Upheld, recommendations

Summary

Mr C complained that staff failed to communicate properly with him when he arrived at Hairmyres Hospital following his wife (Mrs A)'s admission with a suspected stroke. Mr C had told the paramedics who called at his home that he thought the time of onset for the stroke was about 02:00, when he heard Mrs A collapse. When he was with Mrs A in the emergency department, and subsequently on admission to a ward, no members of staff asked him for more information which may have narrowed the potential timing of the stroke. Mr C subsequently learned that thrombolysis treatment (medication to dissolve blood clots), which can limit the damage caused by a stroke, was available but has to be given within a certain timescale to be effective. Mrs A was not given thrombolysis treatment as the clinicians had deemed that there was insufficient information available which would have identified the potential time of onset of the stroke.

We took independent advice from an adviser in acute medicine. We found that, although the staff had taken into account the information provided to the paramedics, they missed the opportunity to question Mr C further as he may have been able to provide information which would have narrowed down the potential timings. The staff took the decision not to provide thrombolysis treatment without speaking to Mr C. We noted that even if they had obtained further information from Mr C it was possible that they may still have decided not to start the thrombolysis treatment. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate with him. 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 consider all available sources of information available before deciding whether or not to commence thrombolysis treatment.

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 on behalf of his late brother (Mr A), who had been a patient at Monklands Hospital. Mr A went missing from the ward but staff failed to notice his absence for a period of several hours. Subsequently, Mr A died outwith the hospital premises a few days later. Mr C complained to the board about the care and treatment they provided to Mr A. His complaints related to observation, medication and shared accommodation on the ward.

In response to Mr C's complaints, the board carried out a significant adverse event review (SAER), which is a type of investigation designed to identify what, how and why a particular adverse event happened. The SAER concluded that ward staff had not observed Mr A properly in terms of their procedures and, therefore, his care fell below a reasonable standard. The review also found that, when Mr A's absence was established, staff did not properly share this information with each other and did not escalate the matter in a timely manner. As a result of the failings identified by the SAER, the board took action to address these issues. Mr C then brought his complaints to us.

We took independent advice from two clinical advisers. We found evidence to support that Mr A's medication was appropriately managed. In addition, his transfer from a single room to shared accommodation was reasonable. Although the board's SAER found that staff had not properly observed Mr A, we were critical that the SAER did not explore the reasons why this failing occurred. We were also concerned that the SAER did not identify evidence of poor recording-keeping by staff in terms of Mr A's medical and risk assessments. We considered that Mr A may have been at higher risk than what had been determined. Due to the poor standard of record-keeping we could not conclude for certain whether Mr A's observation level should have been increased. However, we considered that a greater awareness was required by staff. Whilst we noted that further steps had been taken by the board to address the failings they had identified, we recommended additional action to be taken to ensure these issues do not happen again.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the poor record-keeping and for the failings identified in relation to observations. 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:

• Standardised documents relating to medical and risk assessment should be completed properly.
• The board should ensure that adverse event reviews adequately identify all failures and the underlying causes of untoward events, in line with relevant guidance.
• The findings of this complaint should be fed back to relevant staff in a supportive way.
• Time off the ward should be properly documented and failure to return plans should identify when a patient fails to return to the ward.

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 to us that the board had failed to provide reasonable care and treatment to his late sister (Ms A) when she was admitted to Wishaw General Hospital. Ms A had injured her hip in a fall. Scans were carried out in the hospital to explore concerns that she may have fractured her pelvis. These scans did not show any obvious fractures and Ms A was discharged from hospital two days after her admission.

Ms A died several days later. A post-mortem was carried out and the cause of death was found to be deep vein thrombosis (DVT) resulting in pulmonary embolism (where a blood clot in the leg travels up and blocks one of the blood vessels in the lungs). Mr C complained that Ms A had not been given any medication to prevent this when she was discharged from hospital.

