Health

Summary

C complained that the Scottish Ambulance Service (SAS) unreasonably delayed in dispatching an ambulance for their late parent (A) and, as a result, this had an adverse impact on A’s care and treatment. C questioned why an SAS call handler initially advised them that an ambulance was not needed, when a locum GP subsequently arranged for one as soon as they learned of A’s condition. Shortly after arriving at A&E, A died following a cardiac arrest.

We took independent advice from a paramedic adviser. We found that the actions of the SAS in relation to the allocation and dispatch of an ambulance for A were reasonable, based on the information, resources, and systems in place at the time. We also found that the project improvement initiatives the SAS are undertaking to mitigate the challenges with the triaging of abdominal pain are reasonable. Therefore, we did not uphold the complaint. We did, however, provide feedback to the SAS that when responding to a complaint, where possible, it would be helpful if they provided the complainant with information and explanation of any improvement initiatives that they are taking to address issues raised within the complaint.

Summary

C complained about the treatment provided to their partner (A) when they were admitted to hospital. A presented to the A&E after they woke up feeling generally unwell. A experienced weakness, lost vision, and pins and needles in their hands and feet. When assessed in the A&E, A gave a history of a three-day headache.

There was a delay in A being assessed in the A&E. Given A’s symptoms, the consultant’s working diagnosis was an atypical migraine. They considered the possibility of a stroke but concluded this was less likely based on A's presentation. A was then transferred to the Acute Medical Unit before quickly being transferred to the care of the Stroke Team. A Computerised Tomography (CT) brain scan was carried out and confirmed a stroke. A further CT scan the next day confirmed that A had suffered a second stroke.

C complained that there was an unreasonable failure by the A&E to diagnose that A had suffered a stroke. In addition to this, C complained that A was not provided appropriate treatment in the form of thrombolysis (medicine to get rid of blood clots in the brain) or thrombectomy (surgery to remove a blood clot or drain fluid from the brain).

We took independent advice from an emergency medicine consultant. We found that an atypical migraine was a reasonable working diagnosis. We found that reasonable consideration was given to the possibility of a stroke and A’s history of diabetes was taken into account.

We considered that there was sufficient reason to arrange a CT scan to assist diagnosis while A was admitted to the A&E. This was due to C’s symptoms and the diagnostic uncertainty. However, earlier imaging was unlikely to have made a material difference to the outcome. In addition to this, we noted that A had suffered a posterior circulation stroke, which is known to be challenging to identify.

We concluded that there was not an unreasonable failure to diagnose A's stroke because of the atypical features of A’s presentation. In addition to this, A was appropriately transferred to the AMU for further investigation, which was promptly carried out. Given the above, we did not uphold this complaint. However, we provided the board with feedback that earlier CT imaging was warranted.

In respect of the treatment provided to A, we found that A would not have been eligible for either thrombolysis or thrombectomy. Overall, we considered the treatment provided to A in the A&E was reasonable. Therefore, we did not uphold this complaint.

Summary

C, a Patient Advice and Support Service (PASS) adviser, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A was under the care of two health boards for treatment of a concurrent bladder and colorectal cancer. While the bladder cancer was timeously treated, A died without having received treatment for the colorectal cancer. C also complained that the board failed to reasonably meet their obligations in accordance with Duty of Candour.

We took independent advice from a colorectal surgeon. We found that there was a failure to provide a reasonable standard of care and treatment to A, particularly in relation to a failure to mark an MRI scan request as urgent, and a failure to report the results of scopes in the normal way. We upheld this complaint. We also found that the board failed to meet their obligations in accordance with Duty of Candour. We upheld this 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/meaningful-apologies.

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

• Patients should receive reasonable and timeous care.

Summary

C complained about the care and treatment provided to their late parent (A) by a GP Practice. Following a road traffic accident, A was found to be in atrial fibrillation (a type of heart rhythm where the heartbeat is not steady). The hospital asked the GP to review A for anticoagulation (medication to prevent blood clots from forming or growing) once their injuries had resolved. Several weeks later A had an appointment at the practice and was referred for a 24-hour ECG (a medical test that records the heart’s activity over a 24-hour period). Before the results could be assessed by the practice, A suffered a stroke. C complained that the practice unreasonably delayed in initiating anticoagulant therapy.

