Health

Summary

C complained about the care and treatment provided to their late spouse (A) by the practice. A was provisionally diagnosed with torticollis (where the head becomes persistently turned to one side associated with painful muscle spasms) by the practice. Six months later A was admitted to hospital and diagnosed with transitional cell carcinoma (a type of bladder cancer) and a secondary tumour was growing on the spine. A died a few month's later. C complained that the practice failed to provide a reasonable standard of care and treatment in the months before A’s diagnosis and once A was discharged from hospital.

We took independent advice from a GP. We found that the practice unreasonably failed to arrange face-to-face appointments, or carry out more detailed clinical examinations, history taking and assessment of red flag symptoms. There was a lack of continuity in the care A experienced and it was unreasonable that there was a delay in actioning a referral upgrade to urgent. While we accepted that there was a poor prognosis, earlier intervention might have improved the management of A’s pain. Therefore, we upheld this part of C's complaint.

In relation to A's care after their hospital admission, we found that it was unreasonable that A was not reviewed by a GP until seven days after discharge and not directly examined by a clinician when they reported a new symptom. We also noted that no detailed assessment was carried out of A’s analgesic (painkiller) requirements. We found that the practice did not provide reasonable care in accordance with the relevant standards on discharge. Therefore, we upheld this part of C's complaint.

We also found that while the practice completed a Significant Event Analysis, this learning could have been carried out in a more timely way. We noted that the practice's own complaint investigation did not identify the full extent of the failings in this case. While areas for learning and improvement have been recognised and acknowledged by the practice, these were only identified in response to our enquiries.

Recommendations

What we asked the organisation to do in this case:

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

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

• Wherever possible and where it is clinically appropriate, patients should receive face-to-face appointments, where a detailed clinical examination can be carried out, a detailed history taken and assessment of any red flag symptoms, and receive continuity of care.
• Patients with new diagnoses of cancer should receive prompt review by a GP, including appropriate Anticipatory Care Planning, completion of an eKIS summary and be added to a Palliative Care disease register to facilitate multi-disciplinary care planning.
• When a relevant adverse event occurs, the practice should promptly carry out an appropriate adverse event review to investigate the cause and identify any potential learning in line with the National Framework for Scotland (www.healthcareimprovementscotland.scot/).

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures. They should ensure that failings, as well as good practice are identified and that learning and information gathered from complaints is used to drive service improvement.

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 was diagnosed with a kidney stone by a neighbouring board. Shortly after, they attended Greater Glasgow and Clyde's Urology Department and received an X-ray. C complained that the board failed to identify the kidney stone, resulting in surgery several weeks later and a kidney injury.

We took independent advice from a consultant urologist. We found that while it was not possible to determine whether the board failed to identify a kidney stone on the X-ray, the board did have doubt about whether the stone had passed. At this point the board should have checked this by means of a CT scan. We found that it was not possible to determine whether failing to confirm a kidney stone, and delayed treatment, would result in a kidney injury. We upheld this part of the complaint because it was unreasonable for the board to have doubt about whether there was a stone present, but not to confirm this.

C complained that the board had failed to arrange a follow-up appointment within an appropriate time period. We found that when passage of the stone was not confirmed, a follow up CT scan should have been arranged within 2 weeks, and that the plan to wait a further 6 weeks in these circumstances was unreasonable. Therefore, we upheld this part of C’s complaint.

C also complained that the board did not clearly communicate their diagnosis, and their subsequent request for clarification on how they came to have surgery after being told there was no kidney stone present. We found that there were shortcomings in the board’s communication with C, both in relation to the kidney stone and in providing an explanation as to how they came to have surgery. Both of these might have been relatively easily avoided or resolved. We therefore upheld this part of C’s complaint.

We asked the board to reflect on the imprecision of using plain X-rays and consider the possibility of updating practice by using low dose non-contrast CT scans as standard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific communication and process failings identified in respect of their complaints. 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 have a full understanding of what is happening in relation to their diagnosis and ongoing treatment plan. The board should ensure that patients are sign posted to the relevant complaints procedure when they raise concerns.
• Relevant staff should be aware of the requirements of ensuring that patients are stone free, either by spontaneous passage or clinical removal after 4 to 6 weeks of initial presentation, in accordance with the relevant guidance.

