Upheld, recommendations

Summary

Mrs C complained that the board unreasonably discharged her from a community mental health team. She believed that she was discharged due to the absence of her usual community psychiatric nurse (CPN), who had been off work for a number of months at the time of discharge. Mrs C said that she had not been regularly seen or supported during this absence, only receiving two appointments, the focus of which were her discharge from services. While complaining to the board, she also became aware that her previous diagnosis of bipolar disorder (a mental health condition marked by alternating periods of elation and depression) had been changed to a possible diagnosis of borderline personality disorder (BPD, a disorder of mood and how a person interacts with others). Mrs C complained that she had never been informed of this change and that the board failed to communicate with her appropriately.

We took independent advice from a CPN. We found no evidence to suggest that Mrs C's discharge was related to staffing issues. Prior to the CPN's absence, she had a clear care plan in place and was being seen around every two weeks. One of the aims of the plan was to explore a possible alternative diagnosis of BPD. There was also recorded agreement that any future discharge would be clearly planned in advance and communicated, to ensure that this happened in a supportive manner. We considered that the overall decison to discharge Mrs C was reasonable. However, the adviser explained that, under Scottish Government guidance, the board should have implemented an Integrated Care Pathway (ICP) which would define the care and support offered to people with personality disorders. We noted that it did not appear that the board had an ICP in place for BPD.

We also found that there was a lack of continuity in the support provided to Mrs  C once her CPN was absent. Prior to discharge, Mrs C had been without support for around four months, despite her care plan stipulating that she would be seen every two weeks. The adviser noted that the care plan should have been updated to reflect the CPN's absence but this did not happen. They also confirmed that, while Mrs C was aware that a diagnosis of BPD was being considered, no formal diagnosis had been given. However, they noted that Mrs C had now been referred back to the board for the specific purpose of reaching a clear diagnosis.

Overall we found that the decision to discharge Mrs C was reasonable. However, the manner that this was handled and communicated to Mrs C was not in line with the agreed care plan or relevant guidance. Therefore, we upheld both of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to appropriately handle her discharge and failing to clearly communicate her change of diagnosis. 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 an ICP to guide care provision for patients with BPD.
• Care plans should be reviewed and appropriately amended when a member of staff is absent from work long-term to ensure consistency of care.

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 provided to her late husband (Mr  A) at Ninewells Hospital. Mr A was resident in a care home and had Alzheimer's disease. He was referred to the emergency department by his GP as he was suffering from hip pain and could not bear weight. The GP asked that staff at the hospital rule out bony injury as a cause of Mr A's symptoms. X-rays were carried out and Mr A was discharged back to the care home after staff found no significant changes from previous x-rays. Four days later, an emergency referral was made for Mr A and he was admitted to hospital. Subsequent tests showed that Mr A had an abscess (a painful swelling caused by a build-up of pus) in his hip. It was determined that he was not suitable for surgery and Mr A was referred to the palliative (end of life) care team. Mr A died in hospital a few days later. Mrs C complained that Mr A's care in the emergency department was unreasonable and that there had been confusion over his palliative care referral. She also complained about how the board handled her complaint.

We took independent advice from an acute care consultant and from an emergency medicine consultant. The advice highlighted that Mr A's pain and inability to straighten his leg should have prompted further action by the staff who saw him in the emergency department. However, there was no indication that earlier treatment would have changed the outcome for Mr A. We also found that national guidance from the Scottish Intercollegiate Guidelines Network (SIGN) in SIGN 111 recommended tests that could have identified Mr A's infection earlier and that the care he received fell short of what he required as a patient with dementia. Therefore, we found that the care and treatment Mr A received was unreasonable and upheld this aspect of Mrs C's complaint.

In relation to communication around palliative care arrangements, we found that the board had identified failings and had apologised to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint but made no recommendations as we considered that this had been adequately dealt with by the board.

Finally, we found that Mrs C had not been kept properly updated during the complaints process, which exceeded the 20 working day timescale set out in the board's complaints handling procedure. 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 the decision to discharge Mr A without further investigation of the cause of his hip pain and for the failings in the handling of her complaint. 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:

• Emergency department staff should take appropriate account of patients' cognitive impairments given that these make them more vulnerable to healthcare associated harm.
• SIGN 111 should be followed for patients with suspected hip fracture.