We took independent advice from a GP. Following our initial enquiries, the practice provided additional explanation regarding the complexity of the decision making as to whether to prescribe anticoagulation to A, and the reasoning behind their decision to wait for the results of the 24-hour ECG. Following this additional explanation, we considered that the practice’s position and treatment plan was reasonable. We therefore did not uphold the complaint. However, we noted that not everything the practice had said in their further explanation was documented in the medical records and we provided feedback to the practice on this point.

Summary

C complained about the care and treatment provided to their late parent (A) by a GP Practice when A was a resident in a care home. Care home staff had reported that A was agitated and unsettled, possibly in pain and with poor sleep at night. The practice requested that care home staff take a set of observations (temperature, oxygen saturation, pulse, blood pressure) and obtain a urine sample. When observations were later taken by care home staff, the practice advised that they were all normal, thereby giving a NEWS Score (a tool used to quickly determine the degree of illness of a patient and identify acute deterioration) of 0. They said that no visit was indicated at that time and queries about medication for agitation would be discussed on the next GP round to the care home. C was of the view that the report of agitation and confusion should have led to GP review.

We took independent advice from a GP. We found that the care and treatment provided to A was unreasonable, as A had delirium until proven otherwise and should have been seen and assessed for this. We also noted that the practice appear to have relied on a NEWS score to decide no visit was needed, but NEWS is not validated for use in primary care. We therefore upheld the complaint.

During the course of our investigation the practice carried out a Significant Event Review. As a result, they had developed a protocol, to be used alongside physiological measurements, for assessing delirium in the care home setting and had shared and discussed this with the care home. We considered these actions to reasonably address the failings in this case, so aside from apologising to C, we made no further learning and improvement recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to assess A for delirium. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .

Summary

C complained about the board’s assessment of their parent (A) and the decision not to admit A to hospital for further assessment and treatment. C felt that the board inappropriately relied on information provided on behalf of A, rather than speaking with A directly, and that decisions were based on unreliable information.

A tested positive for COVID-19 in their care home and the following day, care home staff contacted NHS24 about A’s condition and the call was passed to NHS Lanarkshire Out of Hours service. The call was triaged for a clinician to call back, and an out of hours GP contacted the care home shortly afterwards. During the call with the out of hours GP, the decision was taken not to admit A to hospital, but for care home staff to contact A’s GP the following day. A died later that day. In their response, the board explained that the out of hours GP spoke with A’s carers and concluded that an appropriate assessment was undertaken.

We took independent advice from a specialist in general and geriatric medicine. We found that the assessment of A conducted over the telephone was reasonable. The record of the assessment was of the level and standard expected. We concluded that the assessment of A’s condition and the decision not to admit A to hospital at that time was reasonable. We therefore did not uphold the complaint.

Summary

C complained about the care and treatment provided to their late parent (A). A was admitted to hospital due to a nose bleed that would not stop. During admission, A used a hospital trolley to cross the ward to the toilet. A jug of water spilt from the trolley and A fell, sustaining a fractured shoulder and a fractured knee. C was concerned about A’s medical and nursing care and about the communication from the board.

We took independent advice from a nursing adviser and a consultant geriatrician.

We found that the falls screening questions were not completed on A’s admission, safe care pauses were not demonstrable from the daily care plan or nursing documentation, A’s walking aid was not within reach and a decision was made to mobilise A when the floor was wet, rather than call for help and ensure the environment was safe. We found that the board’s investigation into A’s fall did not make attempts to identify the second staff member who witnessed the fall and take a statement from them. There was also a failure to activate the Duty of Candour process in this case. We found that A’s B12 injection should have been administered in a more timely way and that medical staff did not promptly inform C and their family of the results of the X-rays and the implications of the fractures for A. Finally, we found that the board did not respond to all of the concerns that C raised. We upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family 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:

• Appropriate steps should be taken in the prevention and management of falls.
• Where appropriate, patients and/or their families should be informed of the results of X-rays by medical staff.
• When an incident occurs that falls within the Duty of Candour legislation, the board’s Duty of Candour processes should be activated without delay.
• Where a patient has fallen and sustained harm, attempts should be made to identify and take statements from all the staff who witnessed the fall.
• Where clinically appropriate, B12 injections should be administered in a timely way.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded toin accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. 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.