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 provide them and their baby (A) with appropriate care and treatment both during and after A’s delivery at the hospital. This included failing to advise C that one of the doctors involved in the delivery of A was a first year speciality trainee doctor and that the use of forceps in A’s delivery resulted in them suffering permanent injuries, erb’s palsy (a condition often caused by birth trauma that can affect the movement and feeling in a baby's arm) and phrenic nerve palsy (respiratory distress which can be caused by nerve damage during birth). C also complained that there was a failure by the board to carry out further investigations of A’s erb’s palsy, a failure to deal with A’s respiratory distress and diagnose that they had phrenic nerve palsy and a failure to adequately monitor A’s weight.

We took independent advice from two medical advisers, a consultant obstetrician and gynaecologist and a consultant neonatologist.

We found that birth injuries could occur even though there were no obvious difficulties with the birth. Given this and the evidence available, it was not possible to establish the cause of A’s injuries. However, we found there was a lack of communication with C during the consent process, C was not consented for the involvement of junior trainee speciality doctors at the birth of A and it was not explained to C that teaching of staff would take place during the birth. We found that no consideration was given to the use of ultrasound to determine the position of A prior to delivery, in accordance with Royal College of Obstetricians and Gynaecologists guidance, and medical documentation around the events of A’s birth was not of the expected standard in terms of the level of detail recorded. We, therefore, upheld this part of C’s complaint.

In terms of the care and treatment of A following delivery, we found that, overall, this was reasonable. We found that there were no concerns about the diagnosis and treatment of A’s Erb’s palsy and that A did not have respiratory problems, or the key signs associated with phrenic nerve palsy. However, we found that the board failed to adequately monitor A’s weight during their hospital stay, which was acknowledged by the board, and we upheld this part of C’s complaint on that basis.

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 informed when junior trainee speciality doctors are to be involved in their care and treatment and when teaching of staff will be included. These discussions should be clearly recorded as part of the consent process. The following issues should be included in the board’s guidance on obtaining consent: (i) staff should provide an explanation to the patient as to who will be overseeing the birth, and if they will be assisted by other doctors in training; (ii) that members of the clinical team introduce themselves to the patient and explain what their role will be.
• Routine consideration should be given to the use of ultrasound for determining and confirming the position of the fetal head in accordance with the RCOG Guidance, especially when rotation of the baby is required.

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 parent (A) about the care and treatment A received from the board while they were in hospital.

C complained that the hospital failed to consider the relevant medical and practical considerations, particularly with respect to A’s medication and whether it may have contributed to delirium and the falls A suffered while in hospital. C also complained that the board had failed to adequately consult with family members when the decision was made to discharge A. C further complained that the board’s handling of their complaint was unreasonable.

We took independent advice from a consultant specialising in the care of the elderly. We found that C had raised legitimate concerns that the medication could contribute to delirium and the risk of falls. It appeared that the dose prescribed had changed on a number of occasions without a clear rationale recorded in the records and that the care provided with respect to prescribing and monitoring A’s medication fell below a reasonable standard. We therefore upheld this aspect of the complaint.

We also identified a lack of detail in the pre-discharge assessment of A, and a lack of discussion with the family. We upheld this aspect of the complaint.

Lastly, there were elements of C’s complaint that were not adequately or accurately addressed in the board's complaint response and on this basis we upheld this aspect 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:

• A patient’s suitability for discharge should be appropriately assessed. The rationale for discharge should be properly documented and any relevant documentation completed. Where appropriate, the patient’s family should be included in discussions about planning for the patient’s discharge.
• Decisions about medication prescribed for a patient and any changes to that medication should be accurately recorded in the patient’s medical records and contain details of all pertinent information.
• Staff are aware of the importance of prescribing and monitoring a patient’s medication appropriately.

In relation to complaints handling, we recommended:

• Complaint responses should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaint responses should address the key issues raised, should be factually accurate and should acknowledge the concerns of the complainant.

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 their late parent (A) received during their attendance at A&E. A was seen in A&E as a GP referral to the hospital’s medical team. C complained that the medical team failed to recognise the nature and severity of A’s condition and their general vulnerability, that they failed to institute an appropriate and timely treatment plan and that there was a failure in record keeping. C also complained that A was discharged home without appropriate medication, without an appropriate discharge letter and without alerting their family and that the board had ignored their Duty of Candour and Ethics Code.

