Health

Summary

Mr C complained about the care and treatment his sister (Miss A) received after she was admitted to Hairmyres Hospital, specifically about the medication prescribed, the standard of communication and the discharge planning. Mr C also complained about the community care, mainly the lack of care plan and the actions of a staff member.

We took independent advice from a consultant psychiatrist and from a mental health nurse. In terms of the hospital care, we found that the medication changes made during Miss A’s hospital admission were both appropriate and consistent, with established and agreed treatment protocols, and that the approach taken was reasonable. We also found that there was evidence to support a reasonable level of communication, and that the discharge planning was appropriate, as Miss A discharged herself voluntarily, and staff had no power to stop this or to detain her. Therefore, we did not uphold this aspect of the complaint.

In terms of the community care, we found that the records did not show that Miss A's risk to herself was underestimated by staff and that the incident which caused her admission to hospital was not predictable. We found that the care planning was reasonable, noting specifically that staff identified Miss A’s health and social-care needs, her goals for care and interventions, and that these were evaluated and updated. Importantly, there was also clear evidence that Miss A was involved in this process. Therefore, we did not uphold this aspect of the complaint.

Summary

Mrs C complained about a decision that was taken by the board to refuse out-of-area funding for a paediatric consultant for her child's (Child A) care. Mrs C said that the process leading up to the decision, how the decision was communicated to her and how the board handled her complaint was unreasonable.

We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine) and found that the board followed the correct process in reaching a decision regarding the referral and, therefore, did not uphold this part of the complaint.

However, we identified that the board had failed to provide Mrs C with a clear explanation of the process that they followed and the rationale for their decision; to give correct information to Mrs C regarding a third doctor's involvement; to correct their error when communicating with Mrs C; and to provide relevant information to SPSO in this regard in response to our enquiries. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide clear explanations, for providing her with erroneous information; failing to correct this error; and for the complaint handling failings. The apology should acknowledge the impact this has had on Mrs C. 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:

• Notifying clinicians and families should receive a full explanation of the outcome of funding requests, including information on the evidence used to reach that decision.
• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: http://www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

Summary

Mrs C manages a direct payment (a cash payment paid under self-directed support in order to purchase care at home) on behalf of her disabled son (Mr A). The board contacted Mrs C to progress a review of the direct payment and to review the decision that Mrs C should be permitted to be employed as a Personal Assistant (PA) for Mr A. The direct payment included funding for two carers to provide two-to-one support to Mr A. Following the review, the board decided the funding should be reduced to only pay for one PA until a second PA was recruited to provide the two-to-one support. The board also decided that Mrs C should no longer be employed as a PA,and they advised that a second PA needed to be recruited.

Mrs C complained that the board acted unreasonably in respect of the review of the direct payment. Mrs C felt that the board unfairly blamed her for the failure to complete the review and that their decision to reduce the funding was unreasonable. Mrs C also complained that the board's decision regarding her employment as a PA was not in accordance with self-directed support legislation.

We took independent advice from a social worker. We found that the board acted reasonably in respect of both complaints. We identified that the local authority's decision to reduce the funding until a second PA was recruited was reasonable as the funding should only be used to meet the agreed outcomes detailed in the support plan. We also identified that the board acted reasonably by providing Mrs C adequate notice to recruit an alternative PA. Therefore, we did not uphold the complaints.

Summary

Mr C complained about the care and treatment his relation (Ms A) received at Raigmore Hospital. Ms A suffered from MPO ANCA associated vasculitis (a rare autoimmune disease) and was admitted to hospital with symptoms of diarrhoea and vomiting, headaches and abdominal pain. Ms A experienced episodes of haemoptysis (coughing up blood) while in hospital and died later that day.

We took independent advice from an adviser in acute medicine. We found that, when Ms A was admitted to hospital, a consultant review indicated that a pulmonary haemorrhage (an acute bleeding from the lung, from the upper respiratory tract and the trachea, and the alveoli) was a potential concern along with two other possibilities. We considered it was reasonable at the outset that the board did not proceed to give Ms A a chest x-ray as gastroenteritis (inflammation of the stomach and intestines) was suspected and there was only one episode of haemoptysis. However, we found that there was an unreasonable delay in performing a chest x-ray on Ms A following a second episode of haemoptysis. There was, therefore, a delay in identifying a pulmonary haemorrhage. We noted a member of the nursing staff appeared to identify the possibility of a pulmonary haemorrhage, and whilst this was communicated to the doctor, it was not acted upon. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for an unreasonable delay in performing a chest x-ray on your Ms A following a second episode of haemoptysis and a delay in identifying a pulmonary haemorrhage, given a consultant review indicated a pulmonary haemorrhage was a potential concern. 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:

• Raise awareness and understanding of MPO ANCA associated vasculitis and pulmonary haemorrhage. Ensure all staff feel they can raise concerns with a senior member of staff if they consider their concerns are not being addressed. Ensure safety measures are in place to ensure less experienced staff are aware of potential symptoms/problems.