Summary

C complained about the lack of care and treatment that the board provided in relation to not being recalled for a colonoscopy. C had undergone regular colonoscopies to monitor disease progression. C was not recalled when the next colonoscopy was due. The COVID-19 pandemic led to suspension of services with a long backlog of patients. When C did subsequently undergo a colonoscopy, this led to a diagnosis of cancer.

We took independent advice from a consultant gastroenterologist and hepatologist. We found that the board failed to identify C as someone at significant increased risk that needed the procedure to be re-booked as a priority. We found that it was unreasonable that C’s colonoscopy was an overdue procedure that was not clinically reviewed. Therefore, we upheld this complaint. We also found that it was unreasonable that the board had not carried out a significant adverse event review into the matter.

C also complained that the board failed to provide a reasonable response to their complaint. We found that the board’s complaint handling of C’s complaint was unreasonable, as the failure to clinically review C’s overdue procedure and failure to identify C as someone at significant increased risk, were inadequately investigated as part of the complaints process. In light of that specific failing, we also upheld this 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:

• The board should have a robust clinical prioritisation process for rescheduling endoscopy procedures that may have been delayed for whatever reason
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. 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.

Summary

C, a Patient Advice and Support Service (PASS) adviser, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A was under the care of two health boards for treatment of a concurrent bladder and colorectal cancer. C complained about the care and treatment received for their colorectal cancer. They also complained about the adequacy and conclusions reached by a Level 2 Adverse Event Review and a Level 1 Significant Adverse Event Review carried out by board A, as well as a lack of transparency under the Duty of Candour and the way that they had handled the complaint. While the bladder cancer was timeously treated, A died without having received treatment for the colorectal cancer.

In responding to the complaint, the board outlined their management of A’s colorectal cancer through the regional multi disciplinary team process, having reviewed the care and treatment as a Level 2 adverse event review and a Level 1 significant adverse event review.

We took independent advice from a colorectal surgeon. We found that there was a failure to provide a reasonable standard of care and treatment to A, particularly in relation to delays in initiating treatment for their colorectal cancer. We upheld this complaint. We found that the Adverse Event Review and the Significant Adverse Event Review (SAER) conducted by the board were inadequate, with inaccuracies in the timeline and unsupported conclusions. We upheld this complaint. We found that there was a failure by the board to meet their Duty of Candour obligations, and we upheld this complaint. We also found that the board’s handling of the complaint was unreasonable, and we upheld this 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:

• Patients should receive reasonable and timeous care.
• When an unexpected or unintended incident occurs, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type, including but not limited to adverse event reviews and Duty of Candour.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with HYPERLINK "https://www.spso.org.uk/the-model-complaints-handling-procedures" The Model Complaints Handling Procedures | SPSO. Complaint investigations should fully investigate the matters of complaint made and identify actions for learning and improvement.

Summary

C complained about the care and treatment that they received from the board. In particular, C complained that the board had failed to recognise or timeously act on the significance of the severity of their pain and abdominal symptoms. C later received emergency surgery in treatment of a ruptured caecum including formation of a stoma.

We took independent advice from an obstetric adviser and a general surgery adviser.

We found that C’s care had been reasonably managed in relation to their discharge from obstetrics and their re-admission when symptoms continued. We considered that the plan made for surgery was reasonable, noting the rare and rapidly progressing nature of the complication C experienced. We also considered the board’s own review of the episode of care was reasonable.

We found that there were aspects of C’s care which were unreasonably managed, specifically, that there were incomplete medical records kept following a surgical review. On balance, we considered the standard of care provided to C was reasonable. We did not uphold this complaint.