Health

Summary

C was Power of Attorney (POA) for the patient (A). C complained about the care and treatment that A received in hospital. A suffered two falls, resulting in five fractured ribs. A also acquired pressure sores, contracted pneumonia and died shortly after discharge. C that they were not timeously informed of the falls or A’s deteriorating health. C also complained about the board's handling of their complaint.

The board advised that A was assessed by a doctor after both falls and pain medication was increased. Due to ongoing pain, x-rays and a CT scan were taken weeks later which showed the injury. The board advised that treatment would have been the same if they had known of the injury earlier. The board also noted that they had increased care rounding following the falls and provided a pressure relieving mattress.

They acknowledged that on some occasions care rounding had been delayed due to clinical pressures. The board apologised that A had developed pressure sores and that they had not communicated effectively with C. They advised that staff had been reminded of falls guidance, pressure ulcer guidance and to contact POAs and next of kin.

We took independent advice from a nurse. We found that the board had not regularly evaluated the risk of falls before A fell and did not appropriately review A after their falls. We found that they had not sufficiently managed the risk of pressure ulcers and did not appropriately manage the pressure ulcers once they had developed. We also considered that POA documentation was not correctly filled in on admission and that C had not been appropriately updated regarding important health matters or A’s falls.

We found that the complaint response had taken too long, that C had not been regularly updated and that the complaint investigation could have been more thorough. We upheld all aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise that C was not appropriately recorded as POA and was not kept informed of A’s pneumonia and pressure sores. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• 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/information-leaflets.

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

• Documentation should meet the required NMC “The Code” standards, in regards to assessment, planning, implementation and evaluation of nursing care (APIE process), including for falls. Care and comfort rounding should be carried out timeously. Wound assessment should be carried out and recorded, to guide treatment. Datix incidents should be escalated to Adverse Events for review when there has been avoidable 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

C complained about the care and treatment given to their partner (A) while in hospital, which they believe led to A's death. In response to the complaint, the board acknowledged and apologised that communication with C had not been effective. However, A had been aware of the severity of their diagnosis and prognosis and was able to make their own decisions and all communication had been with them.

We took independent advice from a consultant in acute and general medicine. We found that, while significant parts of A’s care and treatment had been reasonable, there was a delay in the diagnosis and initiation of cancer treatment. In terms of the Scottish referral guidelines for suspected cancer, patients referred via the urgent suspected cancer pathway should receive their first treatment within 62 days of receipt of the referral, which did not happen in this case.

We also found that there were unacceptable delays in relation to acting upon the results of the PET scan and a delay in A’s subsequent diagnosis. In addition, we found that at the time of A’s death a morbidity and mortality meeting (M&M) had not taken place. However, the board confirmed that a new M&M process had been implemented so that all deaths were reviewed through this process. We upheld the complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

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/information-leaflets.

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

• Patients should be treated in line with relevant cancer referral guidelines. Scans should be carried out and reported within a reasonable time frame.

In relation to complaints handling, we recommended:

• There should be a formal review and consideration of a robust investigation process when complaints are received so that any potential learning is identified and actions can be considered to reduce the risk of failures in care in the future.

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 that they received from the board when under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) for foot surgery.

We took independent advice from an orthopaedic adviser. We found that the bones of C’s toe had been reset in the wrong position and the fixation was unreasonable. We also found that C was unreasonably managed at their first post-operative review, noting that C’s x-rays were described as satisfactory which was not the case. The decision to watch and wait was also unreasonable, as by this point a good outcome from the surgery would not have been possible based on the x-rays. We considered that it was unreasonable for the board to discharge C from orthopaedics at the next review appointment when the problem remained unresolved.

There were aspect of C’s care and treatment which we found were reasonable, particularly in relation to the three further surgeries C received. However, we recognised that that these had only been necessary due to the failure which had occurred during the original surgery. On balance, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board’s response contained factually inaccurate information, that there had been delays in complaint handling and that there had been a failure to update C during this time. We upheld this part of 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:

• Patients should receive reasonable surgical 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.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaints Handling Procedure TheModel Complaints Handling Procedures | SPSO. Complaint investigations should fully investigate the matters of complaint made and identify actions for learning and improvement.

Summary

C complained that their GP practice failed to provide them with reasonable care and treatment. C attended the practice with loss of appetite, vomiting, concentrated urine, poor fluid intake, a temperature of 38.7 degrees, and a high heart rate.

