Mid Scotland and Fife

Summary
Mr A suffered from anxiety, depression and panic attacks for many years; he attended his GP regularly and was prescribed Citalopram and, on occasion, diazepam.  In March 2013, Mr A saw an out-of-hours GP, describing worsening symptoms and feeling suicidal.  He was prescribed lorazepam and told to see his GP the next day; Mr A attended the out-of-hours GP again the next day and reported suicidal feelings again; he was then seen by a Duty Psychiatrist and discharged with a plan to refer for a medication review.  Two days later, Mr A attended the Accident and Emergency Department at the Victoria Hospital after taking an overdose.  He was discharged, and his parents (Mr and Mrs C) contacted his GP to say they felt they could not leave him alone due to his state.  The following day, Mr A took his own life.

Mr and Mrs C complained to the Board and, along with Mr A's partner, met with Board staff.  The Board said that, because Mr A's suicidal thoughts had been fleeting and intermittent, a decision was made that he could be treated safely in the community.  He had also been declined further medication, which he had requested, due to the risk of overdose.  A Significant Events Analysis was then carried out, where it was identified that benzodiazepine withdrawal may have been a factor in Mr A's mental health deterioration.  It concluded that, in hindsight, Mr A's level of risk to himself had not been anticipated.  A number of recommendations were made.

My investigation was mindful that we were reviewing what happened with the benefit of hindsight; nevertheless, I found that although the initial assessment by the out-of-hours GP was reasonable, the Duty Psychiatrist's assessment did not detail suicide risk factors and there was no evidence that Mr A's partner, who had attended with him, was included in discussions.  Mr A was not told what to do should his condition deteriorate further.  When Mr A attended A&E, staff did not know that he had already presented twice to NHS services with suicidal feelings, which he was now acting upon.  Had staff known this, they would have been able to see that Mr A's condition was developing, and different, more urgent action may have been taken.  I upheld Mr C's complaint that the Board failed to provide Mr A with appropriate care, support and treatment following his visits to hospital in April 2013.

Mr C also complained that the Board unreasonably failed to provide Mr C's family with sufficient information about Mr A's health to allow them to support him, and I upheld this complaint too.  The Board's SEA had already recommended that, in cases where suicide plans have been expressed and hospital admission is not taking place, it would be best practice to agree with patients that partners, family or carers are fully informed to help prevent harm.  We found that Mr A's partner, who had attended all the hospital assessments, did not appear to have been involved in decisions about treatment.  In addition, neither Mr A's partner nor Mr and Mrs C appeared to have been given any advice about how to deal with the on-going situation.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mr and Mrs C and Mr A's partner for the failings identified in this report;
• (ii)  provide me with evidence of the action taken in response to the recommendations of the Significant Event Analysis;
• (iii)  review Mr A's case with a view to improving the level and effectiveness of communication between frontline staff likely to deal with self-harm cases particularly where a patient has presented to multiple services with the same issue; and
• (iv)  review how patient records are maintained and shared between departments to ensure that escalating levels of risk are identified at the earliest opportunity.

Summary
Mrs C complained about the care and treatment provided to her late husband Mr A.  Mr A was admitted to Wishaw General Hospital on 24 February 2014 and died there on 6 March 2014.  Mr A had been unwell for some time prior to admission and cared for by family members at home.  In the days leading up to his admission his condition had deteriorated and he had been hallucinating and unable to swallow.  Mrs C complained about a number of the aspects of care provided to Mr A.  In their response to her complaint, the board accepted some failings and apologised.  Mrs C remained unhappy and asked the SPSO to investigate.  I took independent advice from a consultant physician and a nursing adviser.

