Health

Summary

C complained about the the care and treatment that their late sibling (A) received following emergency abdominal surgery at the Royal Infirmary of Edinburgh. C said that the board failed to provide them with adequate care and treatment in relation to the placement, monitoring and management of a central venous catheter insertion line (catheter placed into a large vein) and the administration of Total Parenteral Nutrition (TPN, a method of feeding that bypasses the gastrointestinal tract). C also complained that the board failed to adequately communicate regarding a Significant Adverse Event Review (SAER).

The board upheld aspects of C’s complaint relating to communication but did not uphold aspects relating to care and treatment. However, while the SAER did not identify any failings in A’s care, it did identify some improvements to the board’s procedure on the management of central venous catheter insertion lines.

We took independent advice from a consultant anaesthetist. We found that repeated doses of TPN were administered extravascularly (outside of the vein) when A was in an intensive care unit and this was an avoidable complication. We found that there was a failure to communicate adequately with A in providing them with a reasonable explanation as to how and why the complication from the central venous catheter line had occurred. We also found that the SAER failed to acknowledge failings in A’s care and management.

We upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

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

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

• Where appropriate, there should also be effective communication with patients and/or families in relation to complications. Significant adverse event reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward.

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 provided to their late spouse (A). A had primary sclerosing cholangitis (PSC, a chronic disease of the liver) and was under specialist supervision due to the increased risk of cholangiocarcinoma (CCA, cancer of the bile duct). An MRI scan identified a lesion in A's liver. A's case was discussed at multi-disciplinary team (MDT) meetings and further imaging and tests were carried out. This included a CA 19-9 test (a test to measure the amount of this protein in the blood). A was diagnosed with cancer a few weeks later.

A planned to undergo surgery but this was postponed after a scan showed the cancer had spread to A’s liver. Further tests and imaging confirmed that surgery was no longer an option and A died around seven months later. C complained that the board did not undertake CA 19-9 tests within a reasonable timescale. They also complained about the communication around A's diagnosis and the conclusion that there was no curative surgical option for A.

We took independent advice from a consultant hepatologist (specialist in the liver, gallbladder, bile ducts, and pancreas). We found that there are no clinical guidelines which demand the carrying out of a CA 19-9 test or mandate its timescale. Therefore, we did not uphold this part of C's complaint.

In relation to communication, we found that A was informed of their cancer diagnosis at an arranged clinic appointment which took place around a week after the MDT meeting. This indicated that the diagnosis was treated as an urgent priority and communicated to A within a reasonable timescale. However, we found that it should have been made clear to A from the beginning that there was only a minimal chance of curative surgery being effective. Following postponement of A's surgery, investigations should have been undertaken quickly and the situation clearly explained to A. On balance, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the board did not communicate clearly the implications of changes to decisions about surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients are made aware of the risk of developing the different types of cancers when PSC is suspected or diagnosed. Patients are made aware that potential for management decisions in relation to their care and treatment can be changed at the last minute, and what the likely consequences of such changes can be – particularly in the case of cancellation of planned curative surgery. All relevant communications about the patient’s diagnosis and treatment are documented in the patient’s clinical records and letters.

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 provided to their child (A). A was urgently referred to the Child and Adolescent Mental Health Service (CAMHS) following a crisis in which they absconded from home whilst awaiting an Autism Spectrum Disorder (ASD) assessment. They initially received input from a nurse via video calls, but this stopped when the nurse changed roles.

A was placed on a waiting list for psychological therapies and was prescribed fluoxetine (an antidepressant). An Autism Diagnostic Observation Schedule (ADOS, a tool used to help clinicians assess autism) was carried out but C was not given a copy of the report.

C complained to the board about a lack of therapeutic input and lack of medication review. A was reviewed by a consultant psychiatrist during the investigation of the complaints and C expanded their complaint to include concerns about the brevity and content of this review. The board responded to C’s complaint but their response did not address all the points of complaint and a further response was provided later. C was subsequently given a copy of the ADOS report.

We took independent advice from a consultant child and adolescent psychiatrist. We found that the care and treatment provided to A was not line with national guidelines. A was not offered therapeutic input in the form of psychological therapy concurrent with their medication as they should have been and the reviews of A’s medication were unreasonable, due to their infrequency, brevity and virtual format. We upheld this part of C's complaint.