C was prescribed antibiotics and given advice on what to do if their condition worsened. C’s condition deteriorated and they attended the practice again. C was referred for a chest x-ray and diagnosed with empyema (pockets of pus that have collected inside a body cavity). C’s condition was life-threatening and they remain impacted by it.

In their response to the complaint, the practice arranged an independent review of C's treatment by a respiratory consultant. They noted that C had a significant tachycardia (heart rate exceeding 100 beats per minute at rest). The practice said that this could have been discussed with the Acute Medical Unit at the time. However, it was likely that they would have advised to treat C at home rather than to admit them.

We took independent advice from a GP. We found that C’s presentation and clinical examination findings were suggestive of pneumonia at least, and indicated that they were at high risk of sepsis. We found that C should have been admitted to hospital rather than sent home with antibiotics. Therefore, we upheld C's complaint.

During the course of our investigation the practice confirmed further reflection and learning. We were satisfied that in doing so they had appropriately addressed the failings in C’s care.

Recommendations

What we asked the organisation to do in this case:

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

Summary

C complained that the board failed to consider their request for bariatric surgery reasonably. C also complained that the board failed to handle their complaint reasonably. C suffers from complex physical and mental health issues. They were referred for bariatric surgery by the clinicians treating their medical conditions. C attended a number of assessment appointments to determine their suitability for surgery. C was concerned by the assessment process and asked to see the report being submitted to the Multi-Disciplinary Team (MDT) meeting but this request was refused. C was not accepted for surgery.

C received a copy of the assessment report through a subject access request. C was told by the board that they would accept a complaint from C if their complaint was made within 12 months. C complained a few months later. The board delayed in acknowledging and responding to the complaint but met with C to agree how the complaint would be handled. The following month, the board wrote to C stating that they would not investigate the complaint, because it had been submitted outwith the time limit for investigation.

We took independent advice from a consultant psychologist. We found that C should have been allowed the opportunity to provide feedback on the assessment process before it was discussed at an MDT. C had been promised an appointment to do this, but the appointment was not made. However, we considered that the assessment itself had been reasonable. Therefore, we did not uphold this part of C's complaint.

In relation to complaints handling, we found that C was not properly informed about the process that the board intended to follow and was repeatedly given the impression that the case would be investigated. The board did not demonstrate how it had determined C’s complaint was out of time. Therefore, we upheld this part of 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/information-leaflets.

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

• The board should have robust administrative systems in place to ensure appointments are arranged as intended and that patients are effectively communicated with.
• In relation to complaints handling, we recommended
• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when they make a complaint.
• The board should ensure timebar decisions reference the relevant board guidance.

Summary

C complained on behalf of their partner (A) about the care and treatment provided to A by the board when they presented to the obstetric triage department 25 weeks’ gestation with pain and abdominal tightening. A was assessed as having Braxton Hicks (when the womb contracts and relaxes during pregnancy, also known as ‘false labour’) given advice on what to do if their condition worsened, and discharged. Four weeks’ later A suffered preterm prelabour rupture of the membranes (PPROM) and their child was delivered prematurely.

C complained about the care and treatment provided to A as they considered the assessment at 25 weeks’ gestation was a missed opportunity for further investigation or follow-up.

The board’s complaint investigation identified that according to local guidelines, A should have been reviewed by a more senior doctor. However, they were of the view that it was unlikely that this would have led to a different outcome.

We took independent advice from a medical adviser. We found that while there were some areas for potential improvement, overall the care and treatment provided to A was reasonable. We therefore did not uphold C's complaint, though we did provide feedback to the board according to the adviser’s comments.

Summary

C complained about the care and treatment given to their late sibling (A) by the board. A, who had a history of addiction issues and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties), was admitted to A&E after overdosing on non-prescription drugs. A was treated for the overdose and was discharged to C’s care. A died the following day. C complained that the board inappropriately discharged A and that the treating doctor had failed to communicate adequately with them.