We took independent advice from a consultant trauma and orthopaedic surgeon. We found that a risk assessment for DVT should have been carried out when Ms A was admitted to the hospital ward, but that there was no evidence this had been done. Ms A's risk of DVT should also have been reviewed during her period of admission and this would have indicated that she was at increased risk of DVT.

We found that Ms A should have been prescribed medication to prevent DVT on the night she was admitted. There should also have been a documented discussion about whether she should receive this medication when she was discharged, although the records suggested that she had regained her full mobility at that time. A formal risk assessment for DVT when Ms A was admitted to hospital would have provided enough concern for her to be prescribed TED stockings (stockings that help to prevent blood clots) whilst she was a patient and also on discharge. Given these failings, we upheld Mr C's complaint, although we were unable to say whether or not adequate treatment would have prevented Ms A's death.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide appropriate care and treatment to Ms 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:

• Patients admitted to hospital should be assessed for DVT risk in line with national guidance, appropriate treatment should be instigated and the patient's DVT risk should be routinely reviewed during their stay in hospital.
• Patients, particularly those admitted to an orthopaedic department, should be adequately assessed for their safety before discharge and the assessment should be clearly documented.

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 that the board did not obtain his consent to carry out a vasectomy (a procedure where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) at Hairmyres Hospital, as he said that he was not fully advised of the risks in advance. He also complained that his vasectomy was not performed appropriately, as afterwards he developed complications such as a blood clot and chronic pain.

We took independent advice from a consultant urologist. The adviser considered that Mr C was properly told about the risks of having a vasectomy in advance. However, the adviser said that Mr C should have been given or emailed an information leaflet, instead of being directed to a website for information about vasectomies. The adviser also considered that the consent form Mr C signed for the procedure should have included the need to use contraception until sterilisation (inability to reproduce) had been proven.

The adviser found that a highly unusual step was taken to complete the vasectomy. The adviser considered that it was not reasonable to do this without Mr C's specific consent, as it could have increased the risk of complications. Even if Mr C's consent had been obtained, the adviser considered that it would not have been reasonable to take this step, as it would not have made procedure easier to carry out. In addition, the adviser found a discrepancy between the typed and handwritten records of the procedure, which was of concern. The adviser also found that Mr C should have been given surgical stockings after the procedure to prevent deep vein thrombosis. We upheld both aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain appropriate consent from him and for failing to carry out the vasectomy to a reasonable standard. 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:

• Patients should either be given copies of the information leaflets or better guidance about how to find them, if they are directed to a website.
• The vasectomy consent form should tell patients to use back-up contraception (until they have provided enough semen specimens that are clear of sperm to confirm sterilisation has been achieved).
• Staff should ensure that more complex vasectomy cases are identified in advance of anaesthesia, so that additional or unusual steps can be planned with patient consent.
• All procedures should be appropriately documented in the medical records.
• The clinicians involved should reflect on the adviser's comments that it was not reasonable to take the unusual step that they did take to complete Mr C's vasectomy.
• Patients should be given surgical stockings to prevent deep vein thrombosis, unless it would cause the patient harm.

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 and support worker, complained on behalf of her client (Ms A). Ms C said that, following a referral from Ms A's GP because of her back pain, the orthopaedic department at Raigmore Hospital delayed unreasonably in offering Ms A an appointment and therefore delayed in offering her treatment.

The board acknowledged that there had been a delay and apologised for this. They said that this had been due to the demand for orthopaedic services and noted that Ms A had opted to begin investigations of her back pain privately. After a scan was carried out privately, an urgent GP referral was made to the board and Ms A then received an appointment. It was then determined that she would benefit from an operation.

However, because the board could not perform the operation within 12 weeks, Ms A exercised her right to have treatment outside the board's area. As a result of her complaint the board apologised and said that they had taken steps to avoid a similar situation occurring again in the future.

