Upheld, recommendations

Summary

Mrs C complained that her late husband (Mr A) had been taken to the wrong hospital by the ambulance service. Mrs C explained that, when Mr A became ill, she recognised signs of a stroke and called an ambulance. She said she thought that, according to the protocol in place at the time, Mr A should have been admitted to the Hyper Acute Stroke Unit at a particular hospital. He was taken to a different hospital and Mrs C felt that this had had an impact on the treatment he was given.

We took independent advice from a paramedic. We found that, on the basis of the information given by Mrs C in the emergency call, the ambulance crew should have suspected a stroke and on this basis should have taken Mr A to the stroke unit at the hospital where Mrs C thought he should have gone. We, therefore, upheld this complaint. We noted that the ambulance service had carried out stroke education since the events of this complaint; however we recommended that they carry out an audit to confirm that patients are being taken to the correct hospital. We also noted that the ambulance crew had failed to document a test they carried out, and we made a recommendation on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for unreasonably taking Mr A to the hospital they did, rather than the specialist stroke unit elsewhere.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:

• Tests carried out by ambulance crews when attending a patient should be documented.
• In similar situations, suspected stroke patients should routinely be taken to the Hyper Acute Stroke Unit, as opposed to the local emergency department in line with protocol.

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 provided to his father (Mr A) at the Western General Hospital. Mr C complained that there was a delay in the board diagnosing Mr A's non-Hodgkin's lymphoma (a form of blood cancer), and that the board did not follow-up his complaint in a reasonable way.

We took independent advice from a consultant radiologist (a doctor who specialises in x-rays and scans) and from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that there was an error in the reporting of a scan that Mr A had undergone for an unrelated condition, which resulted in a delay in the cancer diagnosis. We found that the board had acknowledged this delay and had taken some action to address this failing, however we made a further recommendation on this matter.

We also found that, after a meeting had been held with Mr C regarding his complaint, there appeared to be some uncertainty within the board as to what action they had agreed to take. We found that they should have contacted Mr C to clarify what outcome he was seeking and the failure to do so meant there were perceived delays in complaint handling.

We upheld both of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the unreasonable delay in diagnosing him with non-Hodgkin's lymphoma; and apologise to Mr C for failing to follow up his complaint in a reasonable way. 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:

• As far as possible, scan findings should be accurately reported.

In relation to complaints handling, we recommended:

• Where it is not clear what outcome is expected from a complaint, steps should be taken to find out.

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 about the care and treatment she received at Wishaw General Hospital. Her concerns included that the consultant failed to initially list her for a colonoscopy (examination of the bowel with a camera on a flexible tube) as intended, and she was subsequently listed for a gastroscopy (examination of the gullet and stomach with thin, flexible telescope) in error. Ms C said that this error was not identified until the day of the procedure, despite her having called up in advance to query it. She said that the consultant did not contact her at any stage with an explanation of her results or treatment plan. Ms C also said that the consultant discharged her from their care as a result of her having submitted a complaint to the board. Although Ms C was later advised that they would arrange for one of their colleagues to see her instead, she heard nothing further.

We took independent advice from a consultant gastroenterologist (a doctor who specialises in the digestive system). We found that the board failed to list Ms C for a colonoscopy and later listed her for a gastroscopy in error. We also found that this error was not identified until the day of the procedure. We noted that a letter from the consultant to Ms C, requesting a stool sample, failed to explain the reasoning behind the request and inform Ms C of the findings and of a further management plan.

We also found that the consultant unreasonably discharged Ms C from their care and failed to ensure safe transfer of the necessary information on her case to a colleague, in line with the correct guidelines. We considered that the board then failed to take appropriate action when this was raised with them. Therefore, we found that the care and treatment Ms C received was unreasonable and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for sending a letter requesting a stool sample that contained inadequate information; unreasonably discharging her from their care; and failing to ensure safe transfer of the necessary information on her case to a colleague.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:

• Patients should be accurately listed for endoscopic procedures and the steps for this process documented. Phone contact by patients about listed procedures should be documented, tracked, and where appropriate, acted on.
• Essential patient information on care and treatment should be provided to the patient. Patients should be discharged from care in line with the correct guidelines. Patients should have the safe transfer of the necessary information on their case to another consultant.

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, who works for an advocacy and support agency, complained about the care and treatment that her client (Mrs B)'s adult son (Mr A) received from the board's mental health services. Mrs B and Mr A had been told that Mr A had an assumed borderline personality disorder and that, as part of his treatment, he would attend a specified cognitive behaviour therapy programme. However, the decision was taken that Mr A should attend another course which caused Mr A and his family great distress and they felt that the staff had not diagnosed his condition appropriately. Subsequently, Mr A was reassessed by a consultant psychiatrist as having an Emotionally Unstable Personality Disorder (EUPD) and was placed on the original specified cognitive behaviour therapy programme. The family felt that there was an undue delay in the diagnosis of EUPD.