C complained that the board did not respond to their complaint within a reasonable timescale. We found that the board's initial complaint response was far beyond the 20-working day timescale. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to provide them with reasonable care and treatment. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Apologise to C and A for the failings in complaint handling. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• The board should ensure their understanding of the points of complaint at the outset of an investigation are correct and respond to complaints within 20 working days where possible. 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 that they were unreasonably removed from the practice list. Practices are entitled to remove patients from their lists in certain circumstances. However, the practice must be able to demonstrate that they have acted in a way that is consistent with The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018 and General Medical Council guidance to ending a professional relationship with a patient.

We found that the practice had not acted in accordance with the relevant regulations and guidance when removing C from their practice list. They had not provided any contemporaneous written records setting out the reason why no warning was given in this case and the circumstances of the removal. Therefore, we upheld this complaint.

We also identified that in relation to complaint handling, the practice complaint response did not address C’s points of complaint, which is contrary to the Model Complaints Handling Procedure, which states that you must make sure that any complaints or concerns raised by the patient are responded to promptly, fully and honestly. We fed this back to the practice.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for to failing identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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 actions taken by a GP after attending the practice with sudden hearing loss. The GP initially diagnosed and treated ear wax impaction. When C attended again, the GP considered that they had Eustachian tube dysfunction (the Eustachian tube is blocked or does not open properly). C complained that the GP failed to provide reasonable care and treatment and unreasonably declined them a second opinion and a private referral to an Ear, Nose and Throat (ENT) specialist. Following a later private referral, C was diagnosed with Sudden Sensorineural Hearing Loss (rapid loss of hearing). C has permanent deafness and tinnitus, which they believe could have been avoided had their condition been treated promptly.

We took independent GP advice and found that, based on C’s symptoms and examination findings available at the time, the GP’s care and treatment were reasonable. Clinical guidelines recommend urgent ENT referral only where sudden hearing loss is unexplained by outer or middle ear causes. The GP reasonably believed there to be such explanations for the hearing loss. We did not uphold this part of C's complaint.

However, we considered that the GP could have listened more carefully to C’s description of their symptoms. Although there was more wax in the left ear, the hearing loss was in the right ear. The use of a tuning fork test could have helped determine whether C’s hearing loss was due to a problem in the outer or middle ear (such as blocked wax), or in the inner ear or nerve, as was the case for C. We noted that the practice had implemented learning following C’s complaint.

We found that it was reasonable for the GP not to make a private referral at the second consultation, as treatment was ongoing for a common, reversible condition. Once C formally requested a private referral a few weeks later, this was completed within 24 hours. We did not uphold this part of C’s complaint.

While we identified delays and communication issues in the practice’s complaints handling, we noted that the practice had multiple meetings with C, provided follow-up responses, and had undertaken complaints handling training. We considered that the practice had taken appropriate steps to address shortcomings in their complaints handling. Therefore, we made no recommendations.

Summary

C complained about the dental treatment provided to their adult child (A). C said that A requested a replacement upper retainer (a custom-made device used to maintain the position of teeth after orthodontic treatment) after theirs broke. The dentist provided A with an upper soft splint (a protective device designed to stabilise teeth and reduce the effects of grinding). C said that A's orthodontic work had relapsed, and that they raised this at A's next appointment but felt their concerns were dismissed. C also complained about the handling of their complaint.

We took independent advice from a dentist. We found that the records made by the dentist at the time of A’s initial appointment were sparse and lacking in detail and that there was insufficient information detailed to suggest that an upper soft splint was appropriate in A’s case and that informed consent for this treatment was obtained. There was also a lack of detail in the clinical records in relation to the dentist’s handling of A’s concerns about orthodontic relapse at their subsequent appointment. While both A and the dentist agreed that A raised the issue of spacing at A’s appointment, we could not conclude that this was dealt with appropriately due to the lack of records in this regard. Therefore we upheld this part for C's complaint.