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, who works for an advocacy and support agency, complained on behalf of her client (Mrs A) that the consent process followed for an above knee amputation of Mrs A's leg was unreasonable. Mrs A had been admitted to Balfour Hospital for treatment of severe chronic leg ulcers and amputation was planned when other options were exhausted.

We took independent advice from a consultant physician. Although we found that Mrs A had been fully aware of the plan for surgery and had discussed this with staff on the ward, we found that the consent form had not been signed until the day of the procedure. We also found that there was a lack of evidence in both the medical records and the consent form to confirm that the risks and benefits of the surgery were appropriately discussed with Mrs A. The advice we received highlighted that this did not follow national guidance on consent and that, while Mrs A's post-operative care was appropriate, her delirium had not been monitored using the appropriate test. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A that the consent process for her above the knee amputation was unreasonable. 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 consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery and what is discussed as part of the consent taking process, including risks and benefits, should be documented.
• Where appropriate, patients should be tested for post-operative delirium.

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 complained about treatment he received at the Royal Infirmary Edinburgh after suffering a head injury. He raised concerns that the board had failed to identify a fracture to his skull on his first attendance, as they did not carry out a CT scan until he was referred back to hospital by his GP two days after being discharged.

This case was very similar to a complaint we had recently upheld (201508264). In that case, we recommended that the board carry out an audit of similar head injury cases treated at the hospital. As the audit was still in progress at the time of Mr C's complaint, we asked the board to include his case in their consideration. They did so, and repeated what they had told Mr C in their response to his complaint - that they considered the treatment he received was appropriate. They also maintained this position in response to enquiries we made throughout our investigation.

We took independent advice from a consultant in emergency medicine. The adviser told us that the board's failure to carry out a CT scan on Mr C's first admission was unreasonable as the board had recorded that Mr C had a severe and persisting headache and Mr C had suffered a fall from a height greater than one metre. Under guidance from the Scottish Intercollegiate Guidelines Network  (SIGN) and the board's protocol in place at that time, this should have led to a CT scan being arranged. We also found that the board had failed to carry out enough observations of Mr C's level of consciousness. In particular, the board had failed to record that Mr C was reviewed by an experienced doctor before being discharged. SIGN guidelines specify that an experienced doctor should review all head injury patients before they are discharged to ensure that six specific criteria are met. However, this failling had since been remedied by a new procedure implemented following case 201508264.

We were also concerned that, despite a number of these failings being a repetition of those highlighted in case 201508264, the board had failed to identify the failings, either in response to Mr C's complaint, as part of the audit they carried out into his care or when responding to our enquiries. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide appropriate treatment for his head injury. 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:

• All staff should follow the protocols in place with regards to patients with head injuries.

In relation to complaints handling, we recommended:

• The board's investigations at all stages should identify failures in care and, where failings are identified, make proportionate changes to avoid similar mistakes in future.

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 complained about the care and treatment his late wife (Mrs A) received while she was a patient in Wishaw General Hospital. Mr C was concerned about both the medical and nursing care Mrs A received, and about the way that the board handled his complaint.

In regards to Mrs A's medical treatment, Mr C questioned the length of time a central line (a tube placed by needle into a large, central vein of the body to administer drugs or take blood samples) was in place. Mr C also complained that there was an unreasonable delay by medical staff in reviewing blood test results, and subsequently in Mrs A receiving antibiotics. Mr C believed that, because of poor treatment, Mrs A was denied the opportunity of starting chemotherapy treatment.

We took independent advice from a consultant general surgeon with experience in oncology (cancer treatment) We found that, following Mrs A's admission surgery and further investigations being carried out, it was confirmed that she had extensive, incurable cancer and all further treatment was to be palliative (end of life care). We considered that the length of time Mrs A's central line was in place and the actions of medical staff in prioritising the alleviation of Mrs A's severe pain was reasonable. However, we found that there was a significant delay of several hours in reviewing Mrs A's blood test results and starting appropriate antibiotics. While we found that it was unlikely that the delay in starting antibiotics significantly changed Mrs A's outcome, given her underlying condition and poor prognosis, the delay was unacceptable. Therefore, we upheld this aspect of Mr  C's complaint. The board had already acknowledged that there was an unacceptable delay, due to a breakdown in communication involving both junior and senior doctors, and had noted that this has been addressed with staff.