When responding to C’s complaint, the board accepted that there were failings in relation to some aspects of A’s care and treatment. They apologised that C had not been informed about A being discharged. They explained that this had been shared with relevant staff and that they were making changes to ensure families and carers were contacted prior to the patient being discharged. The board also accepted that A should have been provided with a copy of their discharge letter given their vulnerability. They explained that consideration would be given to printing off discharge letters and giving them to medical patients in certain circumstances. Further, the board accepted that there had been failings in relation to record keeping and in relation to A’s medical notes. They indicated that this would be brought to the attention of the relevant staff, would be part of the medical induction and would be discussed in a clinical forum.

We took independent advice from a consultant in emergency medicine. We found that the care and treatment given to A whilst in A&E was reasonable as was the decision to discharge A. There was no evidence to suggest that A's death was linked to any aspect of the care and treatment they received in A&E. However, we found that, in addition to the failings identified by the board that are detailed above, there was no evidence that the board had any process in place to examine this type of case to ascertain whether it met the threshold for a Significant Adverse Event Review (SAER). We upheld the complaint.

We also found that there was a failure by the board to fully address the issues raised when responding to C’s complaint and that there were undue delays in updating C and responding to them about their 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/information-leaflets.

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

• There should be clarity around the board’s policy and processes for identifying and initiating a SAER (Significant Adverse Event Review) in cases where a patient has come to series harm (death) shortly after discharge.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedure. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Complainants should also be kept updated on their complaints in line with the Model Complaints Handling Procedure. Additionally, learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

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, an advocacy worker, complained on behalf of the family of A, about a failure to appropriately investigate A’s symptoms, and a consequent delay in diagnosing and treating their cancer.

We took independent medical advice from a radiology consultant (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), an Ear, Nose and Throat (ENT) consultant and a general medical consultant. We found that the initial scans A received were reported reasonably and did not show any malignancy. When A’s GP later referred them to ENT, we noted that consideration should have been given to upgrading this to urgent. It remained routine and A was not seen until nine weeks after the referral, at which point their cancer was diagnosed.

In the meantime, A had been admitted to hospital under the care of the general medical team. We found that the medical team did not place sufficient emphasis on A’s physical symptoms, which were ‘red flags’ for the possibility of cancer. There was a failure to scan A’s neck, which is where their symptoms were. We also found that A should have been referred to ENT more urgently, preferably as an inpatient. The general medical team wrote to ENT asking for the earlier ENT referral to be expedited, but the letter did not sufficiently emphasise the physical concerns and placed undue emphasis on the likelihood of the problems being of a psychological nature. Had an ENT review been arranged while A was an inpatient, it is likely that their cancer would have been diagnosed at this point.

We concluded that the board failed to reasonably investigate A’s symptoms and upheld the complaint. We noted that an earlier diagnosis around the time A was an inpatient would have been unlikely to have affected the outcome for A. However, we recognised it would have given A and their family more time to come to terms with the diagnosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the issues 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’ physical symptoms should be thoroughly assessed and they should be appropriately referred for review and scanning/x-ray as required in accordance with their presenting symptoms.
• Referrals to ENT should be appropriately triaged and upgraded as required.

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 nursing care provided to their late spouse (A) during their admission to hospital. C raised specific concerns about the personal care and stoma care provided.

We took independent advice from a nurse. We found that the personal care provided to A was reasonable. However, we identified significant failings in how A’s ileostomy care needs were provided and significant gaps in documentation. Therefore we upheld this part of C's complaint.

C also complained about the communication with both A and C about A's health and prognosis. We found that prior to A’s decline C was communicated with in a reasonable manner. In relation to the communication with A in the days before their passing, we found that A was experiencing increasing confusion and cognitive impairment throughout their stay in hospital and at times lacked capacity. In light of this, it was unreasonable to inform A of their poor health without C present. 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 in this investigation. 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 communicated with in a reasonable manner, and, in line with their capacity, with next of kin present for support if necessary.
• Patients should have a person-centred care plan and staff should follow this.
• The care delivered should be captured in appropriate documentation.
• Stoma care is appropriately recorded in the correct area to support correct stoma care being provided in a reasonable manner.