My investigation found that although her complaint had been upheld, the complaints process had only looked at Mr A's care in a superficial manner.  Not all the clinical staff involved in the case had commented and may have been left unaware of the outcome of the board's investigation.  I also found a number of significant failings.  There was a lack of any overall plan for Mr A's care and treatment, and the treatment he did receive fell well below a level that Mr A should have expected on a number of points.  There was no specific assessment of his swallowing difficulties or monitoring of the dehydration that he presented with on admission.  Significantly, there was evidence of confusion between staff about whether Mr A was being provided with active or end of life care.  Mr A was being proposed for referrals and investigations just two days before palliative care and a possible transfer to a hospice was considered although there was no apparent change in his condition.  One doctor noted on file that Mrs C wrongly believed Mr A was dying.  However, there is also evidence that other staff did think Mr A was dying and the board acknowledged in their investigation that end of life care would have been more appropriate throughout this admission.  Mrs C told us she received conflicting information about his condition and received a call from occupational therapy about physical aids she may need to care for him at home when it should have been clear he would not be discharged.  Alongside the failings in the treatment and the confusion around this, I was also critical that there was no evidence Mr A's family were appropriately involved in decision-making.  On the day he died, Mr A had a gastroscopy to investigate some of his symptoms.  We found that there had been no clear assessment of the risks of such a procedure and further, that, at the time, Mr A did not have the capacity to consent to such a procedure.  A certificate of incapacity was in place that allowed medical staff to provide general treatment as Mr A could not legally consent to this.  It did not provide for this specific procedure which would normally require additional consent and Mrs C and her family should have been involved in this decision.  This means that Mr A was denied safeguards put in place by legislation to protect adults with incapacity when the decision whether or not to go ahead with the gastroscopy was made.  Mr A did not recover well from this procedure and, while there was some treatment following his return to the ward, there was little evidence this deterioration was properly assessed.

I found there were also failings around the very sensitive issue of when Mr A had died and who should be informed of his death.  The records indicate Mr A died around 13.40 to 13.50.  However the death certificate recorded the time as 15.13.  This difference happened because it was not until then that a doctor confirmed the death.  However, advice by the Chief Medical Officer makes it clear that this approach is wrong and that doctors should seek to put on the certificate as accurate an actual time as possible based on the available information and not simply the time they confirm the death.  Following Mr A's death, the decision was made not to notify the procurator fiscal.  This assessment was made using a standard checklist.  I found no problems with the checklist but it had been wrongly completed and said there were no reasons for Mr A's death to be reported.  In fact, Mr A potentially met two criteria – deaths which were clinically unexplained and which may be due to an anaesthetic.  Mr A died from unknown causes on the day he had had an invasive procedure and there was evidence he had deteriorated following that procedure.  I made a number of recommendations as a result of my investigation.  They reflect that some action had been taken by the board prior to my investigation and the significant changes to the procedures around certification of death introduced on 13 May 2015.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mrs C for the failure to report her husband's death to the Procurator Fiscal and the use of an inaccurate time of death;
• (ii)  notify the Crown Office and Procurator Fiscal Service of the omission to report Mr A's death to the Procurator Fiscal on 6 March 2014;
• (iii)  ensure that all relevant staff are aware of the current requirements for reporting a death to the Procurator Fiscal;
• (iv)  ensure that relevant staff are aware of the Code of Practice for practitioners authorised to carry out medical treatment under Part 5 of the Adults with Incapacity (Scotland) Act 2000;
• (v)  present this case and the findings of this report at a medical/respiratory departmental meeting; and
• (vi)  ensure that this case is included in the appraisals of the relevant consultants and the educational portfolios of relevant trainee staff.

Summary
Mrs C complained on behalf of her grandmother (Mrs A) about the time it took to provide Mrs A with treatment.  Mrs A had a long history of incontinence problems, and her GP referred her to the board in August 2012.  In November 2012, Mrs A had her first appointment at Wishaw General Hospital.  In May 2013, tests at a second appointment identified the problem as stress incontinence.  At a third appointment in October 2013 a doctor suggested that surgery might address this, and said that Mrs A would be referred to a specialist consultant.  This, however, did not happen and when by January 2014 nothing had been heard, Mrs A, her GP and Mrs C all contacted the hospital.  Mrs A was eventually referred to a consultant in February 2014, and was placed on a waiting list for surgery.

Meanwhile, in September 2013 new national guidelines had been produced for managing incontinence in women and subsequently the board formed a group to discuss the best way to treat patients like Mrs A.  The group discussed Mrs A's case at their first meeting in March 2014.  They decided that, per the guidelines, rather than her being on the waiting list, they should instead refer her to a specialist centre at another board (Hospital 2) to consider her treatment.  She eventually had surgery in February 2015, some two and a half years after her initial referral.

In February 2014, Mrs C had complained to the board about the delays.  They explained why these happened, acknowledged that they were unacceptable and apologised for this and for the distress caused.  Mrs C was unhappy with their response as it did not say whether anything had been done to stop this happening again.

I took independent advice from two advisers, a consultant physician and a consultant gynaecologist.  The consultant physician said that the delays after the first appointment were unacceptable, and that there was a failure of care when Mrs A was not referred to the specialist consultant in October 2013.  Both advisers found the delay in referring Mrs A to the specialist centre unacceptable, although the consultant gynaecologist confirmed that in Mrs A's case it was entirely correct to follow the guidelines and refer her there for consideration.