We took independent advice from a consultant orthopaedic and trauma surgeon. We found that the care and treatment offered to Ms A had been in accordance with national guidance. The adviser noted that Ms A had arranged a private consultation and scan whilst she was on the board's waiting list. The adviser said that this was a matter of her choice, as was her decision to go outwith the area for her operation. Nevertheless, there was no doubt that there had been delay in offering Ms A treatment. The board missed the initial 12 week waiting time after Ms A's first GP referral. They were also unable to meet the target for treatment after Ms A was seen subsequent to the urgent referral. Finally, the board had only discussed Ms A's options for treatment with her after the treatment time guarantee had expired. For these reasons, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to make her aware that they would be unable to meet the required treatment standards until after the treatment target date had passed. Also apologise for failing to discuss the options for out of area treatment with Ms A until after the treatment time guarantee date had passed.

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

• Inform patients as soon as possible of any inability to meet treatment targets and provide them with information about the options available to them in the circumstances.

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 to us that that the medical practice had failed to provide her with appropriate care and treatment when she phoned to report that she was suffering from vaginal bleeding and cramps and was in the early stages of pregnancy. Miss C believed that the GP who she spoke to had inferred that she had suffered a miscarriage. However, later testing revealed that Miss C had not suffered a miscarriage.

The GP had apologised for the miscommunication and said that they had not meant for their comments to be interpreted that Miss C had suffered a miscarriage, but had meant that it was a possibility. We took independent advice from a GP adviser and concluded that the GP had not put themselves in a position to arrive at a potential diagnosis for Miss C's symptoms and that they should have offered Miss C a face-to-face consultation so that they could carry out an examination. This would also have given Miss C some reassurance about her condition. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to offer Miss C a face to face GP appointment.

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 that the board unreasonably failed to provide him with appropriate dental treatment when he was held on remand in prison. He said that the board failed to x-ray his tooth and should have tried to save his tooth, rather than only offering tooth extraction. Mr C was concerned that the board advised him that, as an untried prisoner, he did not qualify for the same dental treatment as a convicted prisoner or a person who was not in prison.

We took independent advice from a dental practitioner. The adviser said that the board should have carried out an x-ray of Mr C's tooth as part of his dental treatment. They said that the board failed to discuss the risks and benefits of all treatment options with Mr C and record the discussion in the dental records. The adviser also said that the board should have offered to provide root canal treatment for Mr C's affected tooth, in accordance with the NHS Guidance. As a result of these failings, Mr C suffered intermittent pain from his affected tooth for a considerable period.

The adviser explained that the board were correct in their view that Mr C did not qualify for the same dental treatment as a convicted prisoner or a person who was not in prison. This was because the NHS Guidance indicated that an untried prisoner was entitled to some, but not all, of the NHS treatments available to a convicted prisoner or someone who was not in prison. However, we were concerned that it appeared that the board were not aware of the full range of treatment available to prisoners on remand. Given the failings identified, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for:
• failing to x-ray his tooth
• failing to discuss the risks and benefits of all treatment options with Mr C and record this discussion in the dental records
• failing to offer root canal treatment, in accordance with NHS Guidance.
• 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 circumstances such as Mr C's, the board should x-ray patients' teeth.
• The risks and benefits of all treatment options should be discussed with patients and these discussions should be recorded in the dental records.
• Root canal treatment should be offered in cases such as Mr C's, in accordance with the NHS 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

Mr C complained that his care and treatment over two admissions to the Royal Alexandra Hospital was inadequate.

Mr C had suffered from two separate incidences of a collapsed lung in quick succession. During the first admission, Mr C disputed the board's position that it had been reasonable to discharge him. During the second admission Mr C's condition worsened. An x-ray was requested and preparations were made for inserting a chest drain. There was then significant deterioration in Mr C's condition. The board accepted that Mr C could have died due to this deterioration. The board said that they did not believe a critical incident review (CIR) was appropriate in the circumstances. They said that Mr C had been suffering from a complex condition and that it was this, rather than any failings by staff, which had contributed to the deterioration. Mr C disputed this, and he disputed the standard of the nursing care he received. Mr C said his deterioration had not been noticed because he was not being monitored properly.

