Upheld, recommendations

Summary

Ms C complained to us on behalf of her sister (Ms A). Ms A had sustained a head injury after a climbing accident. She attended hospital and was kept in overnight. After being discharged, Ms A became unwell, was visited at home by an out-of-hours GP and was then taken by ambulance to the emergency department at another hospital, St John's Hospital. She was diagnosed with post-concussion syndrome (when concussion symptoms last for weeks or even months after the injury which caused the concussion) and was discharged home. Ms A still felt unwell and was subsequently admitted to a third hospital and where she was diagnosed as having had a series of mini-strokes. Ms C complained that the board failed to provide Ms A with appropriate care and treatment when she attended St John's Hospital and unreasonably discharged Ms A from St John's hospital.

We took independent advice from a consultant in emergency medicine, a general medicine consultant with experience in stroke medicine and a radiologist (a doctor who uses medical imaging such as x-rays, ultrasounds and scans). We found that there were two documented symptoms that should have prompted the emergency staff to consider a diagnosis of stroke for Ms A. We also found failings in the board’s handling of the radiology aspects of Ms C’s complaint and her concerns about the out-of-hours GP’s notes on their assessment of Ms A. We upheld this aspect of Ms C's complaint.

In terms of Ms A’s discharge, we found that Ms A was not well enough to have been sent home and should not have been discharged from hospital. We considered that her working diagnosis should have been stroke, not post-concussion syndrome, and she should have been referred to the hospital’s stroke team. We, therefore, upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Ms A for the failings in Ms A’s care and treatment, her discharge from hospital and the investigation of Ms C's complaint. 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:

• Emergency department staff should note key symptoms and reach an appropriate diagnosis, in a case such as this.
• Patients should not be discharged in circumstances such as this.

In relation to complaints handling, we recommended:

• Issues set out by patients in their complaints should be raised with relevant staff in a timeous manner.
• Complaints should be fully and appropriately investigated.

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, an advocacy worker, complained on behalf of her client (Ms A) that the board failed to provide Ms A with a reasonable standard of mental health care and treatment. Ms A suffered from long term anxiety and depression and was referred for assessment at New Craigs Psychiatric Hospital. She was diagnosed with hypomania (a less severe form of the manic phase of bipolar affective disorder) and was started on the appropriate medication for this diagnosis. Three months later, Ms A was informed that she had been misdiagnosed and was advised to slowly come off the medication. The board apologised to Ms A for this error in diagnosis and acknowledged the distress the consequences had caused her. Ms A was unhappy with this response and Mrs C brought her complaint to us.

We took independent advice from a consultant in forensic psychiatry. They noted that Ms A's medical records did not detail what, if any, action was taken to explore other options to carry out a second opinion following a request from Ms A. We also found that the board unreasonably prescribed Ms A third level medication (medication prescribed if the first two are insufficient) in the first instance. Although this decision may not have been unreasonable itself, we found that the reasoning for this prescription was not clearly recorded. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to record the justification for her prescription and for failing to document whether all reasonable options were explored in response to her request for a second opinion. 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:

• Prescribing clinicians should be mindful of current clinical guidelines and ensure that they document decisions with sufficient detail to support the rationale for treatment options.
• Processes should be in place to ensure reasonable requests for second opinions are met.
• Clinical staff should keep accurate and sufficiently detailed clinical 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

Mrs C complained that the board did not adequately investigate and treat the cause of her back pain.

We took independent advice from an orthopaedic surgeon (a surgeon who specialises in the musculoskeltal system). We found that the board did not evidence that a full history and examination of Mrs C was carried out at her out-patient appointment, and that the discharge letter to Mrs C’s GP did not detail any treatment plan. We considered this to be unreasonable. We also found that, following Mrs C’s assessment and examination, her case was not discussed with a consultant prior to any decisions being made about her care and treatment. There was delay in Mrs C receiving treatment at the pain clinic which was partly due to a delay in the board dictating the referral letter. We found that this delay was unreasonable and exceeded the national waiting time standards. We upheld Mrs C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to take an adequate history and examination and for the delay in treatment.

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

• Orthopaedic Registrars should be reminded about the importance of good record-keeping, which should include a detailed history and examination and the treatment plan.
• Decisions about patient care within the Orthopaedic Spinal service should be made with appropriate senior supervision and this should be recorded.
• Orthopaedic Registrars should adhere to reasonable timescales when dictating medical correspondence.
• Patients with chronic back pain should be treated within national wait time standards. The board should consider advising patients in a timely manner that they may not be seen within waiting time targets.

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 has a chronic abdominal condition and regularly requires hospital treatment for severe pain and sickness. He was taken by ambulance to Glasgow Royal Infirmary (GRI), suffering from these symptoms. He told us that he advised the doctor treating him that he was ordinarily treated with a morphine drip. Instead, he was given oral pain relief, although he said he was vomiting repeatedly. After becoming frustrated with staff he was asked to leave under police escort, and required medical treatment at another hospital later that day. He complained that he was not given adequate pain relief or treatment at GRI.

