Upheld, recommendations

Summary

Mrs C complained about the care and treatment her late son (Mr A) received when he was admitted to the Western General Hospital. Mr A had duchenne muscular dystrophy (a genetic disorder characterised by progressive muscle degeneration and weakness) and an associated heart condition and was admitted to the hospital with abdominal pain and swelling. He died in the hospital a week after he was admitted.

We took independent advice from a consultant general surgeon and a nurse. We found that it had been reasonable to admit Mr A to a surgical ward. He was examined by a surgical registrar and the on-call medical registrar which was an example of good care. However, we found that there had been a number of failings in the care and treatment provided to Mr A. In particular that:

• he should have been treated by a multi-disciplinary group of consultants, including a cardiologist (a doctor who specialises in the study or treatment of heart diseases and heart abnormalities);

• it was unreasonable for a consultant from the hospital's ventilation service not to take appropriate steps to evaluate Mr A when they were informed of his admission;

• it was unreasonable not to record Mr A's fluid intake/output;

• staff failed to act appropriately on an abnormal CT scan;

• staff unreasonably failed to reconsider the diagnosis of kidney infection;

• it was unreasonable for a junior doctor to propose discharging him;

• communication between general surgery and urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system) was poor;

• no moving and handling assessment was carried out when Mr A was admitted to hospital; and

• no equipment was available for the safe movement and transfer of Mr A three days after he was admitted to hospital.

We upheld Mrs C's complaint about the care and treatment provided to Mr A, however, we found that it was highly likely that the outcome would have been the same for Mr A if these failings had not occurred.

Mrs C also complained that the communication with her family had been unreasonable. We found that whilst there was evidence of discussions with the family and of staff responding to their concerns, Mr A had complex needs and the family should have been involved in his care in a planned and collaborative way. There was no evidence of this. We found that there had been a lack of appropriate engagement with the family in the assessment and care planning for Mr A and that the communication with his family had been poor. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with reasonable care and treatment in the hospital and for the poor communication with her family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• The board should ensure that appropriate multi-disciplinary management is triggered when a deteriorating adult with duchenne muscular dystrophy is admitted to hospital.
• Patients identified as being at risk should have their fluid intake and output accurately monitored.
• The board should ensure that CT scans are acted on appropriately and that the diagnosis is reconsidered in the light of any new findings.
• Patients should be appropriately reviewed and discussed with a relevant member of staff before discharge is proposed.

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr  A) by the board. Mrs C was concerned that failings in Mr A's care and treatment led to his death. The cause of Mr A's death was pulmonary embolism (a blood clot in the lungs).

Mrs C complained that the board did not give Mr A an appropriate consultation or examination when he attended the out-of-hours service and was seen by a doctor and a nurse. We took independent advice from a GP adviser and from a nurse. We found that the board held no records of Mr A's consultation with the doctor or the nurse, and we considered this to be unreasonable. In response to our investigation, the board acknowledged that they did not hold adequate records. They said that a reminder had been issued to out-of-hours staff about good record-keeping standards, and that audits of reports had since been carried out. We asked to see evidence of this. We upheld this aspect of Mrs C's complaint.

Following Mr A's attendance at the out-of-hours service, he attended A&E at Monklands Hospital. Mrs C complained that appropriate investigations were not carried out. We took independent advice from a consultant in emergency medicine. We found that the majority of the investigations carried out in A&E were reasonable. We also found that the history and examinations undertaken would not reasonably have led doctors to suspect a pulmonary embolism. However, we found that there was a failure to investigate an abnormality on Mr  A's electrocardiogram (ECG - a test which records the electrical activity of the heart). This abnormality would indicate the possibility of an acute coronary sydrome (when the heart is not getting enough blood), which should have been excluded through further investigations. We noted that, even if these further investigations had been carried out, it is not possible to conclude that Mr A's pulmonary embolism would have been identified. We upheld this aspect of Mrs  C's complaint.