The board did not identify any failings in A’s care, but did apologise that A was discharged with a cannula in place. The board also apologised for communication failures with C. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant in emergency medicine. We found that A was monitored for approximately 12 hours before discharge. This is the minimum period recommended by Toxbase (the primary clinical toxicology database of the National Poisons Information Service). However, we found that A would have required observation over and above this minimum period. This was because of A’s history of acute seizures, intoxication with opiate drugs and their complex medical history. In the circumstances, we found that it would have been reasonable for A to have remained as an in-patient to enable a greater period of medical observation. Therefore, we considered that the decision to discharge A was unreasonable. 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 decision. 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:

• Internal reviews should include a thorough consideration of all of the relevant evidence including clinical records and there should be reflection on these in an open and transparent manner in order that lessons can be learned.
• Overdoses complicated with seizure activity and aspiration lower respiratory tract infection may require observation over and above the advice provided by Toxbase. Patients admitted with overdoses and who present with a history of seizure activity should be admitted for a minimum of 24 hours observation. Concerns raised by relative(s) of patients should be listened to by staff.

Summary

C complained about the obstetrics (specialists in pregnancy and childbirth) care and treatment that they received from the board during and after the delivery of their baby by planned caesarean section. C said that there was a delay in diagnosing retained products of conception (tissue that remains in the uterus after a pregnancy) which led to infection. C also said that they were kept nil by mouth (not allowed to consume food or drink by mouth) for over 30 hours as their surgery for evacuation of the retained products kept being delayed.

We took independent advice from a consultant obstetrician and gynaecologist. We found that some aspects of C’s care and treatment were reasonable. However, a doctor should have attended when C passed a large clot. There was also a misunderstanding between C and a doctor regarding how long they would be kept nil by mouth for before their evacuation procedure. We also found that the board failed to address C’s concerns about the conduct of a sonographer (specialist in the use of ultrasonic imaging devices) in their response to the complaint. 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/information-leaflets.

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

• Doctors should attend when advised that patients have passed large clots following c-section delivery and are too tender for fundal palpation.
• In cases such as this, a DATIX should be submitted by the board and the case reviewed by the hospital’s obstetric risk management team.

In relation to complaints handling, we recommended:

• In their stage 2 responses to complainants, the board should address all the issues raised and demonstrate that each element has been fully and fairly investigated, in accordance with NHS Model Complaints Handling Procedure. The board should also answer enquiries from this office in full.

Summary

C complained about the care and treatment provided to their parent (A) in relation to a number of hospital admissions. C complained that A was discharged without clear advice as to whether they had sepsis, and how to manage A’s condition. C also said that the board did not provide a discharge letter. C complained that when A attended hospital four days later, they should have been admitted rather than being sent home with oral antibiotics. Lastly, C said that when A was readmitted to hospital the following month, a day passed before they were seen by a consultant.

We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that, while A received appropriate care during their initial admission, the board's communication around A's sepsis was unreasonable. They also did not provide an interim discharge summary.

In relation to A's second discharge, we found that A's symptoms raised the possibility of a complicated kidney infection. Therefore, we considered that discharging A with oral antibiotics was unreasonable. A should have received treatment with IV antibiotics and consideration should have been given to admission, which may potentially have prevented the need for A to be admitted the following month. We upheld these parts of C's complaint.

Finally, we found that A's condition when they were readmitted did not meet the criteria for an urgent consultant review. 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 the failings identified in this decision. 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:

• Decisions on admission and treatment with IV antibiotics should be in keeping with European Association of Urology (EAU) guidelines on Urological Infections and The UK Health Security Agency guidance on antimicrobial intravenous-to-oral switch (IVOS) criteria for prompt switch for adults.
• Immediate discharge letters should be issued at the time of discharge and patients and where applicable their families, should receive appropriate advice on discharge which should be documented in the patient’s medical records.
• Patients with sepsis and their family members and carers should be given opportunities to ask questions about a diagnosis, treatment options, prognosis, and complications. There should be a willingness to repeat any information as needed.

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. 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 care and treatment provided to their late parent (A). A had a terminal illness and was discharged from hospital to be cared for at home. A few days later, the family requested a visit from a doctor. They spoke to a doctor on the phone but it was an Advanced Nurse Practitioner that visited them at home. C was also unhappy that A was not provided with emergency medication.

We took independent advice on the complaint from a GP. We found that A should have had a named and experienced clinical lead coordinating and planning their care. We found that it would have been preferable that a GP had visited A following their discharge from hospital. However, it was not unreasonable that A was visited by an ANP. We found that A should have been provided with emergency medicine. We upheld C's complaint.

We noted that the practice had recognised potential failings and had demonstrated that they had taken reasonable learning and improvement action. Therefore, we made no further recommendations.