We took independent advice from an adviser who specialises in acute and general medicine. We found that it was not apparent from the records whether an adequate assessment of Mr C’s pain had been carried out. We also noted no documentation of the events causing him to be asked to leave/escorted out, which we considered unreasonable. The adviser could see no definite cause for concern about the proposed treatment plan from GRI, but they noted that Mr C had chronic abdominal pain and that the pattern of his admissions made it likely that he would require admission for pain relief and that oral pain relief would be unlikely to manage his pain sufficiently.

We considered that, if Mr C had been aggressive and abusive to staff, it was reasonable to ask him to leave. We found that if he was tolerating oral pain relief and his pain had improved, then it was also appropriate that he was discharged. However, we found that it was not reasonable that none of this was documented. If Mr C’s pain was not controlled on oral medication, other routes or forms of pain relief should have been tried prior to discharge, assuming that staff were not placed in danger when attempting this. Without an adequate assessment of his pain having been recorded, we were not able to say with any certainty that his treatment was reasonable, or whether further steps to control his pain should have been taken at that time.

On balance, we upheld Mr C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the lack of evidence of an adequate assessment of Mr C's pain, and for not adequately recording the circumstances surrounding them asking him to leave. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Given Mr C's condition is chronic, the board should put in place a care plan for him. This should cover pain control (what to try, what route to administer), likelihood of requiring admission, which team to admit under, risk of self-discharge, risk of violence and aggression, and how to manage any behaviour perceived as violent or aggressive.

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

• Staff should be familiar with Royal College of Emergency Medicine Best Practice Guideline ‘Management of Pain in Adults’ December 2014. They should clearly document their assessment of patients’ pain.
• There should be clear guidelines in place for pain management. Junior doctors should be trained in pain management.
• All relevant staff should be trained in dealing with violence and aggression and understand the importance of documentation in these situations.

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

For a number of years, Mr C had suffered with arthritis (inflamation of the joints) and had problems with his ankle and his knee. He attended the Glasgow Ambulatory Care Hospital, where it was considered that he would be suitable for an ankle procedure. However, it was decided that the opinion of a knee specialist should be obtained first. Mr C complained that he had to wait an unduly long period of time before he was given appropriate treatment.

We took independent advice from a consultant orthopaedic surgeon (a doctor who specialises in conditions involving the musculoskeletal system). We found that Mr C was suffering a complex condition and that it was reasonable for his care to involve multiple consultants. However, we also found that Mr C had to wait an unreasonable amount of time before he saw a knee surgeon in the first instance, and that having a combined consultation may have been more effective. Whilst we found that the subsequent care and treatment were reasonable, we upheld the complaint due to the initial delay in Mr C seeing a knee surgeon.

Mr C also complained about poor communication. We found that he appeared not to understand the reasons for the number of consultants involved in his care, and he had not understood his care plan. We considered that these issues were avoidable, and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• An apology should be sent to Mr C for the delay in obtaining the knee surgeon's opinion. 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:

• Inter-departmental clinical referrals should be made within a reasonable time.
• The clinician concerned should take care to ensure that their communication with patients is understood.

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 that the Royal Hospital for Sick Children Glasgow unreasonably failed to accept a referral from her daughter (Miss A)'s GP. The GP had made the referral to endocrinology (a branch of medicine dealing with hormones) for Miss A to be assessed for her diagnosis of hypothyroidism (under active thyroid). Miss A's thyroid function tests had been reported as normal and the board rejected the referral. Ms C felt that it was wrong that the board refused to see Miss A as she was reporting symptoms which needed to be addressed.

We took independent advice from a consultant endocrinologist. We found that, although the thyroid function tests were normal, Miss A was still showing symptoms relating to hypothyroidism. It would have been reasonable for the board to have seen Miss A and her family, where they could have discussed the symptoms in more detail and explored potential explanations as to why Miss A was feeling the way she did. Alternatively, if they remained of the view that a consultation was not required, then they could have provided the GP with suggestions of what further investigations or assessments could be arranged through the primary care setting. This may have led to additional diagnoses being discovered. We considered that the board could have been more proactive when considering the GP referral. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to see Miss A at a consultation or to have provided advice to her GP about alternative treatment or investigations. 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 cases where staff do not consider that a GP referral warrants a consultation, they should consider providing the GP with information about alternative treatments or investigations if 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

Ms C's child (Child A) was admitted to hospital and diagnosed with hydrocephalus (a build-up of fluid on the brain). Ms C complained that the health visiting team failed to take adequate steps to identify Child A's hydrocephalus before the admission to hospital. She also considered that the board failed to investigate her complaint appropriately.

We took independent advice from a health visitor. We found that some of Child A's growth measurements were not taken properly. At the six week assessment (where a decision is taken about future monitoring of growth), we found that some of their measurements were not accurately recorded or plotted in the 'red book' (a national standard health and development record given to parents/carers at a child's birth). Therefore, there was a failure to recognise Child A's small length which would have required a plan to be put in place for further observation and measurement. We also found a failure to assess the discrepancy in the three measurements taken of Child A's weight, length and head circumference. We considered that if steps had been put in place to closely monitor growth, then the health vising team may have identified Child A's hydrocephalus. We upheld this aspect of Ms C's complaint.