We also found that the board's own complaints investigation did not identify or address the failings in care provided to Mr A, and so we made a recommendation in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and her family for the failure to record the consultation with the doctor and the assessment carried out by the nurse at the out-of-hours service and the failure to investigate the abnormality on Mr A's ECG in A&E. 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:

• Abnormalities on patient ECG's carried out in A&E should be properly investigated.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

Summary

Mr C, a solicitor, complained on behalf of his client (Ms B) regarding the way the board managed her daughter's (Ms A) transition from paediatric services to adult services. In particular, Ms B was concerned about the co-ordination of Ms A's care and her ability to access services when she needed to.

We took independent advice from a consultant paediatrician. While we found evidence of good practice in relation to a number of areas of transition care, we found little evidence of co-ordinated planning to support transition. In particular, we considered that a healthcare professional responsible for managing and co-ordinating transition should have been identified, as indicated by the board's transition guidance. We further noted that the board's guidance did not appear to have been reviewed in line with the planned timescales for review. We found that the board had appropriately met with Ms A's family and listened to their concerns, however, there was also evidence that the board and Ms A's GP had differing views on who was leading clinically. On balance, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A and Ms B for the lack of coordination and support from a lead healthcare professional during the transition from paediatric services to adult services. 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:

• Clinical teams within paediatric and adult services should have structured discussion to contribute to the planning of patients' transitions and this should be documented.
• There should be guidance in place detailing a clear pathway for transition from children's to adult services for practitioners to use to guide transition management.
• Patients with complex health needs, their family members and carers should be properly informed about who is responsible for coordinating their care at difference stages of transition.

Summary

Miss C complained about the care and treatment provided to her late father (Mr  A) during admissions in Monklands Hospital and Coathill Hospital.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nurse with expertise in pressure ulcer prevention.

Miss C raised concern that Mr A, who had diabetes, was discharged from Monklands Hospital with a large pressure ulcer on his left foot. In response to Miss C's complaint, the board acknowledged that there was little documentation of the care provided for Mr A's feet and they apologised for this. We found no evidence that medical staff reviewed Mr A's feet during this admission and considered that this was unreasonable in the circumstances. We also found a number of failings in the way nursing staff assessed, documented and managed Mr A's feet during the admission. We noted that there was a delay in referral to the podiatry team (the area of medicine which deals with the feet and ankles) and no evidence that Mr A was physically reviewed by podiatry. Finally, we were critical about the lack of information and equipment given to Mr A and his family before discharge and that the board did not ensure that arrangements for ongoing care were in place. We upheld this aspect of Miss C's complaint.

During a subsequent admission in Coathill Hospital, Mr A was found to have fallen. Initially, no injuries were noted by either nursing or medical staff. When Mr A was reviewed by an occupational therapist the day following the fall, pain was noted yet this was not escalated to the medical team. The board apologised to Miss C for this failing. Two days following the fall, nursing staff found Mr A to be in pain and an x-ray was arranged. This identified that Mr A had a broken hip and he received treatment the following day. We found that the initial medical review did not appear to have included an examination to specifically assess if Mr A had suffered any injuries as a result of his fall. We also considered that there was an unreasonable delay in arranging an x-ray and diagnosing Mr A's hip fracture. 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 failings in nursing and medical care, failing to provide sufficient equipment and information prior to discharge, failing to ensure that arrangements for ongoing care were in place and the unreasonable delay in diagnosing Mr A's hip fracture. 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:

• Where a patient has a combination of poor blood supply, diabetes, and wounds on the feet, a medical examination should be carried out prior to discharge.
• All patients with diabetes who have existing foot damage or develop foot damage should be referred to podiatry as soon as the damage is discovered. Patients at risk of developing pressure damage to their feet should be assessed and fitted with protective footwear. Nursing staff should complete a wound assessment chart for every wound a patient has. Patients at risk of developing pressure damage or who have existing pressure damage should have a plan of care in place for interventions at least every two hours. Staff must be able to diagnose and grade pressure damage and accurately report their findings. Where a patient requires specialist assessment by a podiatrist a review should be carried out within a reasonable time.
• Patients and their families/carers should be provided with verbal and written information on pressure ulcer risk, details of a patient's pressure damage and how to manage this whilst preventing further damage, details of follow- up arrangements for wound dressing, a supply of wound dressings and pressure relieving footwear.
• Where a patient has fallen whilst in hospital, a medical examination for injury should be performed promptly.

