the optic nerve becomes damaged).

We took independent advice from a consultant ophthalmologist. We found that it had been an unreasonable for Mr C to wait for seven months for the appointment. We noted that the board had apologised to Mr C for the unacceptable length of time he had had to wait for the appointment. We also found that there was a lack of documentation of the triaging process (a process in which things are ranked in terms of importance or priority) used by the board for referral to secondary ophthalmic care which made the auditing of the triage decisions impossible. We upheld Mr C's complaint.

Recommendations

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

• Cases of possible glaucoma who have optic disc and visual field changes typical of glaucoma should be seen within four to six weeks.
• Triage systems for referral to secondary ophthalmic care should be transparent and auditable and should specify the desired appointment time in weeks.

Summary

Mrs C complained about the nursing care that her late mother (Mrs A) received at Broadford Hospital. Mrs C had a number of concerns about the board's record-keeping and also complained about the communication from the nursing staff. Mrs A was admitted to the hospital where a provisional diagnosis of urinary sepsis (blood infection) was made. Mrs A also developed a pressure ulcer while at the hospital.

We took independent advice from a nursing adviser. We found that:

• daily checks on Mrs A's Peripheral Vascular Catheter were not recorded.

• a “Getting to Know Me” document was not in place for Mrs A.

• a Short Term Care Plan was in place for Mrs A for more than 48 hours.

• Mrs A's urine output was not recorded on the Feed/Fluid Balance Chart when she was being treated for sepsis.

• no Active Care or Care Rounding Charts were in place for Mrs A.

• the board failed to provide reasonable pressure ulcer care to Mrs A and there was no evidence that the family were informed of Mrs A's pressure ulcer.

The board also identified some record-keeping failures during their own investigation of Mrs C's complaint and said that they had taken steps to address these. We asked the board to provide evidence of the action they had already taken.

In light of the above, we upheld Mrs C's complaints that the board failed to provide Mrs A with reasonable nursing care and that the board failed to communicate reasonably with Mrs A's family.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mrs A with reasonable nursing care during her admission to hospital. The apology should meet the standard 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:

• Daily checks on Peripheral Vascular Catheters should be carried out and recorded in accordance with relevant standards.
• The appropriate care plan should be in place in accordance with relevant guidance.
• Patient Feed/Fluid Balance Charts should be completed in line with policy and guidance.
• There should be appropriate assessment, monitoring, recording and communication regarding patients at risk of developing pressure ulcers in accordance with relevant policies and guidance.
• A “Getting to Know Me” document should be used to support person centred care for older people in hospital, especially if they are frail.
• Active Care or Care Rounding Charts should be used to evidence that patients have been asked about their care and comfort needs.

Summary

Mrs C complained about the care and treatment her late husband (Mr A) received at Raigmore Hospital. Mr A had a history of numerous medical conditions and was seen in the cardiology department (the branch of medicine that deals with diseases and abnormalities of the heart) due to a build up of fluid. It was decided that no cardiac intervention was needed and the plan was to see Mr A again in six months, however, six weeks later he developed an infection and required to be admitted to hospital. Mr A's kidney function also deteriorated and treatment was aimed at aiding his heart function and fluid balance. Mr A's condition continued to deteriorate and he later died. Mrs C complained that Mr A's renal and cardiology care was unreasonable.

We took independent advice from consultants in cardiology and renal medicine. We found that Mr A's condition was a complex one and it was difficult to balance his heart function and fluid balance. Mr A's deteriorating kidneys meant that he retained more fluid which put a greater strain on his heart and there was a precarious balance to be achieved between his body having too much fluid and too little. This took a great deal of clinical skill and overall, his care and treatment had been reasonable. However, we also found that there had been inadequate cardiology follow-up after Mr A had been discharged from hospital, although this did not impact on his care. Furthermore, Mrs C and Mr A were unaware, until just before Mr A died, that he was most unlikely to survive. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff failed unreasonably to respond to Mr A's attempts to complain about his care and treatment and appeared unaware of the board's complaints procedure. We found that Mrs C and Mr A experienced difficulties in pursuing a complaint and upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to discuss Mr A's prognosis, to provide appropiate follow-up and for the lack of knowledge about the complaints process. 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:

• In patients with conditions that are likely to impact upon their prognosis, early discussion should be had with the patient and their family that is clear, unambiguous and documented.
• Cardiology patients should be appropriately followed-up/reviewed.
• All staff should be aware of the complaints process and able to advise accordingly.

Summary

Mr C complained about the way the practice handled his complaint.

We found that the practice failed to adhere to the NHS Scotland Model Complaints Handling Procedure (CHP). In particular they failed to acknowledge Mr C's complaint within three working days, failed to ensure that the complaint response detailed the right to bring the complaint to this office and failed to ensure that the complaint response addressed all the issues raised by Mr C. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to handle his 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.

In relation to complaints handling, we recommended:

• When responding to complaints the practice should follow their complaints handling procedure and all staff should be aware of this and the model CHP for the NHS.

Summary

Mr C complained about the care and treatment he received from the practice. In particular, Mr C complained that the practice did not perform more thorough examinations which he said resulted in a delay in him being diagnosed with cancer.

We took independent advice from a GP. We found that the practice failed to examine and document Mr C's sore throat at a consultation. Therefore, we upheld this aspect of Mr C's complaint. However, we found no evidence that the examination of Mr C's sore throat would have changed the practice's management plan for his symptoms or have an effect on his eventual diagnosis or clinical outcome.