In relation to Mrs A's nursing care, Mr C was concerned over elements of record- keeping and the frequency and recording of some of Mrs A's observations by nursing staff. We took independent advice from a nurse. We found that certain aspects of Mrs A's nursing care were good however, both advisers noted failings in the quality of the completion of some of Mrs A's records and in the frequency of her observations. Therefore, we upheld this aspect of Mr C's complaint. The board had already acknowledged that these issues were unacceptable and noted that they had apologised and taken action.

Finally, Mr C was dissatisfied with the board's response to the concerns he and his family raised about Mrs A's care and treatment. In relation to a meeting which was held to discuss Mr C's concerns, we identified certain aspects that we found to be unreasonable. For this reason, we considered that the board had not responded reasonably to Mr C's complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failings identified including a breakdown in communication causing a significant delay in reviewing Mrs  A's blood test results and starting appropriate antibiotics failings by nursing staff in record keeping; and a failure to respond to concerns raised by Mr C and his family following a meeting. 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:

• Current practices and processes and the working relationship between junior and senior doctors should be improved to minimise the risk of a future similar event occurring. Ensure that the importance of effective handover is emphasised as part of a junior doctor's induction. Ensure appropriate timescales are in place for requesting, performing and documenting results, and actions taken, for investigations such as blood tests.
• Nursing observations should be carried out in line with the board's Medical  Early Warning flowchart and the scoring system should be accurately applied. Nursing care charts and care bundles should be completed accurately and in line with the Nursing and Midwifery Council's guidance on record-keeping. The board should reissue relevant staff with their central line care policy and provide appropriate education to staff to support this. Also, senior nurses should routinely audit compliance with the central line maintenance bundle.

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 attended the emergency department of Glasgow Royal Infirmary twice with severe abdominal pain. On both occasions, Mrs C was told she had stomach flu and was discharged home. Mrs C's GP decided to refer her to the hospital's surgical department, as she was still in severe pain. She was then found to have a hernia (a condition where an internal part of the bodypushes through a weakness in the muscle or surrounding tissue wall) in her stomach and a small bowel obstruction.

Mrs C complained that the board failed to give her appropriate care and treatment during her two attendances to the emergency department. Specifically, Mrs C complained that she was misdiagnosed with stomach flu and was not given appropriate pain relief.

We took independent advice from a consultant in emergency medicine and from a nurse. We found that all appropriate investigations were carried out into Mrs  C's condition on both occassions. On the basis of those investigations, we considered that it was reasonable that Mrs C was diagnosed with stomach flu. However, we found that Mrs C's pain level was not appropriately assessed or recorded and that there was an unreasonable delay in giving her pain relief medication. Therefore, 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 appropriately assess and record her level of pain, and for the delay in giving her pain relief 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:

• Pain levels should be assessed and recorded appropriately. Timely and appropriate pain relief should then be provided to patients, and staff should check with patients whether they require pain relief medication.

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 practice failed to carry out appropriate checks for allergies before prescribing penicillin. Mrs C was visited by a GP at home and prescribed an antibiotic containing penicillin which she is allergic to. Mrs C did not suffer any ill-effects as she read the information on the packet and therefore did not take the medication. The practice said that the GP asked Mrs C if she was allergic to penicillin before prescribing, which Mrs C denies. They also noted that doctors do not have sight of patients' medical records when on house calls but that the GP looked at the patient's medical summary before the appointment.

We took independent advice from a GP. They considered that it was reasonable for the surgery to check a patient's records before leaving the practice and to ask the patient if they were allergic to any medications. We found that Mrs C's penicillin allergy was noted on the medical summary the GP said that they had referred to. We considered that if the GP had checked this first they ought to have been alert to prescribing penicillin in a patient with allergies. Although the practice acted reasonably in checking the medical records before the home visit, we considered the allergy should have been picked up then. 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 take sufficient steps to establish that she was allergic to penicillin, and prescribing her an antibiotic that contained penicillin. 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 GPs should be reminded of the importance of carefully checking records before house calls (or if that is not possible, checking for allergies by phoning the surgery), in addition to asking patients about allergies, before prescribing penicillin.