We took independent medical and nursing advice. The medical adviser said that the decision to discharge Mr C following his first admission was appropriate and was supported by the medical evidence. However, the adviser found that during Mr C's second admission there had been a failure by medical staff to identify that a chest drain had not been correctly inserted, which had contributed to his deterioration. It would therefore have been appropriate to conduct an CIR. The medical adviser noted that Mr C's condition could have deteriorated very quickly and it could not be assumed that the severity of Mr C's condition and deterioration was due to an absence of clinical observation. The nursing advice we received found that, aside from some acknowledged failings, the overall standard of care was reasonable. The board had accepted the nursing failings and had taken action to address them.

We found that the board should have conducted a CIR into Mr C's deterioration during his second admission, as this could have identified useful learning for staff. We also found that the board should provide evidence that it had followed through with the work it had committed to in order to address the nursing failings it had accepted had taken place. On balance, we upheld Mr C's complaint that the care and treatment provided to him across the two admissions had been inadequate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failings in his care, and for failing to carry out a critical incident review. This apology should comply with SPSO guidelines on making an apology.

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

• The board should review Mr C's second admission and his subsequent deterioration with the clinical staff involved. This review should include what action was taken to review the x-ray taken and the action taken on Mr C's subsequent deterioration. This review should also include evidence of the resultant learning or improvements.

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

Summary

Mrs C complained that the board failed to care for her in a sensitive manner at Aberdeen Maternity Hospital after she had a miscarriage. Mrs C said that she had found staff to be lacking in empathy. There had also been some confusion in relation to the forms which required to be completed to confirm her wishes for disposal of the foetal remains. Mrs C said that she understood that she had completed the forms required and that she would not be contacted again unless there was any foetal abnormality, but she was contacted a couple of days later and asked to return to the ward to complete another form. Although Mrs C had stated her wish for the cremated remains to be scattered without her being present, she then received a phone call several months later advising that the ashes were ready to be collected.

We took independent advice from a nursing adviser, who noted that the board's correspondence with Mrs C had been poor, and that their apology in their response to her complaint had fallen short of a reasonable standard. We found that, although the board had apologised for some of the failings in Mrs C's care, they had failed to address all of the questions she had raised with them. We upheld Mrs C's complaint. We noted that the board had changed their processes in relation to recording patients' wishes about foetal remains, so we did not make any recommendations in this regard. However, we did recommend that the board re-issue an apology to Mrs C that is in line with SPSO guidance on apology.

Recommendations

What we asked the organisation to do in this case:

• The board should re-issue an apology for the failings identified. The apology should comply with the SPSO guidance on apology.

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 service, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) when he was admitted to Dr Gray's Hospital. Mr A suffered from congestive heart failure and was admitted to the hospital due to feeling tired and unwell, having chest pain, weight gain, nausea and vomiting. Ms C complained that the medical care and treatment provided to Mr A was unreasonable, and that he was not discharged in a reasonable way.

We took independent advice from a consultant physician. We found that, whilst overall assessments of Mr A and the general care and treatment provided to him was of a reasonable standard, there were gaps in weight monitoring. We noted that the board had previously addressed this matter. We also found that the issue of Mr A's internal defibrillator (a small device implanted into the body used to treat abnormal heart rhythms) was not recorded as having been discussed when a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place, and that the general record-keeping around the DNACPR decision was poor. We upheld this aspect of Ms C's complaint.

With regards to Mr A's discharge, we found that it was not reasonable to discharge Mr A as he had only recently been changed from having his medicine administered intravenously (into a vein) to taking it orally, and he was still on supplemental oxygen therapy at the point of the discharge decision. The adviser was critical that these issues were not monitored further prior to Mr A's discharge. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to provide a reasonable standard of medical care and treatment to Mr A during his admission and for failing to ensure that Mr A was discharged 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:

• Discussions around de-activation of internal defibrillators should occur and be documented at the same time as discussions around DNACPR. DNACPR decisions should be adequately documented and should include the reason for the decision.
• Any switch from intravenous to oral medication should be checked to be effective, supplementary oxygen should be stopped and oxygen levels should be monitored prior to discharge.

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.