Summary

Mr C visited his dentist due to pain in one of his teeth and agreed to a proposed course of treatment with the dentist. Mr C believed this would be provided under the NHS. Mr C found the communication around the cost of the treatment confusing saying that the dentist had not properly explained the costs or what was required before the procedure, and Mr C was concerned that he was over-charged. Mr C also complained about the standard of treatment he received and that the dentist failed to handle his complaint reasonably.

We took independent advice from a dental adviser. We found that the dentist failed to communicate the treatment plan and options in a reasonable way and that Mr C was not in a position to give informed consent; the breakdown of treatment options (NHS and private/independent) were not in line with relevant regulations; unacceptable materials were used; the findings of x-rays were unreasonably reported on; there was an unreasonable standard of care especially periodontal (gum) care; there was an unreasonable standard of record-keeping; and there were discrepancies in what was charged. We also found that the dentist failed to deal with the complaint in line with the complaints handling procedure. We upheld all aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to communicate with him in a reasonable way about the proposed treatment and costs, failing to provide Mr C with a reasonable standard of treatment and failing to handle his complaint reasonably. The apology should meet the standards set out in theSPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Reimburse Mr C for the costs of the dental treatment he underwent. The payment should be made by the date indicated: if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

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

• Ensure the dentist communicates with and obtains consent from patients in line with the relevant regulations and standards.
• Ensure all breakdown of treatment options are delivered in line with the relevant regulations.
• Ensure that only materials deemed acceptable under the regulations are used.
• Ensure x-rays are reported on in line with the relevant regulations.
• Ensure care is delivered to a reasonable standard.
• Ensure record-keeping is in line with the relevant standards and guidance.

In relation to complaints handling, we recommended:

• Ensure all complaints are dealt with in line with the complaints handling procedure.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by Queen Elizabeth University Hospital and by Gartnavel General Hospital. After Mrs A died, amyloidosis disease (a condition caused by the accumulation and deposition of amyloid protein in the body in various organisations) was diagnosed. Mrs C complained that, had this condition been diagnosed earlier, Mrs A would not have suffered as she did and that she would not have been subjected to unnecessary physiotherapy or to a one-night hospital transfer which she believes exacerbated Mrs A's condition. Mrs C also complained that the board wrongly discharged her mother on one occasion and failed to admit her to a high dependency unit, but sent her to a rehabilitation unit instead.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that the medical investigations, treatment, physiotherapy and nursing care provided to Mrs A were reasonable. We did not uphold these aspects of the complaint.

However, we concluded that the decision to discharge Mrs A home from hospital on one occasion was unreasonable; the decision to admit Mrs A for rehabilitation was not appropriate due to her frailty; and the decision to transfer her to a general hospital was not reasonable. Therefore, we upheld these aspects of the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to discuss other possible options for Mrs A’s discharge and for transferring her inappropriately. 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:

• Before transferring or discharging frail patients consideration should be given to all the options for discharge/ transfer; whether a patient’s condition is stable enough for any transfer and whether a patient’s condition is such that they will benefit from rehabilitation if appropriate.

Summary

Mr C’s father (Mr A) was referred by his GP to the Royal Alexandra Hospital for investigation of breathlessness. Two chest x-rays and a CT scan were performed over the following months. Mr A attended A&E seven months after his initial referral with severe pain in his side and back and a further x-ray was carried out. Mr A was admitted to hospital later that month following a fall, and a further x-ray and CT scan were carried out. Further to a biopsy (tissue sample) of an identified mass, Mr A was told he had incurable cancer. He died the following month.

Mr C complained about a failure to diagnose the cancer from the first CT scan. We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques). We found that an abnormality on the CT scan was not reported. This resulted in an avoidable delay of approximately three months in the diagnosis of Mr A’s cancer. Therefore, we upheld this aspect of the complaint. The board have already apologised to Mr C for not picking up the cancer on the CT scan, and have undertook to discuss this at a learning meeting.

Mr C also complained about a delay in notifying Mr A of the results of this CT scan. We took independent advice from a consultant physician. We found that the scan result had been left on a consultant’s desk awaiting dictation, and the consultant had retired. It took Mr A’s prompting before a secretary arranged for another consultant to review and share the result. Mr A received the result ten weeks after it had been reported. We considered this delay was unreasonable and that a more robust system was required. We also noted that the board had not addressed this aspect of Mr C's complaint. Therefore, we upheld this aspect of the complaint.

Mr C also complained that there was a failure to diagnose Mr A's cancer from the x-ray taken during his admission to A&E. We found that the x-ray raised the possibility of an abnormality and suggested a repeat CT scan which was later carried out. We considered that this was appropriate and there was no unreasonable failure to diagnose the cancer directly from the x-ray. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in informing Mr A of the result of his CT scan, and for failing to address Mr C's complaint about this. 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 needs to be a robust system in place for reviewing and communicating imaging results. The board should review their system and provide this office with an assurance that mechanisms are in place to avoid a repeat of the circumstances which contributed to the delay in this case.
• The board should reflect on the adviser's comments in relation to minimising any systems deficiencies which might contribute to perceptual errors when reporting imaging studies, unless such reflection occurred as part of the Learning from Discrepancies me

In relation to complaints handling, we recommended:

• The board should adhere to their Complaints Policy and Procedure, and aim ‘to establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response’.