Summary

Mr C complained on behalf of his mother (Mrs A) regarding cataract surgery (surgery which involves replacing the cloudy lens inside the eye with an artificial one) she received at Hairmyres Hospital. Mr C stated that the board failed to give his mother the appropriate priority for surgery and failed to provide surgery within a reasonable period of time.

We took independent advice from a 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 the categorisation of non-priority was reasonable according to nationwide practice. However, when Mr C notified the board that Mrs A's condition had deteriorated whilst she was on the waiting list for surgery, no further review of her condition was offered. This meant that there was no opportunity to assess if Mrs A required to move up the waiting list. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the surgery waiting time, we found that Mrs A was referred for an out-patient appointment outside the NHS target times. We noted that Mrs A could not be referred for surgery elsewhere in order to cut down on her waiting time due to her condition and the density of her cataract. However, Mrs A was given surgery 22 weeks after being listed for surgery which was outside the NHS treatment guarantee time of 12 weeks. We upheld this aspect of Mr C's complaint. However, we acknowledged that the board had apologised for this delay which reflects the current situation nationwide due to the demand on the NHS for eye surgery.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for the failure to re-assess Mrs A whilst she was on the waiting list to establish if her priority for surgery had changed. 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:

• Where the patient, relative or GP notifies the board of rapid deterioration, steps should be taken to re-assess the patient to establish if their prioritisation for surgery has changed.

Summary

Ms C complained about the care and treatment she received at Royal Alexandra Hospital following the birth of her daughter. Ms C felt that staff did not provide her with advice on breastfeeding techniques. She also raised concern that staff denied her a medical review, despite the fact that she felt she had suffered a lot of blood loss. As a result of her dissatisfaction with the care provided, Ms C discharged herself from hospital against medical advice and put her care in the hands of the community midwife team instead.

We took independent advice from a midwife. We found that, although there was evidence that Ms C had received some advice and support regarding breastfeeding, it was not to the standard expected in the board's breastfeeding policy. There was also a lack of entries in the records regarding communication in the immediate post-natal period. From a clinical perspective, there were no concerns about the amount of blood which Ms C had lost, and we found that she was kept under appropriate medical review. On balance, given the failings in record-keeping and communication, we considered that there was a failing in care and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to provide her with breastfeeding advice and support in line with the board's policy. 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:

• Staff should be aware of the board's breastfeeding policy in order that appropriate advice and support is provided to new mothers.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's late wife (Mrs  A) when she was an in-patient at Queen Elizabeth University Hospital.

We took independent advice from a consultant physician. We found that, on one occasion, Mrs A was not given her dose of insulin, and that the reasons for this were not clear. We found that this resulted in Mrs A developing diabetic ketoacidosis (DKA – a potentially life threatening complication of diabetes, which happens when the body starts running out of insulin), and that there was a delay in the DKA protocol being commenced. We also found that there was a failure in communication between medical and nursing staff around the plan to measure Mrs A's blood pressure. There were also inconsistencies in recording Mrs A's intolerance to certain medication. We found that Mrs A was prescribed a medication which she had an intolerance to without the rationale for this decision being recorded.

We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to provide reasonable care and treatment to Mrs A with regards to administration of insulin, the delay in DKA protocol being commenced and the poor management of medication. 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 the importance of insulin in patients with Type 1 diabetes. Diabetes medication should be given when required, and reasons for not doing this should be clearly documented.
• The DKA protocol should be commenced within the appropriate timeframe wherever possible.
• There should be one clear way for communicating tasks and results between staff groups. This should include a way for medical staff to remember what investigations and instructions they are awaiting the results of.
• Allergy/intolerance information should be recorded consistently.
• If medication is to be prescribed despite a recorded allergy/intolerance, the reasons for this should be documented.

Summary

Mr C complained about the care and treatment he received at New Victoria Hospital. Mr C had been experiencing ongoing and worsening pain in his hip region and considered that there was an unreasonable delay in treating the cause of this pain.

We took independent medical advice from a consultant orthopaedic surgeon (a  surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system).