We took independent advice from two mental health advisers and found that Mr A had been seen by a number of clinicians in mental health over an extended period of three years. We found that, although Mr A had displayed some traits of EUPD, no formal structured assessments had been completed which would have led to an earlier diagnosis of EUPD. We found that this was contrary to national and local guidance. The assessments which were carried out during the period lacked detail and consistency. They concentrated on current symptoms, rather than someone taking on collective responsibility and arriving at a diagnosis of EUPD by carrying out a structured assessment using recognised tools. We also found that there was a failure by the board in arranging for Mr A to receive a second medical opinion which had been requested by one of the consultant psychiatrists. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B and his family for the unreasonable delay in reaching a diagnosis of EUPD and for not arranging a second medical opinion. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should familiarise them themselves with relevant guidance for personality disorders.
• Staff should ensure that requests for a second medical opinion are actioned.

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, who works for an advocacy and support agency, complained on behalf of his client (Ms A) about the care and treatment she received at Royal Alexandria Hospital. Specifically, the complaint was about a procedure in which Ms A was given a femoral line (a tube placed by needle into a large vein near the groin) for pain relief. Mr C complained that Ms A was not given any warning or explanation before the procedure. Mr C also complained that it was not carried out properly, as Ms A found it extremely painful.

We took independent advice from a consultant in acute medicine. We found that Ms A should have been given alternative pain relief while medical staff prepared to insert the femoral line. We noted that Ms A's consent for the procedure was not properly obtained and/or documented. Finally, we found that the board had a checklist for carrying out this type of procedure but as it was not used, it was unclear if the procedure was carried out appropriately. Therefore, we considered that the board failed to provide Ms A with reasonable care and treatment and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for not giving her appropriate pain relief, for failing to obtain and/or document her consent appropriately, and for failing to document the procedure reasonably. 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:

• Adequate pain relief should be given to all patients.
• Information given verbally to a patient about a procedure should be documented (including the rationale for the procedure, any alternatives, the risks involved and what the procedure will entail), along with the outcome of the consent discussion.
• Femoral lines should be inserted using the appropriate technique, equipment and anaesthetic, which can be ensured by using the central line checklist.

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 about the care and treatment provided to her by Southern General Hospital and Victoria Infirmary in relation to a diagnosis of follicular lymphoma (a type of blood cancer). Ms C had two appointments with extended scope physiotherapy practitioners (ESPs) within the orthopaedics department regarding pain in her shoulder which later developed a lump. She complained that the ESPs did not carry out reasonable assessments which resulted in a delay in her being diagnosed with lymphoma. Ms C also complained that after her diagnosis of lymphoma, there was a failure on the part of the haematologists (doctors who specialise in medicine of the blood) to investigate her reports of back pain appropriately, and that this turned out to be due to another lymphoma mass pressing on her spine. Finally, Ms C complained that the board failed to communicate reasonably with her regarding her condition.

We took independent advice from an ESP and from a consultant haematologist. We found that the ESPs failed to take a full history and assess for 'red flag' symptoms (symptoms which may be indicative of a serious illness such as cancer) when seeing Ms C. We also found that when Ms C was unable to tolerate a scan which had been arranged, no further attempts were made by the ESP to investigate the lump on Ms C's shoulder. We found that this resulted in a delay of around four months in Ms C being diagnosed with follicular lymphoma and we upheld this aspect of Ms C's complaint.

We found that the assessments and examinations by haematologists when Ms C was reporting back pain after her diagnosis of lymphoma were reasonable. However, there was a failure to make suitable arrangements to enable her to undergo a scan and this resulted in a delay in identifying the lymphoma masses pressing on Ms C's spine. Therefore, we considered that the care and treatment Ms C received following her diagnosis of lymphoma was unreasonable. We upheld this aspect of Ms C's complaint.

In relation to the boards communication with Ms C, we found that the clinic letters regarding her treatment were only sent to her GP. We considered that it would have been beneficial for these letters to be sent to Ms C as well in order for her to have a better understanding of her care and treatment. We also noted that it would have been beneficial for Ms C to have an identifiable key worker who could act as her first point of contact. 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 unreasonably delaying in diagnosing her with follicular lymphoma; failing to provide her with reasonable care and treatment after she was diagnosed with lymphoma; and failing to communicate reasonably with her regarding her condition. 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:

• A full history, including assessment of red flag symptoms, should be taken by ESPs; and painful lumps or swellings should be scanned.
• When a patient is unable to, or finds it difficult to tolerate scanning, discussion should take place between departments and with the patient in order to make suitable arrangements for them to undergo necessary scanning.
• Haematology patients should be copied into clinic letters to their GPs.
• Haematology patients should have an identifiable key worker (either a named consultant or clinical nurse specialist) who serves as their first point of contact.

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 that staff at Queen Elizabeth University Hospital failed to provide her late mother (Mrs A) with appropriate medical treatment in view of her presenting symptoms. Miss C raised a number of concerns about Mrs A's treatment following her arrival at hospital, when she was thought to have new onset confusion due to a possible urinary tract infection or a stroke. Mrs A died six days later.