Summary

Ms C, an advocate, complained on behalf of her client (Ms A) about the standard of communication between clinicians and Ms A in relation to breast implant reconstruction. Ms A was concerned about the outcome of the procedure saying that her breasts were completely asymmetrical and the skin on top of her left breast was bunched up. Ms C said that Ms A had not been given realistic expectations about the results of the procedure.

We took independent advice from an adviser in plastic surgery. We found that there were shortcomings in record-keeping which meant it was not entirely clear what was discussed with Ms A or what information was provided. The evidence from the clinical notes indicated that the risks were outlined during at least one consultation, but there was a lack of documented evidence that Ms A was informed in a clear way that her breasts may not be symmetrical in size, shape and volume following the procedure. We upheld the complaint. However, we made no recommendations in light of the action already taken by the board to resolve the complaint.

Summary

Ms C complained that the board failed to provide reasonable care and treatment to her friend (Mr A) at the Queen Elizabeth University Hospital, before his death. Mr A had been admitted to the hospital due to exacerbation of his asthma and flu. After a few days, his condition deteriorated. He died six days after being admitted to hospital.

We took independent advice from a consultant in acute medicine. We found that:

• more information about Mr A’s alcohol intake should have been obtained;

• if the alcohol liaison nurse’s entry had been read or actioned, his diazepam (a tranquillizingmuscle-relaxant drug used to relieve anxiety) prescription would probably have been cancelled;

• there was a failure to respond promptly to his deterioration;

• it was unreasonable that he was seen by a junior grade doctor when he was clearly very unwell;

• prescribing sedation and planning to review him four hours later was not an appropriate response to a patient who was deteriorating and showing evidence of lower oxygen levels than normal;

• he should have been seen more promptly after his initial deterioration by a more senior doctor;

• he should have had important investigations such as X-rays and blood tests as soon as he was settled enough to comply with them;

• it was unreasonable that he was not on a fluid balance chart daily from admission;

• he should have been assessed more thoroughly for potential sepsis (blood infection) when he deteriorated; and

• what was written down in the notes did not seem to be have been read by other members of the team.

Therefore, we upheld this aspect of Ms C's complaint.

Ms C also complained about the lack of communication from staff about Mr A’s deterioration. We found that staff should have contacted her earlier than they did. The failure to do so substantiated the concern that staff did not recognise or respond to Mr A’s deterioration appropriately and that they did not recognise how unwell he was. We upheld this aspect of the complaint.

Finally, Ms C complained that the board failed to accept that Mr A had sepsis. She considered that sepsis should have been recorded on his death certificate. We found that the tests that were carried out at that time showed serious infection but did not indicate sepsis. Based on the information available, it was reasonable that sepsis was not recorded on Mr A’s death certificate. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

• Clinical entries in medical notes should be read and acted on. If a decision is taken not to act on the entry, this should be noted. Caution needs to be exercised when sedating patients with respiratory failure.
• Patients who have an elevated Early Warning score should be reviewed regularly, particularly if no definitive management plan has been established. The appropriate tests and investigations should also be carried out, including the tests for sepsis.
• Medical and nursing staff responsible for the care and treatment of a patient should ensure that they read the relevant notes.

Summary

Ms C complained that the board failed to provide a reasonable standard of care and treatment to her brother (Mr A) after he was referred by his GP for bowel problems. Mr A underwent a number of tests and was diagnosed with rectal cancer with liver metastases (tumours that have spread to the liver from other areas of the body).

We took independent advice from a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer) . We found that there were no unreasonable delays in progressing Mr A’s treatment. The actions of staff in relation to carrying out liver and pelvic MRI scans were also reasonable. However, it had not been reasonable to wait until after a multidisciplinary team meeting to confirm the diagnosis of cancer to Mr A. There also should have been more evidence of involvement from a colorectal cancer nurse specialist, and it should have been clear to Mr A who to contact for information and support.

In relation to a consultation that Ms C and Mr A attended about Mr A’s treatment, we found that there should not have been a formal discussion with Mr A and his family about treatment until the relevant investigations had been completed. When he was seen, this should have been by an oncologist and not a colorectal surgeon. In addition, at the meeting Mr A was told that a further test had been arranged the previous week, whereas this test was only requested on the day of the meeting. In view of these failings, we upheld Ms C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mr A with reasonable care and treatment. The apology should meet the standardsset 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 early contact with patients to discuss the diagnosis
• All patients, newly diagnosed or with a suspected diagnosis of colorectal cancer, should have access at diagnosis to a clinical nurse specialist for support, advice and information.
• The board should consider when to arrange the key out-patient appointment and who the primary clinician should be.