Health

Summary

C complained about the care and treatment they received from the board when they attended the hospital with pain and a tight feeling in their leg. C raised concerns that the board failed to: reasonably assess them on admission to hospital, and undertake the correct scans; provide them with timely information about their test results; reasonably identify an arterial clot and diagnose their condition; and provide them with reasonable treatment following admission to hospital.

We took independent advice from a consultant in acute medicine. We found that a detailed clinical assessment of C’s right leg and foot was carried out on their admission to hospital, and that it was reasonable that the clinicians did not identify an arterial clot at that time. We found that the possible diagnoses that were considered at the time were correct, and the diagnosis of plantar fasciitis was a reasonable conclusion to have reached. We also found that the correct scan had been carried out to exclude deep vein thrombosis (DVT, a blood clot in a vein) as a cause of C’s symptoms, and that the care and attention C received from medical staff was reasonable.

Therefore, we did not uphold C’s complaint.

Summary

C complained about the medical and nursing care they received for a spinal condition. C said the care led to avoidable complications and delayed their transfer to a specialist spinal unit.

We took independent advice from a consultant in orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found a number of failings in the nursing care C received. This included poor record keeping and a failure to manage C’s skin care appropriately. This led to avoidable pressure injuries which were a significant factor in delaying C’s transfer. In terms of medical care, we found that the ward C was placed on lacked the necessary equipment to manage a patient in their condition. We found the medical and nursing care C received fell below a reasonable standard and upheld these parts of C’s complaint.

C also complained that the board failed to provide them with a reasonable standard of physiotherapy. We found that C’s physiotherapy care was of a reasonable standard and was well documented, showing regular review up to the point physiotherapy was stopped on medical advice. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with a reasonable standard of medical and nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Wound charts should be in place for pressure wounds and there should be subsequent weekly assessments. Care rounding should be delivered to the frequency required to prevent pressure damage. Patients should be appropriately moved position to avoid worsening pressure damage.
• Nursing staff correctly follow CPR for feet guidelines and develop person centred treatment plan for patient foot care.
• Patients should be transferred to a hospital and ward which can provide the care they need.
• That a duty of candour review is considered in light of the SPSO's findings.
• When a relevant adverse event occurs, the board should complete a SAER.

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

C complained on behalf of their client (B) about the care and treatment given to B’s late parent (A) while in hospital. B fell on the ward, suffered a cerebral haemorrhage and died several days later. C complained there had been a lack of basic nursing care, a failure to carry out and record nursing risk assessments and routine observations and a failure to maintain documentation to a reasonable standard. C also complained that the level of communication and information sharing with A’s family was unreasonable.

In response to the complaint the board acknowledged there had been failings and explained that action had been taken in response.

We took independent advice from a senior nurse adviser. We found that there were significant and serious failings in A’s care in relation to a failure to consider delirium, the absence and recording of regular vital signs monitoring and observations, a failure in fluid balance management, poor record keeping, a failure to move A in the ward offering more visibility, a lack of a pharmacology review and a failure to have in place an escalation process for staff concerns.

Therefore, we upheld the complaint. However, we recognise the learning already implemented by the board which has led to significant improvements to patient care and addressed the failings identified in this case.

We also provided feedback on the score given on the Serious Adverse Event Review (SAER) report, which was not reflective of the failures identified in this case. SAERs should be reviewed in a timely manner in partnership with the patient and/or their family/carers.

Recommendations

In relation to complaints handling, we recommended:

• Complainants should be kept updated on their complaints in line with the Model Complaints Handling Procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led ComplaintsInvestigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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

C complained about being de-registered from their dental practice. C also complained that the practice failed to handle their complaint reasonably. Due to a broken tooth, C phoned for an emergency appointment and was told they could attend the same day. However when C arrived, they were given a temporary substance to place over the tooth until an appointment the next day. When C later phoned the practice to explain their situation had worsened, they were told to wait until the following day. C emailed the practice to complain about the service they had received but returned the following day to have the tooth treated. A year later, C requested an emergency appointment but was told that they had been de-registered and would not be seen.

We found that there was only very limited evidence to show that the de-registration letter was ever sent and that there was a delay in doing so. We found that the lack of record keeping in this case has made it difficult to assess the practice’s complaint handling. This in itself is unreasonable, given the concerns C raised. Overall, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be notified of de-registration from the practice within a reasonable timeframe. Letters sent by post should be correctly addressed.

In relation to complaints handling, we recommended:

• All complaints should be handled in line with the NHS Model Complaints Handling Procedure (MCHP). In particular, where an early resolution response is provided, a full and accurate record of the decision reached and given to the person should be made. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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

C complained about the board’s decision not to provide thyroid chondroplasty (a surgery to reduce the size of the Adam’s apple) as part of their gender affirming treatment. The board explained that though they used to have surgeons who could carry out this surgery, they no longer do. They said that the Scottish Government does not fund thyroid chondroplasty and therefore they cannot recruit surgeons for the purpose of performing the surgery and are prevented from using public finances to fund it.

We found that there is no obligation for the board to provide thyroid chondroplasty on the basis of Scottish Government protocols. However, protocols state that health boards should ensure they have clear documentation on what is available to their patients and have local policies in place regarding access to them. We gave feedback to the board on this point, but ultimately did not uphold C’s complaint.

C also complained that when they were in the process of having hair removal prior to gender reassignment surgery, the board stopped providing this service. Because hair removal at the site of surgery is a requirement, C had to pay for the hair removal to be completed privately.