In relation to complaint handling, we noted that C and A were offered an informal meeting with the dentist by the practice manager. We found that the reasons for the meeting with C and A should have been made clear to them and that the informal tone and the lack of structure did not fully align with expected standards. We noted that a copy of the written record of the meeting should have been provided to C and the wording used in the complaint response to signpost C to this office was not in line with the standard wording set out in the NHS Model Complaint Handling Procedure. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Dentists should document a patient’s presenting concerns, relevant dental and orthodontic history, findings from clinical examination (including occlusal assessment where relevant), an assessment or diagnosis, the clinical rationale for any proposed treatment, the treatment options discussed, material risks and consequences, and the patient’s consent, in accordance with the Scottish Dental Clinical Effectiveness Programme – Oral Health Assessment and Review guidance and the General Dental Council Standards for the Dental Team. Where orthodontic relapse was a consideration, there should be a structured occlusal assessment and clear recording of potential contributing factors, including referral where indicated.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the NHS Model Complaints Handling Procedure and expected standards. Complainants should be clearly signposted to the SPSO in all stage 2 complaint responses in line with the standard wording at page 30 of the NHS 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 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 care and treatment the board provided to their late parent (A). A was admitted to hospital following a cardiac arrest. Several days later, A was found on the floor of their ensuite bathroom unresponsive and without telemetry (an observation tool that allows the monitoring of cardiac patients). A survived but did not fully recover and died around two months later.

C complained that the board did not adequately monitor A.We took independent advice from a cardiologist (specialist in diseases and abnormalities of the heart). We found that the care and treatment that A received was unreasonable because A was disconnected from their cardiac monitor when mobilising without being supervised by a member of staff. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Documentation and record keeping should meet the required standards and relevant policies.

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 that the board failed to report an injury to their spouse (A)'s wrist. A was in hospice care and was having their wrist examined by a consultant neurologist (specialists in disorders of the nervous system). C reported hearing a crack and that A was in pain. A underwent an x-ray at Forth Valley Royal Hospital but no break or fracture was found. A died a few weeks later.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that clinicians acted reasonably in relation to the wrist examination. We did not uphold this part of C's complaint but provided feedback to the board regarding the records that were made of the examination.

C complained that the board failed to reasonably handle their complaint. The board acknowledged that there were unnecessary delays in providing responses which unreasonably breached the response times in their complaints handling procedure. We found that the board provided C with unreasonable responses to complaints, did not progress investigation of C’s complaints within reasonable timescales and did not update C regarding the progress of their investigations. They also delayed agreeing to meet with C and did not reasonably progress the making of arrangements for their eventual meeting with C.

These issues meant there was a cumulative two year delay in the board providing a reasonably clear and comprehensive response to C’s complaints. Therefore, we upheld this part of C's complaint. In making recommendations, we have taken into account changes the board have made to their complaints handling practices in the time since C’s complaints were first raised.

Recommendations

What we asked the organisation to do in this case:

• Provide a comprehensive apology to A’s family for the cumulative delay in providing a reasonably clear and comprehensive response to the complaints that they had raised. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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 provided to their late spouse (A) by the board. A, who suffered from Polycythaemia Rubra Vera (PV, a blood cancer), died in hospital. At the time of their admission they were seen to be suffering from anaemia, likely as a side effect of their PV medication.

Following a post-mortem, a pathologist noted that A had developed sepsis due to a bacterial infection and that A’s PV had progressed into leukaemia. C complained that the leukaemia was not diagnosed prior to A’s death, and questioned whether the care and treatment provided to A had been reasonable.

We took independent advice from two appropriately qualified advisers: a haematologist (specialist in blood disorders) and a consultant geriatrician (specialist in medicine of the elderly).

We found that from a haematology perspective, A’s care and treatment was reasonable. Appropriate blood tests had been undertaken and A had received appropriate treatment for anaemia. It did not appear that a transformation from PV to leukaemia had been missed.

From a general medical perspective, we found that the approach taken to diagnosis, and the treatment plan provided were also reasonable, and that appropriate care was provided in response to A developing sepsis. Overall, we did not consider that A’s medical care and treatment had been unreasonable. Therefore, we did not uphold C’s complaint.

Summary

C complained that their parent (A) suffered a fall while in hospital. C was concerned that bedrails and falls risk assessments were not appropriately completed prior to A suffering the fall. The board said in their complaint response that both bedrails and falls risk assessments had been carried out appropriately.

We took independent advice from a registered nurse. We found that, from the evidence available to us, the falls and bedrail risk assessments carried out prior to A’s fall were limited and did not inform a comprehensive care plan. The board’s Policy for the Prevention and Management of Adult Inpatients Falling in Hospital Settings did not appear to have been followed. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out appropriate risk assessments and care planning prior to A’s fall. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Falls and bedrails assessments should be completed, in full, within 24 hours of admission and reviewed regularly.

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.