Mr C also complained that the practice failed to handle his complaint reasonably. We found that there was an unreasonable delay in responding to Mr C's complaint and that the practice did not provide a copy of the Complaints Handling Procedure (CHP) to him promptly. Therefore, 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 failing to examine his sore throat at a consultation, the delay in responding to his complaint and failing to provide the CHP promptly. 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 should receive full and appropriate examinations based on their reported symptoms and these should be documented.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model CHP. The model CHP and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Mrs C complained that the board unreasonably refused to offer her a consultation or further treatment to address her facial scarring. The board advised they would not offer Mrs C an appointment as they did not consider her facial scarring would be amenable to treatment.

We took independent advice from a plastic surgeon (a surgeon who repairs or reconstructs missing or damaged tissue and skin). We found that the board wrongly triaged (a process in which things are ranked in terms of importance or priority) Mrs C's referral according to the relevant protocol. We considered that Mrs C should have been offered an out-patient appointment to be assessed more fully. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to triage her referral appropriately and for the failure to offer her a face-to-face appointment with a consultant. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Offer Mrs C an out-patient appointment for her to see an appropriate consultant.

Summary

Mr C complained that the care and treatment he received from the dentist was unreasonable. Mr C had a lump on his tongue and was concerned that he was not referred to oral health or a dental hospital which he said resulted in there being a delay in him being diagnosed with oral cancer.

We took independent advice from a dental adviser. We found that the clinical examination carried out by the dentist was reasonable and, given that the dentist suspected that the lump on Mr C's tongue was a result of trauma, it was reasonable that a topical anaesthetic mouthwash was prescribed and an appointment was made to review Mr C. However, we also found that the dentist had not recorded in Mr C's medical record anything about:

• the history of Mr C's complaint, his past dental history, past medical history and social history.

• the diagnosis considered at the time.

As good record-keeping is an important part of a patient's care and treatment, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to take a full history of his symptoms and record the diagnosis considered. 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:

• Good record-keeping should include a full history of a patient's symptoms and a record of the diagnosis considered.

Summary

Miss C complained about the care and treatment she received from a podiatrist (a physician who specialises in the study and medical treatment of disorders of the foot, ankle and lower extremity) at Glasgow Royal Infirmary for pain in her foot. Miss C said that the way the podiatrist handled her foot caused damage to it. Miss C also said that she was told she would be referred for an ultrasound guided steroid injection and that the podiatrist would follow up on this and ensure something was in place by her next podiatry appointment, but this did not happen.

We took independent advice from a podiatrist. Although it was not possible to determine exactly how the podiatrist handled Miss C's foot, we found that the evidence suggested that the initial manipulation/mobilisation treatment by the podiatrist did cause a flare up of Miss C's symptoms. This was accepted by the board and the podiatrist involved. The board said that the podiatrist apologised, however, there was no record of this. We noted that it would be reasonable to expect that mobilisation/manipulation might create an increase in symptoms, however, there did not appear to be any evidence that Miss C was informed of this or a record of her consent to the treatment. We also found that there were no treatment notes for any of Miss C's appointments.

In terms of the ultrasound guided steroid injection, it appeared that the podiatrist's referral letter for this was not received by the rheumatology department (the  branch of medicine specialising in rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) due to a system failure and this might have resulted in a delay in Miss C's treatment. Therefore, we upheld Miss C's complaint. However, we noted that the podiatrist apologised to Miss C for the length of time it took for review by some of the departments involved in her treatment. We found no evidence that Miss C was advised that the podiatrist would follow up on the steroid injection prior to her next appointment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to advise her that mobilisation and manipulation treatment could have the potential to exacerbate her symptoms, to obtain her consent for such treatment and adequately document this and for the failure in the referral process. 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 who are to receive mobilisation and manipulation treatment should be advised that the treatment can have the potential to exacerbate symptoms, where appropriate, their consent obtained and the information should be documented. There should be appropriate treatment notes for patients' appointments with podiatrists.
• The board should have a robust process in place for such referrals from podiatry to rheumatology.

Summary

Mr C complained about the care and treatment his late father (Mr A) received at Queen Elizabeth University Hospital. Mr A was taken to A&E by ambulance as he had a severe headache, light sensitivity and was vomiting. Mr A was taken for a CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) and was found to have suffered a brain haemorrhage (a type of stroke caused by a blood vessel rupturing, which causes bleeding in or around the brain). Mr A's treatment options were discussed with neurosurgeons (specialists in surgery on the nervous system, especially the brain and spinal cord). They considered that treatment would not be appropriate for him and that his outlook was poor. Mr A died in the hospital several hours later. Mr C complained that there was a delay in assessing Mr A and in carrying out a CT scan. Mr C considered that an earlier diagnosis and treatment could have saved Mr A's life.

We took independent advice from a consultant in emergency medicine. We found that there was an unreasonable delay of almost an hour in a nurse initially assessing Mr A at A&E. We found that although there was a high number of patients that day, Mr A's assessment should not have been delayed, as he had a time sensitive condition. We also found that there was an unreasonable delay in carrying out Mr A's CT scan, which was partly due to the delay in initially assessing Mr A and partly due to the lack of availability of a CT scanner. Therefore, we upheld Mr C's complaint.

We also took independent advice from a consultant neurosurgeon on the impact the delay had on Mr A's treatment options and outlook. We found that the nature of Mr A's condition was so serious that it would have been terminal even with an earlier diagnosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in assessing and triaging Mr A and in carrying out his CT scan. 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 with time critical conditions should be triaged and treated timeously.
• Patients should receive CT scans within a timescale appropriate to their need.