During the course of our investigation, the board accepted that they had not been clear to them at the point of C’s complaint that it is the responsibility of the health board where the patient lives to arrange hair removal prior to gender reassignment surgery. The board apologised for the failure and financial inconvenience caused and offered to reimburse C for the laser hair removal. We upheld the complaint and made no further recommendations.

Summary

C complained on behalf of their parent (A) about the care and treatment they received from the board following neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord). C complained that the board did not provide follow-up care to A and they were not referred to oncology (cancer specialists) for further treatment. C said that A required further surgery to treat recurrent disease a few years later as a result.

The board’s complaint response explained that an administrative error had occurred which had led to A not receiving follow-up care from neurosurgery or a referral to oncology. The administrative error had been managed via staff training to prevent it from happening again. In response to our enquiries the board confirmed that no internal review, such as a Serious Adverse Event Review (SAER), had taken place.

We took independent advice from a neurosurgery adviser. We found that it was unreasonable that A had not received the planned clinical follow-up after their surgery. It was also unreasonable that SAER or Duty of Candour guidance had not been followed in this case. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should initiate statutory duties and processes for learning when it becomes known that a potential harm has occurred. Including, but not limited to, Duty of Candour and adverse event review processes.

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

C complained about the standard of medical care and treatment provided by the board to their late sibling (A) during a long admission to hospital. A’s medical history was complex as they suffered from a number of life threatening conditions during their hospital admission and they were under the care of a number of specialities. It was not until after A died, when the post mortem was performed, that A’s cancer was identified.

C said that the various clinicians should have identified A’s cancer, and that communication was not reasonable. C also said clinicians did not manage A’s pain well which was unreasonable and very distressing for the family.

We took independent advice from specialists in urology (urinary system and male reproductive organs), cardiology (heart), radiology (imaging) and end of life care. We found that treatment decisions were reasonable, and that the board managed A’s pain in a reasonable way. We also found that it was reasonable for clinicians not to have diagnosed A with cancer. Therefore, we did not uphold C’s complaints.

However, there were aspects of communication that the board should consider improving and we provided this as feedback.

Summary

C complained on behalf of their late partner (A) who died from a stroke caused by a blood clot. A was admitted to hospital with seizures after collapsing at home and sustaining a head injury. A couple of days later A was identified to have had a stroke, and they died the next day. C complained that an MRI scan was not carried out in order to verify the cause of A’s seizures (a blood clot), in a timely manner to enable acute stroke interventions.

We took independent advice from a consultant in intensive care medicine and a consultant stroke physician. We found that receiving a CT head scan when A first presented was appropriate. A working diagnosis of seizure was reasonable at that time. We found that it was reasonable that time critical acute stroke interventions were not indicated, and therefore an MRI was not indicated. A repeat CT scan did not show any significant changes from the initial scan. We noted that an MRI scan at this point would have been unlikely to have altered A’s immediate management.

C was concerned that placing A in a medically induced coma masked the progression of the stroke, however, we found that this action was in keeping with guidelines. We considered that the clinical management of A was reasonable. Therefore, we did not uphold C’s complaint.

Summary

C complained about the decision to stop the anticoagulant (blood thinning) medication given to their late parent (A) and a lack of communication with the family around this decision. The practice instructed to stop the medication due to an unexplained bleed. Following this stoppage, A died from a stroke. A’s family contacted the practice to discuss their concerns about the medication but they were unable to speak to a clinician in a timely manner.

We took independent advice from a GP adviser. We found that there were clear indications for A to be on anticoagulant medication and that it was unreasonable that the medication was stopped without a replacement in place. The decision to stop the medication was not fully informed. We noted that the practice did not undertake timely blood tests or communicate with A’s family and the relevant specialists. We also found failings around the administration of blood tests.

The practice carried out a Significant Adverse Event Review (SAER), which we found was not in line with relevant national guidance. We upheld C’s complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Significant Adverse Event Reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward. SAERs should be held in line with relevant guidance.
• Appropriate blood tests should be carried out in line with relevant guidance when anticoagulant medication is stopped or replaced. Test results should be appropriately actioned.
• Contacts to the practice from patients or their carers should be adequately assessed to ensure that they are appropriately escalated and, where necessary, there is discussion with the appropriate member of staff, including clinicians.
• Patients should be fully assessed prior to the stopping of anticoagulation medication with appropriate consideration given to the risks. Full information should be sought, including where appropriate communication with relevant specialists and the family members prior to any decision being reached. Where this information is received in the GP’s absence, arrangements should be in place for this to be picked up by another clinician.

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

C complained about the care and treatment their parent (A) received during a hospital admission. C complained about the way episodes of agitation and aggression were managed by the board including in respect of administration of medicines; bruising to A during episodes of restraint and lack of dignity; a failure to manage their nutritional needs; and poor communication with A’s family.

The board’s response to C’s complaint advised that medication had been used to settle A when other measures had been unsuccessful. The board said that A’s weight loss had been recognised and a referral had been made to the dietician, however, they had been discharged from hospital before a review could take place. It was recognised that documentation including fluid and food intake charts were incomplete and steps would be taken to ensure improved compliance. The board considered there had been good communication with A’s family, however, they apologised for the lack of empathy reported by C, which staff would be asked to reflect on for future learning.

We took independent advice from a senior nurse adviser and a consultant geriatrician (specialist in medicine of the elderly). We found that there were aspects of A’s care which were reasonably managed particularly in relation to the way episodes of agitation and aggression had been managed on the ward. We found there were aspects of A’s care which were unreasonably managed particularly in relation to management of their nutritional needs, record keeping and communication.

On balance, we considered the board failed to provide a reasonable standard of care and treatment to A and we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• The board should ensure effective communication with family members, particularly in circumstances where Adults With Incapacity is in place.

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.