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 provide C with appropriate treatment for a shoulder fracture. C was admitted to hospital suffering from alcohol related seizures. It became apparent that C had also suffered a shoulder fracture. C was discharged 12 days later with an orthopaedic referral (specialists in the treatment of diseases and injuries of the musculoskeletal system) for the following week. C was then scheduled for surgery to realign the fracture. This was subsequently cancelled. When C was seen again the following week a different consultant determined that C’s fracture had now healed to the extent that surgery was no longer a viable option.

C complained that the shoulder is now misaligned, causing discomfort and a reduced range of motion affecting day-to-day life and their ability to work. C believes that opportunities were missed to prevent this outcome. The board’s response stated that C was initially too unwell for surgery, and that the cancelled procedure was because of an emergency admission that had to be prioritised. They also noted that there was reason to suspect that the injury was older than C had stated upon admission.

We took independent advice from an orthopaedic consultant. We found that there had been some challenges for the board in providing care and treatment to C. However, it had been evident from three days before C was initially discharged that the fracture was healing out of alignment. We also found that there was insufficient evidence on which to conclude that the injury was older than stated. We noted that various opportunities were missed for earlier surgical intervention and that there was a lack of ownership of C’s case from an orthopaedic perspective, contributing to a series of small delays which ultimately led to the window of opportunity for effective surgery passing. This amounted to unreasonable care and treatment. 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:

• Discussions about patient care should be documented.
• Upper / lower limb expertise should be obtained promptly where this is appropriate. In addition, where patient care is being transferred, the board should ensure that there is effective communication and that delays are avoided / minimised.

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 parent (A). A was admitted to hospital (Hospital 1) following a period of delirium which was a result of a urinary tract infection (UTI). They were treated with antibiotics but their delirium continued. A was transferred to another hospital for a period of rehabilitation (Hospital 2). C said that a nurse refused to take a urine test when A was showing symptoms of a further UTI, on the basis that A had no temperature. C also complained about a delay in prescribing antibiotics. A’s condition deteriorated again during their admission. C asked for a doctor to be called but they were told that no doctors were available. A deteriorated further that night and required admission to Hospital 1, where they died the following day.

C complained that A was denied access to a doctor. They also complained about communication and a lack of compassion from staff. A’s admission was during a time when visiting was restricted because of COVID-19 guidelines. C complained that staff should have allowed more frequent access to A when A was confused and distressed.

We took independent clinical advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s symptoms were not sufficiently clear to have merited a prescription of antibiotics sooner than they were prescribed. We noted that deterioration in older frail adults is often unpredictable and rapid, and found no failings in care and treatment provided to A. Based on the information available, we found no failings in communication, although we noted that the board had apologised to C already for certain communication failings. We found that staff were following the appropriate policies for visiting.

Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment that their adult grandchild (A) received from the board.

A received regular anti-psychotic medication from the board's mental health service. Separately, A suffered from episodes of paralysis, for which they attended A&E on numerous occasions. A died suddenly at home.

C complained that the board failed to recognise A was seriously unwell, with their episodes of paralysis wrongly being attributed to their mental health condition. On the day of A's death, A had fainted at the health centre after receiving their injection. C said that A attended A&E for assessment but was discharged without treatment.

The board’s response to C’s complaint advised that A had been fully assessed during each of their A&E attendances, with appropriate referral being made to neurology (specialists in the diagnosis and treatment of disorders of the nervous system) and advice sought from the mental health service. The board said that there was no evidence of A attending A&E on the day of their death so were unable to account for the hospital ID band that they had been wearing at the time. The board completed a Significant Adverse Event Review (SAER) in response to C's complaint.

We took independent advice from an A&E consultant and a consultant psychiatrist. We found that A received reasonable care from the board during their A&E attendances and confirmed that there was no record of A having attended A&E on the day of their death. We found that the management and review of A’s mental health was both reasonable and appropriate. Therefore, we did not uphold C's complaint.

We found that the board's complaint response was delayed following the conclusion of the SAER. Therefore, we made a recommendation on complaint handling in keeping with our powers to monitor and promote best practice.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to respond timeously to their complaint following completion of the SAER. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• In relation to complaints handling, we recommended
• Complaint responses should be issued in keeping with the timeframe given by the complaints handling procedure. Where a delay is necessary such as to allow completion of other review processes, the final complaint response should be issued as soon as it is practicably possible on conclusion of the other review process.

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.