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 care and treatment her late mother (Mrs A) received while she was a patient at Inverclyde Royal Hospital. Mrs A was taken to hospital after she was unable to return to bed, finding her legs were too weak. She spent time in the emergency department before being transferred to two different wards. Mrs A died shortly after. Miss C complained about the standard of both clinical and nursing treatment Mrs A received, that the board failed to communicate adequately with her and that they did not respond to her complaint reasonably.

We took independent advice from a consultant physician and a nurse. In relation to Mrs A's clinical and nursing care, we found that certain aspects of her care in the emergency department had been reasonable. However, we also indentified a number of failings including a failure to recognise and investigate whether Mrs  A, given her presenting symptoms, may have had a stroke or sepsis (a blood infection). We also noted there was a delay in administering intravenous fluids and rechecking her National Early Warning Score (NEWS - an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration).

While in the first ward, we found that staff had difficulties interpretating an x-ray of Mrs A's and that there was no written plan as to what to do about clarifying this. We also noted that the board failed to consider whether Mrs A had suffered a subdural haematoma (where blood collects between the skull and the surface of the brain) or possible sepsis. We also noted a failure to ensure that she had received appropriate fluids, monitor her urine output, issues with record-keeping, and a failure to anticipate, recognise and address that she was deteriorating and to plan for this in line with national recommendations. There were also multiple attempts to catheterise Mrs A and no account appeared to have been taken of the distress and discomfort this may have caused her.

When Mrs A was transferred to another ward, we found that there was a failure of continuity of handover between the medical teams caring for Mrs A. It also appeared that although Mrs A was having active treatment with intravenous fluids and regular NEWS, at the same there was a failure to act on her elevated NEWS, recognise that she was dying and manage her end of life care appropriately. Overall, we found that both the clinical and nursing care provided to Mrs A was unreasonable and we upheld these aspects of Miss C's complaint.

In relation to communication, Miss C said that staff failed to inform her or consult with her about Mrs A's care and treatment during her admission, despite the fact that she held welfare power of attorney. We found that an Adults With Incapacity form had not been completed and that Miss C had not been consulted about the plan to insert a catheter. We considered that there appeared to have been a lack of evidence of Miss C having being proactively and regularly updated and a failure to try to understand her needs, expectations and concerns about Mrs A. We also noted that that Mrs A's deterioration did not appear to have been communicated effectively with Miss C. Therefore, we upheld this aspect of her complaint.

In relation to how her complaint was handled, Miss C said that she had not been informed that a significant clinical investigation (SCI) was carried out by the board until she received a copy of the report by the Procurator Fiscal (a legal officer who performs the duties of public prosecutor and coroner). We considered that the board had kept Miss C appropriately updated on the investigation into her complaint, however, the delay was unreasonable. We also noted that she was unaware that the SCI was being carried out and we considered that the board should not have left it to the Procurator Fiscal's office to have made her aware of the SCI report. 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 failing to provide Mrs A with reasonable medical and nursing care and for the failure to reasonably communicate with her about Mrs A's care and treatment. 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 patients present with fluctuating conscious level and reduced power in their limb(s), consideration should be given to whether they have had a stroke or a subdural haematoma and to carrying out a CT brain scan. When patients transfer from the emergency department to an acute medical ward there should be an appropriate re-examination of the patient including their case history.
• Where patients who present meet the SIRS (systematic inflammatory response syndrome), criteria consideration should be given to whether they may have sepsis and appropriate investigations carried out.
• Where patients present with deterioration and fluid overload, consideration should be given to performing a renal ultrasound to look for any obstruction in the urinary tract.
• Where there are difficulties by staff in interpreting an x-ray, consideration should be given to obtaining a formal report from the radiologist or asking for it to be reviewed by a more senior member of staff.
• There should be in place a structured response to patient deterioration where it is clear that the patient is failing to improve or continues to deteriorate as recommended by national guidance.
• Consideration should be given to seeking a more expert practitioner to assist with catheterisation after repeated attempts.
• Where a patient's prescribed rate of fluid is changed, this should be entered on their fluid prescription sheet.
• An Adults with Incapacity form should be completed for patients who lack capacity and discussed with the person who has power of attorney wherever possible.

In relation to complaints handling, we recommended:

• Wherever possible, complaints should be investigated and responded to in line with the board's complaints handling procedure. Where a SCI review is to be carried out, staff should ensure that the patient and/or their family is clearly informed of the action that is being taken.

