Upheld, recommendations

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.

Summary

Miss C had long standing problems with her ears and had a number of operations to deal with this. More recently she began to experience nocturnal seizures (seizures which occur during sleep) which she thought were related to the problems she already had. Miss C complained about the care and treatment she received and that it took too long to get a diagnosis for the seizures. She felt that she had not been listened to and had unreasonably been referred to the psychology service because of stress. The board, however, took the view that her symptoms were unrelated to her existing condition and that her care and treatment had been reasonable.

We took independent advice from consultants in neurology and ENT (ear, nose and throat). We found that the mix of the two conditions from which Miss C suffered required time and effort to investigate and to prove that they were unconnected. We found that the care she received from the ENT and neurology departments was thorough in order to exclude the possibility that Miss C's ear problems were the cause of possible brain disease. We were satisfied that she had been reasonably and appropriately treated. However, we also found that there was a delay of six months between the time her GP referred her and when she received her first out-patient appointment. Once her treatment started, we found that Miss C also had to wait too long for her scans. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in receiving an out-patient appointment and the delay in scans being carried out. 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 receive clinical appointments and scans/tests 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

Mrs C complained about the management of her husband's (Mr A) insulin after he was admitted to Dumfries and Galloway Royal Infirmary for treatment of a stroke. Mr A has a history of diabetes mellitus (a condition that occurs when the body cannot produce sufficient insulin to absorb blood sugar) for which he administers insulin.

In responding to the complaint, the board acknowledged and apologised for a delay in Mr A receiving insulin one evening. The board considered that, during Mr A's admission, staff had followed the correct procedures but more checks of his blood sugar and ketone levels would have allowed staff to act earlier. The board set out a number of measures that they said they had taken regarding staff training and improvements as a result of Mr A's experience.

We took independent advice from a consultant physician specialised in diabetes mellitus. We found that management of the insulin was below the expected standard, given the possibility that diabetic ketoacidosis (DKA, a serious complication of diabetes that occurs when the body produces high levels of ketones) could have been prevented by earlier recognition, more frequent monitoring and more aggressive insulin administration. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff did not specifically inform her or Mr A that he had developed DKA and urosepsis (a secondary infection that develops in the urinary tract). Mrs C said they had only been aware that Mr A had low blood sugar levels. We found that when Mr A developed DKA and urosepsis, there was no record of this having been explained to either of them at the time. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failings in communication. 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 that early recognition of the warning signs and prompt restorative action should prevent DKA from developing.

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 follow-up care and treament he received at Dumfries and Galloway Royal Infirmary. Mr C underwent surgery for prostate cancer in another NHS board area but follow-up care was to take place within his own area. Mr C complained to the board about the way they handled his follow-up care as there were a number of delays. The board decided to undertake a Significant Adverse Event Review (SAER) as a result. Mr C was provided with a draft copy of the SAER at a meeting, however, the response to his complaint was not supplied until a number of months later with a copy of the finalised SAER report. Mr C complained to us that the board had unreasonably failed to provide him with appropriate follow-up care and treatment. He was also concered that the board had not followed their SAER policy appropriately and that there had been unreasonable failings in the way they handled his complaint.

We took independent advice from a consultant urologist. We found that there was a lack of appropriate follow-up care for Mr C and that poor communication between staff caring for him in different board areas had contributed to the issues with his follow-up. We upheld this aspect of Mr C's complaint but noted that the board had acknowledged and apologised for this failing.

In relation to the SAER, we found that it was reasonable in its findings. However, it took far longer to complete than Mr C had been advised, and we found a lack of evidence that the board had kept him updated on their progress. We upheld this aspect of Mr C's complaint.

In relation to Mr C's complaints handling concerns, we found that there had been significant delays in the investigation process and that the board had acknowledged and apologised for this. We also noted that the SAER was a separate process from the investigation of Mr C's complaints and we considered that it would have been helpful had the board's complaint response more clearly addressed the specific concerns he had raised in his original letter of complaint.

Recommendations

What we asked the organisation to do in this case:

• Review Mr C's follow-up care plan to ensure that he receives the appropriate standard going forward.

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

• There should be systems in place to facilitate communication between staff where more than one NHS board is involved in caring for a patient.

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 treatment she received from her dentist, particularly in relation to the fitting of a crown which fractured multiple times and required repairs, and areas of untreated decay.

We took independent advice from a dental adviser. We found that the treatment Ms C received from the dentist was unreasonable and we therefore upheld the complaint. The repair carried out to the crown was unreasonable, as was the failure to investigate the cause of the fracture. There were failings in the dentist's record-keeping, and we found that Ms C was incorrectly charged for the repair. There were also failings around the untreated decay, though the dentist had already acknowledged and reflected on this.

We noted that the dentist had already apologised for some failings. They had also already taken steps to improve their practice and ensure these issues did not arise again, including carrying out an audit on clinical record-keeping, and undertaking some further training. We asked for evidence of these actions and we also made some further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the shortcomings in treatment and record-keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Refund Ms C the money charged for the crown repair.
• Consider reimbursing Ms C for the cost of the crown itself, since it broke twice soon after being fitted and had to be replaced.

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 has type 1 diabetes and needed a consultant-led maternity unit for the delivery of her baby. The board (Board 1) have a service level agreement (SLA) with another health board (Board 2) for the provision of specialist care, which meant Ms C would deliver her baby there. Ms C asked Board 1 if she could instead deliver her baby at a hospital in a different board area (Board 3), where she would have access to greater support from her family. Board 1 refused this request as they did not consider there to be any clinical need for Ms C's care to be transferred to Board 3. Ms C complained that this decision was unreasonable and was taken without consideration of her individual needs.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy, childbirth and the female reproductive system), who was critical that the initial decision was taken at senior midwife level with no apparent medical input. The board indicated that treatment outside the SLA can be approved when there are deemed to be compelling clinical grounds. We were of the view that they should, therefore, have a more robust process in place to fully assess individual medical needs. Medical input was later obtained, but only when Board 1 investigated the complaint. This showed that Ms C's consultant physician was becoming concerned that the stress from the situation was impacting on her health and diabetic control. We considered that these ongoing and developing medical reasons might reasonably have led Board 1 to reconsider their position.

We considered the reasonableness of Board 1's overall refusal, further to Ms C's complaint and their review of the position. We considered that Board 1 had not provided sufficient evidence that they took full account of all Ms C's relevant medical needs (which we noted had evolved with the passage of time). Ms C subsequently registered as a patient in Board 3 and delivered her baby there. We found that Board 1 had sent a letter to Board 3 regarding her diabetic care but her obstetric information did not appear to have been passed on despite the clearly noted requirement for a carefully planned delivery. Overall, we considered that the board unreasonably refused to request for Ms C's maternity care to be transferred to Board 3 and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to take full account of all her relevant clinical needs when refusing her request to deliver her baby in Board 3; and for failing to formally transfer all of Ms C's clinical information to the team when she decided to register as a patient there. 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:

• The board should ensure that they have a robust process in place for considering future requests for out of area maternity referrals, ensuring that patients' clinical needs are fully considered at an appropriate level and in partnership with the patient.
• The board should ensure that all relevant clinical information is passed on to the appropriate hospital when they become aware that out of area maternity care is being delivered to one of their patients, especially where the need for a specialist care plan has been identified.

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.