Upheld, recommendations

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.

Summary

Mrs C complained to us that the practice had failed to appropriately monitor her for any side effects of taking nitrofurantoin medication (antibiotic to treat urinary tract infections) for a number of years. She subsequently went on to develop pulmonary fibrosis (lung disease) and liver disease and she felt that these conditions were a direct result of the practice's failure to monitor her medication.

We took independent advice from a GP adviser and concluded that the practice had failed to appropriately monitor Mrs C's liver function and respiratory status over a number of years. The British National Formulary, which is the gold standard reference and guidance regarding medicines, has over the years highlighted advice and more recently issued safety alerts that patients on long term nitrofurantoin medication should be regularly monitored for liver function and respiratory function, although it does not state the frequency. In addition, Mrs C was exhibiting symptoms which are recognised complications of nitrofurantoin medication. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to monitor her medication.The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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 on behalf of her mother (Mrs B) about the care and treatment provided to her late father (Mr A) following his admission to Victoria Hospital with a painful hip. Mr A, who had prostate cancer, underwent a hip replacement. The oncology (cancer) consultant who had been caring for Mr A went on leave for a number of weeks. During this period a scan found that Mr A's cancer had spread and he was later admitted to a hospice where he died a short time later. Miss C complained about the care and treatment Mr A received following his admission to hospital. In particular, that Mr A had not been informed that his cancer had spread significantly and that his life expectancy was much shorter than he had previously thought.

We took independent advice from an oncology consultant. We found that, during the period Mr A's oncology consultant was on leave, there was no record of him being informed that his cancer had progressed significantly and that his life expectancy was reduced. We also found that the delay in referring Mr A to the oncology team and informing him of the progression of his cancer appeared to have been caused by a lack of senior oncology cover when Mr A's oncology consultant was on leave. However, we noted that had the oncology medical team been contacted earlier it would not have changed Mr A's management as there had been no further treatment available to him. We also found that, in terms of palliative care, there had been no impact on his management as he had continued with his medication. We upheld Miss C's complaint. Whilst we noted that the board had already accepted that there had been a delay in informing Mr A of his cancer progression and had apologised for this failing, we made a further recommendation.

Recommendations

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

• If a consultant goes on leave there should be adequate supportive cover.

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 was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD - a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness) by a private specialist, and she reported a very positive response to the medication prescribed. She had previously been seen by a consultant psychiatrist at Queen Margaret Hospital, who noted longstanding symptoms of anxiety.

Mrs C saw the psychiatrist again following receipt of the private opinion but the psychiatrist did not agree with the ADHD diagnosis and was not willing to support the recommended medication prescription. As Mrs C's GP practice would not agree to prescribing this medication without the support of her NHS psychiatrist, she was required to pay for it privately.

The board offered Mrs C a second opinion from another consultant psychiatrist, who confirmed her ADHD diagnosis and supported the prescribing of the recommended medication. Mrs C complained that the initial psychiatrist unreasonably failed to diagnose her ADHD and did not follow relevant ADHD protocols.

We took independent medical advice from a consultant psychiatrist, who considered that it was reasonable for the first psychiatrist not to have followed specific ADHD diagnostic protocols at Mrs C's initial out-patient appointment. We found that the psychiatrist's management plan following this consultation was appropriate and that it allowed for review of Mrs C's diagnosis, and specific diagnostic protocols to be considered, at future appointments.

However, the board were unable to provide any written record of Mrs C's follow-up consultation with the psychiatrist. We found that the psychiatrist appeared to only have phoned Mrs C's GP to recommend referral for a second opinion. They did not document the call and no clinic letter was produced. Therefore, we considered that there was an absence of adequate medical documentation to support the psychiatrist's diagnosis and, in particular, their rationale for disagreeing with the medical opinion of the private specialist. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the psychiatrist's failure to appropriately document details of their consultation with her, including their rationale for disagreeing with a specialist 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:

• Clinicians should ensure that they adhere to General Medical Council Good Medical Practice guidelines on record keeping and, in particular, they should clearly document their clinical rationale where there is a difference of opinion.

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 transferred to the practice from another practice and, on first attendance at the new practice, was prescribed Sertraline (an anti-depressant medication used to treat anxiety). However, he suffered side effects as a result of this prescription. He was of the opinion that this would have been immediately obvious to the doctor he saw, had they checked with his previous GP, as Mr C had previously been prescribed this medication and had suffered side effects. He was also unhappy with the manner and tone adopted by the doctor. He complained about these matters to the practice and was further concerned by the tone and content of the response he received, which he considered to be confrontational and unprofessional.

Mr C brought his complaints to us. He complained that the practice unreasonably failed to consider his medical history before prescribing Sertraline and that the prescription of Sertraline was inappropriate due to the potential side effects. We took independent advice from a GP. We found that, in order to justify immediately prescribing Sertraline, rather than first trying therapies that did not require medication, the doctor should have documented a pressing clinical need or sought further evidence from Mr C's previous practice to ensure that this was appropriate. However, we found no evidence that this took place. Therefore, we upheld these two aspects of Mr C's complaint.

We also considered that the tone and content of both the clinical records and the practice's complaints responses, both to Mr C and to us, was inappropriate. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to sufficiently evidence the decision to prescribe him Sertraline and for failing to communicate appropriately with him. 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:

• Records should fully evidence any clinical decisions.
• Records and communication should be factual, neutral, and professional in tone and content.

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 raised a complaint about the care and treatment he had received from his dentist when he had two teeth removed and two new teeth added to his existing denture. Mr C later found his denture to be too loose fitting and returned to his dentist. Mr C had clips fitted to make his denture more secure, however, he still felt that it was too loose and was advised by his dentist that a new denture was the only other option. Mr C was unhappy with his treatment and brought his complaint to us.

We took independent advice from a dentist. We found that the dental treatment Mr C received was reasonable and in accordance with usual practice. However, we found issues with patient communication and record-keeping. Mr C was not given a full explanation of his treatment at the outset or advised of the all the possible options and outcomes. We also found that dental records did not mention the advice that the dentist had given to Mr C. On balance, we found Mr C's treatment to be unreasonable and upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not outlining all his options to him at the start of 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.
• Refund Mr C the money he paid for the clips to be fitted.

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.