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, an advocacy worker, complained on behalf of her client (Mr B) about the care and treatment provided to his late father (Mr A) at Queen Elizabeth University Hospital. Mr A had dementia and was admitted to hospital by ambulance after becoming unwell at home. It was suspected that he had urinary retention (inanbility to empty the bladder) and a urinary tract infection. Mr A was treated with antibiotics and fitted with a catheter (a thin tube used to drain and collect urine form the bladder). While in the hospital, Mr A suffered a fall and also developed pressure ulcers. After surgery to fix a bone broken during a fall, Mr  A's condition worsened and he developed pneumonia (an infection of the lungs). Mr  A's condition continued to deteriorate and he later died. Ms C made several complaints about the treatment that was provided for Mr A's urinary tract infection, catheter care, prevention of falls and pressure ulcer care.

We took independent advice from a consultant in acute medicine, a consultant urologist and a nursing adviser. In relation to urinary tract infection treatment and catheter care, we found that Mr A had been started on antibiotics which was reasonable. However, a scan of his urinary tract and bladder had not been carried out ahead of catheterisation. We also found that the completion of catheterisation records was inadequate and that it had been difficult for staff to contact the on call urology team at some points. We noted that Mr A pulled on his catheter and that there had been difficulties in re-catheterising.

In relation to fall risk management and pressure ulcer care, we found that the care planning in the assessment of these risks was unreasonable. We upheld all of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for the failings identified in the investigation of Mr A's urinary tract infection; his catheterisation; and in the assessment and management of his falls and pressure ulcer risk. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org/leaflets-and-guidance.

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

• Bladder scans should be considered and carried out where appropriate.
• Staff should be able, as far as possible, to obtain specialist urology advice/assistance when necessary.
• Accurate medical records should be maintained.
• Staff should respond appropriately in cases where patients try to pull out catheters and have the appropriate catheterisation skills.
• There should be sufficient support and guidance for nurses to carry out comprehensive, structured assessment and care planning. The patient should be re-assessed and their care plan updated as needed throughout the hospital stay. There should be evidence that the patient or their power of attorney informs the care plan and participates in its review.
• National guidance on the prevention and management of pressure ulcers and standards of care for older people in hospital should be implemented appropriately.
• Appropriate pressure relieving equipment should be identified and obtained timeously. There should be an escalation process where there are delays in equipment being 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

Mrs C's husband (Mr A) underwent minor surgery at Victoria Hospital. He was discharged the same day, but died of a blood clot in the lungs two weeks after his surgery. Mrs C complained that the aftercare provided to Mr A was unreasonable. Specifically, she was concerned that Mr A should have been kept in overnight after the surgery, and she felt that when he came home from hospital he was not breathing properly.

We took independent advice from a surgeon. We found that a risk assessment tool had not been filled in. If it had been, it would have shown that Mr A had a number of risk factors for blood clots. This in turn should have led to the consideration of the use of a variety of preventative measures including Flowtron  boots (boots to prevent blod clotting), TED stockings (stockings used to try and prevent blood clots) and heparin (a medication which reduces the ability of the blood to clot), though we noted that these measures may not have changed the eventual outcome. Inconsistencies in the documentation meant that it was unclear if Flowtron boots or TED stockings had been used to prevent venous thrombo-embolism (VTE, or blood clots in the veins), however it was clear that heparin was not considered. We found that it was reasonable not to keep Mr A in hospital overnight, and did not consider that this would have changed the outcome. We found that there were likely to be other reasons for Mr A's breathlessness after the surgery, and did not consider that the blood clot would have been present so soon after surgery.

On balance, we considered that the aftercare provided to Mr A was unreasonable and we upheld Mrs C's complaint.

The board said that this complaint had alerted them to inconsistencies in practices, and confirmed that they were undertaking a review with a view to standardising and ensuring guidelines were followed. We asked for evidence of this and we also made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the poor record-keeping, and for failing to consider the use of heparin after Mr A's surgery. 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 ensure that patients' documentation is completed at every stage of their admission. The General Surgery VTE/Risk Assessment Tool should be completed for all patients.
• Staff in the day surgery unit should be clear about the board's policy for dealing with the presence of risk factors for VTE in day case surgery. (While  the board are reviewing this matter, interim measures should be in place to ensure that appropriate steps are being taken when risk factors are present).

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.