We took independent medical advice from a consultant in emergency medicine and a consultant neurosurgeon. We found that the emergency department staff failed to consider Mrs A's current medication during their assessment of her and failed to record her Glasgow coma score (detailing the level of consciousness in a patient), pupil response and blood sugar level. They also failed to record their decision and actions following receipt of Mrs A's blood clotting test and did not carry out a scan as part of the emergency department's assessment and evaluation of Mrs A. We found that there was a delay in the administration of Mrs A's Beriplex (a drug to help blood clot) and in a second scan being carried out. We also noted that there were discrepancies between the findings of the board's internal report on Miss C's complaint and the board's response to Miss C, resulting in her not receiving adequate explanations of what happened in Mrs A's case. Therefore, we upheld Miss C's complaint. However, we noted that the outcome in Mrs A's case was unavoidable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and her family for failing to carry out an appropriate assessment of Mrs A; failing to note relevant decisions and actions; the delay in administering Beriplex; the delay in carrying out scans; and failing to provide Miss C with an adequate response 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:

• In cases such as this, patient's existing medications should be considered in the emergency department; doctors in the emergency department should record key decisions/actions; an assessment and record should be made of patient's Glasgow coma score, pupil response and blood sufar level; and consideration given to carrying out a scan as part of the emergency department's assessment and evaluation of the patient.
• Medications should be administered in a timely manner.
• Patient deterioration should be appropriately recognised in circumstances such as this, and scans carried out in a timely manner.

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 practice unreasonably removed her from the patient list. Ms C had had concerns about the treatment which she had received from the practice previously but these had been dealt with under the complaints procedure. Ms C was surprised to subsequently receive a letter from the NHS practitioners services advising her of the decision taken by the health board to remove her from the practice patient list due to a breakdown in the professional relationship. Ms C then learned that the instruction to remove her came from the practice and that she had not been given an explanation as to how the practice had come to their decision.

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained about the care and treatment provided to his late relative (Mr A) at Dr Gray's Hospital. Mr A was admitted to hospital following a referral from his GP with raised body temperature/fever, an irregular heart rate and a high 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). Mr A's condition deteriorated over a few days and he was transferred to the high dependency unit where he died a short time later. Mr C complained that the board failed to provide a reasonable standard of both clinical care and nursing care to Mr A. He also complained that the board failed to respond to his complaint in a reasonable way.

We took independent advice from a consultant in acute medicine and a nurse. Regarding Mr A's clinical care, we found that there was poor documentation by medical staff and a lack of concern to Mr A's deterioration and failure to improve. We noted that the severity of Mr A's illness may have been underestimated. Therefore, we upheld this aspect of Mr C's complaint. However, we noted that the board had identified failings and had taken steps to address these.

In relation to Mr A's nursing care, we found that there were no shortcomings in personal care of pain assessment and monitoring or blood sugar monitoring. However, we noted that nursing care in relation to fluid balance fell below a reasonable standard and that there were omissions in the recording of NEWS scores. Therefore, we found that the board failed to provide a reasonable standard of nursing care and upheld Mr C's complaint.

Finally, Mr C complained that he did not receive a response to his complaint from the board until approximately five months after he submitted it. We found that the board did not keep Mr C informed of their progress and that there was an unreasonable delay in responding to his complaint. We upheld this aspect of Mr C's complaint. However, we noted that the board acknowledged that there was an unreasonable delay and apologised to Mr C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for failing to provide a reasonable standard of clinical and nursing care and treatment to Mr A.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:

• Deteriorating patients should have their vital signs checked and the appropriate guidance followed when NEWS scores escalate.
• Fluid balance charts should be completed and used appropriately by nursing staff.
• When a complaint response takes longer than 20 days and/or amended timescales for completion are not met, the complainant should be kept updated on progress.

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 given to her late father (Mr A) by the practice. Specifically that, during the three years prior to a diagnosis of a very rare form of cancer, there were failures to take action on his symptoms, not all tests that were due were carried out, and there were delays in making required referrals. Mrs C believed that this led to a delay in Mr A's diagnosis and affected his outcome.

We took independent advice from a GP. We found that Mr A had a history of dizziness and cardiology problems and he had a pacemaker. It was only after he had persistently raised white blood cells that a referral was made for him to attend hospital but, while the referral was agreed it was not sent for a number of months. Blood tests confirmed his white blood cell count and he was referred to haematology (medicine of the blodo) for further testing where his count was shown to be reduced. Nevertheless, we found that it would have been reasonable for the practice to have arranged repeat tests a few weeks later to ensure that his results had returned to a normal range, and this did not happen. An earlier diagnosis could perhaps have been made, but we could not conclude that an earlier diagnosis would have changed Mr A's outcome. Because of the the delay in making the referral and the failure to repeat tests, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for not arranging further follow-up tests and for the delay in the referral.

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

• In circumstances like this, follow-up blood tests should be arranged. GPs within the practice should ensure they are familiar with the condition Mr A had.
• Referrals should be sent in a timely manner.

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.