I found that there was a general lack of urgency in Mrs A's care, that there were unreasonable delays in investigating and assessing her condition, and that the board did not address these effectively when responding to Mrs C's complaint.  I was particularly concerned that Mrs A was not referred to a consultant in October 2013, and that when handling the complaint the board did not try to find out why this happened.  I upheld Mrs C's complaint and made four recommendations.

Redress and recommendations
I recommended that the Board:

• (i)  conduct a detailed review of the failings around the out-patient appointment of 28 October 2013, particularly treatment time targets and the lack of referral/clinic letter; 
• (ii)  conduct a review of appointment allocation and waiting times for patients within the uro-gynaecology speciality;
• (iii)  apologise and provide an explanation for the delay in referring Mrs A to Hospital 2; and
• (iv)  apologise to Mrs C for failing to provide a reasonable response to her complaint.

Overview
The complainant (Mrs C) raised a number of concerns over the care and treatment her late brother (Mr A) received from Lanarkshire NHS Board (the Board) following his admission to Monklands Hospital on 27 February 2013.  Mr A was admitted with swallowing difficulties and died on 22 March 2013.

Specific complaints and conclusions
The complaints which have been investigated are:

• the Board provided inadequate care and treatment to Mr A (upheld); and
• there were unreasonable delays in care and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their results 'sign off' process at ward level to ensure all results are reviewed before filing;
• conduct a review of their complaints handling to analyse why this result from another health board was not identified as part of their investigation;
• apologise to Mrs C for the failure to diagnose Mr A properly, particularly with the information available from the blood test reported upon after his death; and
• investigate the delay in the time from referral to review by the neurologist and provide staff with advice about how to obtain specialist neurological advice for patients such as Mr A, when a consultant review may be delayed.

Overview
The complainant (Ms C) raised concerns that her late sister (Ms A) was not told of her diagnosis for three weeks after having a scan which showed she had cancer.  Ms A was then told she would be referred to oncology, but no appointment was offered for a further three weeks.  Sadly, Ms A died a few days before the appointment was offered.

Specific complaints and conclusions
The complaints which have been investigated are that Lanarkshire NHS Board (the Board) unreasonably delayed:

• in informing Ms A of her diagnosis (upheld); and
• in offering Ms A an oncology appointment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• undertake a specific internal enquiry to determine why the results of Ms A's scan were missed by both Accident & Emergency staff and radiology.  The investigation should identify process improvements to ensure this situation does not reoccur, and the results of the investigation should be shared with Ms A's family, if they wish;
• issue a written apology to Ms C and her family for the failings this investigation identified;
• raise the findings of this investigation with Consultant 1 for reflection as part of their next performance appraisal; and
• review the Board's complaints handling processes and templates to ensure that:  complaints involving more than one hospital are fully investigated and addressed, with input from all relevant staff (regardless of where the complaint is received); and any failings are clearly identified, and the causes for these, and any action to address them, explained.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) raised concerns about delays by NHS Lanarkshire (the Board) in diagnosing her father (Mr A)’s bowel cancer.  Mr A was seen by a respiratory consultant (the Consultant) at an out-patient clinic at Monklands Hospital (the Hospital) on 24 July 2013 following a referral from his GP.  Mr A had been suffering from breathlessness for a number of months and had been treated for a lower respiratory tract infection.  The Consultant's diagnosis was that Mr A was suffering from mild asthma brought on by the lower respiratory tract infection and blood was taken for routine tests.

Tests of the blood taken by the Consultant showed that Mr A had a low level of haemoglobin (a protein found in red blood cells which carries oxygen around the body).  The laboratory noted that there were features of iron deficiency and that blood loss should be excluded as a possible cause.  The laboratory did not highlight the low haemoglobin level by telephone and the Consultant did not identify or act upon this abnormality when reviewing Mr A's results.

Due to his continuing symptoms, Mr A had further blood tests carried out by his GP on 9 September 2013 and was admitted to the Hospital the following day where he required a blood transfusion.  He was subsequently diagnosed with colon (bowel/large intestine) cancer and liver metastases (the spread of cancer).