In relation to the board's handling of the complaint, we found that the board did not identify or acknowledge that some growth measurements were not properly taken, recorded or plotted. It would have been reasonable to expect that the board would have looked carefully at the measurements and centiles taken and recorded in the red book. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to correctly record Child A's measurements, analyse them and put in place steps to closely monitor their growth. 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:

• To ensure all relevant staff understand how to use and interpret UK-WHO Growth charts in accordance with the requirements of the Royal College of Paediatric and Child health doctors.
• To ensure all relevant staff understand the importance and use of the red book so that information is accurately and consistently documented.
• There should be a review of compliance with the Universal Health Visiting Pathway and a timeline provided for this review.

In relation to complaints handling, we recommended:

• The board should ensure that in investigating complaints they scrutinise evidence carefully.

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 she received from her dentist. When Mrs C developed toothache, she was advised by a different dentist that her tooth needed to be extracted. Mrs C questioned why her tooth was left to decay to such an extent without any prior treatment. She complained that the first dentist failed to record the findings of an x-ray taken of her teeth which led to her tooth not being monitored properly. The dentist acknowledged that they did not record the findings of the x-ray, however they expected any subsequent dentist to review the patient's dental records, including the x-ray.

We took independent advice from a dentist. We found that it would not be reasonable to expect a subsequent dentist to review the x-ray, as they would expect a report of the findings to be included in the patient's records. We concluded that Mrs C's dentist had failed to record the findings of the radiograph in line with the relevant guidance, and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to record the findings of the x-ray. 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:

• Ensure knowledge and future compliance with the Radiation (Medical Exposure) Regulations (2000) and the Faculty of General Dental Practice guidance on Clinical Examination and Record Keeping Standards.
• Ensure knowledge of and future compliance with the Faculty of General Dental Practice guidance on Selection Criteria for Dental Radiography.
• The dentist should ensure full understanding and compliance with the Standards for the Dental Team.

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) about the care and treatment they received at Victoria Hospital. Child A was prescribed various drugs to try to manage their epilepsy (a seizure disorder), including one called phenytoin. Child A later had to be treated in hospital for an overdose of phenytoin. Ms C's main concern was that Child A was not appropriately monitored by the board, which allowed this high level of phenytoin to build up in their blood. Ms C also complained about the board's handling of her complaint.

We took independent medical advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that, when Child A's dose of phenytoin was increased at their clinic review, they were appropriately referred for blood tests to monitor the impact of this increase. However, we found that the clinic review was not appropriately recorded and that there was an unreasonable delay in communicating with her GP about it. We found that the results of Child A's blood tests showed a surprising level of phenytoin in their blood, which should have prompted a clinical review. We also found that appropriate action should then have been taken, which would have been to repeat the blood tests. We upheld this aspect of Ms C's complaint.

Regarding complaints handling, we found that the board delayed in acknowledging Ms C's complaint. We also found that they failed to communicate appropriately with Ms C both during and at the conclusion of their investigation. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to appropriately monitor child A; for the issue identified with record-keeping and GP communication; and for their communication with Ms C in relation to her complaint. 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 results of blood tests carried out to monitor phenytoin levels should be clinically reviewed and actioned appropriately.
• Clinical appointments should be recorded appropriately and actions should be shared with primary care/patients in a timely manner.

In relation to complaints handling, we recommended:

• Updates should be provided to complainants when the twenty working day timescale will not be met; and follow-up correspondence should be responded to appropriately.

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 her late husband (Mr A) received at Galloway Community Hospital after he attended the emergency department (ED) with chest pain. Mr A was diagnosed with gastritis (inflammation of the stomach lining) and was discharged home. He died shortly after from a pulmonary embolism (PE, a blood clot in the blood vessel that carries blood from the heart to the lungs). Mrs C was concerned that Mr A was discharged from the ED without a troponin test (a type of blood test to help confirm or exclude damage to the heart) being carried out. Mrs C also questioned why the ED doctor had not suspected a blood clot when they were aware that Mr A had been treated previously for prostate cancer.

The board carried out a critical incident review of Mr A's care and treatment. They found that a repeat electrocardiogram (ECG, a test that records the electrical activity of the heart) should have been performed given abnormalities had been identified and that a troponin test should have been done. In addition, there was no record of family history/other relevant factors. The board said that they would share these findings with the staff involved in order to ensure learning and undertook to source readily available out-of-hours troponin testing at Galloway Community Hospital.

We took independent advice from a consultant in emergency medicine. We did not consider that Mr A's symptoms were indicative of a PE, however, we determined that it was unreasonable to discharge him with a diagnosis of gastritis. We found that Mr A should have been admitted to hospital and that a repeat ECG and troponin test should have been undertaken. We, therefore, upheld Mrs C's complaint. However, we considered that it was unlikely Mr A's outcome would have been different because ECG and troponin testing is not a test for PE.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to admit Mr A to hospital, arrange a repeat ECG scan, and obtain a blood troponin measurement. 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 ensure in similar circumstances that patients are admitted to hospital.

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.