We found that appropriate investigations were carried out to find the cause of Mr  C's hip pain but the cause of his hip pain was still unclear following these. Mr  C was referred for physiotherapy to see if that improved his condition. However, there was an unreasonable delay in offering Mr C a physiotherapy appointment. This was due to an error in the referral process, as the referral was not received by physiotherapy. We considered this delay to be unreasonable and upheld Mr C's complaint. However, we noted that the board had acknowledged and apologised for this delay.

Recommendations

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

• There should be an appropriate process in place between orthopaedics and physiotherapy to ensure that referrals are received.

Summary

Ms C complained about the care and treatment her late mother (Mrs A) received at Beatson West of Scotland Cancer Centre for metastatic breast cancer. Ms C raised concerns that there were delays between scans and treatment for Mrs A, and in particular that there was a lack of urgency when Mrs A's kidneys were failing.

We took independent advice from an oncology consultant (a specialist in the study and treatment of tumours). We found that whilst overall the scans and treatment for Mrs A's cancer were reasonable, when Mrs A's worsening kidney function was noted in a scan there was a delay in referring her to urology (the  branch of medicine and physiology concerned with the function and disorders of the urinary system). The referral was then lost which the board acknowledged and apologised for. However, they did not explain what action they had taken to prevent this reoccurring in the future, therefore, we made a recommendation on this matter. We also found that when a scan showed that there was disease progression, this should have been escalated to Mrs A's consultant in a more timely manner to allow a discussion regarding stopping Mrs  A's treatment to happen more quickly. We considered the care and treatment provided to Mrs A was unreasonable and upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the delay in referring Mrs A to urology and that the results of the scan which showed disease progression were not escalated to the consultant more 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:

• There should be a policy for escalating significant findings of investigations, in particular scans, to the relevant team or on call team in order to ensure that any required actions regarding these findings are not delayed until a patient attends clinic.
• There should be a system in place to ensure that referrals to urology are acknowledged and acted upon to prevent the situation of a referral letter going missing or not being acted upon.
• Patients with disease progression should have their results escalated to the consultant caring for them as quickly as possible to enable any discussion regarding stopping of treatment and switching to best supportive care to take place as soon as possible.

Summary

Mrs C complained about the care and treatment provided to her late mother (Ms  A) at Woodland View. Ms A was transferred there for rehabilitation after several weeks in hospital, where she was treated for recurrent urinary tract infections (UTIs), and delirium. Ms A suffered further UTIs and did not make progress with her medication. She was transferred to a mental health ward for treatment of her delirium, low mood and physical symptoms. Ms A also had a background history of bipolar disorder (a mental health condition marked by alternating periods of elation and depression). Ms A's condition deteriorated further and she was transferred back to hospital with aspiration pneumonia (a  type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). She was given palliative care and died in hospital.

Mrs C complained that there was inadequate care planning to manage Ms A's delirium and UTIs. She felt staff focussed on Ms A's age and bipolar disorder as an explanation for her condition and did not fully appreciate the impact of the UTIs and delirium. Mrs C was also concerned about the way the hospital and ward transitions were managed, and about Ms A's overall care and treatment. Mrs C said she was not involved in care planning and decisions, despite being Ms A's carer and welfare power of attorney, and she felt some nursing staff were hostile or resistant when she made suggestions for Ms A's care. The board met with Mrs C when she first complained (during Ms A's admission) and a number of actions were agreed, but Mrs C said these were never completed. The board also gave a written response to Mrs C's later complaint (following Ms A's transfer back to hospital). Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse. We found there was a lack of proactive care planning for Ms A's UTIs and delirium at times, and Ms A had also had an untreated UTI for about ten days. While we did not find evidence that staff were hostile or lacked compassion, we found that Mrs C was not always included in care planning for her mother, and there were not always clear and comprehensive records of communication. We also found that the board did not have evidence to show they had fully followed through on some of the actions agreed at the complaint meeting. We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in care planning, communication and complaint handling. 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:

• Where a patient suffers from recurrent urinary tract infections and/or delirium, there should be dedicated care planning to address this (and this should be carried over where a patient changes wards).
• The patient's carer or welfare power of attorney should be fully and proactively involved in care planning.

In relation to complaints handling, we recommended:

• Any actions agreed following a complaint should be completed.
• Where a complaint investigation finds that errors or failings have occurred (although not in relation to the specific complaints raised), the board should still acknowledge and apologise for this.