Specific complaints and conclusions
The complaints which have been investigated are that the Board failed to:

• take appropriate action when Mr A's blood result showed an abnormally low haemoglobin level (upheld); and
• ensure that Mr A received timely follow up treatment when the abnormally low haemoglobin level was discovered (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• confirm the outcome of their review of this incident and advise what steps have been taken to prevent recurrence in future;
• review their governance arrangements for identifying systems errors like this in future;
• apologise for the failure to implement the Telephoning of Results Protocol;
• apologise for the delay in Mr A's diagnosis;
• confirm that this matter will be, or has been, discussed at the Consultant's annual appraisal;
• conduct a Board level review of the tracking of test results in both paper and electronic formats; and the role of individuals who order tests and report their results; and
• make the outcome of any recommendations arising from the Board level review available to us, Mr A and his family.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Ms C), acting as Independent Advocate for Miss A, raised a concern about the decisions taken by staff about artificial feeding by nasogastric (NG) tube for Miss A during a hospital admission from 25 June 2011 and 8 September 2011. Ms C also raised a concern about a lack of consultation with her about a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision in September 2011. Ms C also had concerns about the accuracy of Lanarkshire NHS Board (the Board)'s response to her complaint in October 2011.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) during a hospital admission from 25 June 2011 to 8 September 2011, a flawed decision was taken to remove an NG tube (upheld);
• (b) a DNACPR decision was taken without appropriate consultation with Ms C as Miss A's advocacy worker (upheld); and (c) Lanarkshire NHS Board's complaint reply of 1 December 2011 inaccurately stated that a particular clinician had known Miss A since 2004 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) use the circumstances of Miss A's case to review their practice in respect of patients with learning difficulties and/or suspected dementia, with particular focus on a review of the quality of decision making, the recording of decision making and the quality of record-keeping on admission and concerning DNACPR decisions; and
• (ii) review their procedures for investigating complaints to ensure that responses are both accurate and can be justified.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her daughter (Mrs A) for mental health problems by Forth Valley NHS Board (the Board) prior to her death by suicide on 11 October 2012.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not:

• offer a reasonable diagnosis (not upheld); and
• provide a reasonable standard of care and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review the approach taken by the Intensive Home Treatment Team to the assessment of risk to ensure that presenting risk factors are systematically considered and recorded and that the rationale behind clinical decision making is transparent;
• remind medical staff of the importance of accurate and signed contemporaneous notes;
• review the process for communicating medical reviews of patients to IHTT staff, to ensure that all relevant information is made available timeously;
• review the process for discharging patients from the IHTT to ensure that medical staff's opinions are considered; and
• apologise for the failings identified in this report.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mr C) raised a number of concerns that the diagnostic journey he underwent for an abdominal problem was unreasonable and has left him with on-going and debilitating symptoms.

Specific complaint and conclusion
The complaint which has been investigated is that Lanarkshire NHS Board's diagnostic actions were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• ensure, as a matter of priority, the Consultant reflects on the events investigated and discusses all learning points at  their next annual appraisal.  Including when and how a cancer diagnosis is made and communicated;
• ensure that all the medical staff involved in this case are reminded of the importance of adhering to the General Medical Council guidance on record-keeping;
• urgently review the diagnostic process used for colon cancer, including the use of Multi-Disciplinary Team discussions, taking into account national guidance;
• issue a written offer for Mr C to insert a note of clarification in his clinical records where necessary, as mentioned in the draft complaint response;
• review its monitoring process for the handling of complaints to ensure that a robust system is in place to prevent complaint responses that are due for issue being  delayed and that if unavoidable delays occur, complainants are kept informed; and
• issue a written apology to Mr C for the failings identified during this investigation.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) raised a number of concerns over the care and treatment she received from Lanarkshire NHS Board (the Board) between July and October 2013.  Mrs C had twice suffered from cancer and was alert to its possible return.  She complained that the Board's handling of her treatment in this time unreasonably delayed the cancer diagnosis she ultimately received in October 2013.  Mrs C was also dissatisfied with the accuracy of the Board's response to her complaint.

Specific complaints and conclusions
The complaints which have been investigated are:

• (a) the Board did not provide reasonable care and treatment to Mrs C between July and October 2013 (upheld); and
• (b) the Board's response to Mrs C's complaint of 15 November 2013 was not reasonable due to its containing inaccuracies (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• raise this matter at Doctor 6's next appraisal as a learning point;
• carry out a significant incident review to ensure that the failings highlighted, including the lack of recognition of the severity and urgency of the situation and responsibility for taking the case forward, are fully addressed and acted upon to prevent recurrence;
• address the reasons for the inaccuracies in their response to Mrs C's complaint as part of the significant incident review; and
• apologise to Mrs C in writing for the failings identified in this report.

The Board have accepted the recommendations and will act on them accordingly