Health

Summary

Mr C, a patient advocate, complained on behalf of his client (Mrs B) about Western Isles Hospital. Mrs B was unhappy with the care provided to her mother (Mrs A) who was admitted to the hospital and received treatment for sepsis (a blood infection). Mrs A's condition significantly deteriorated in the weeks following admission. She was then transferred to a hospital in Glasgow, where she died from her illness.

In response to the complaint, the board identified learning and improvement in relation to communication and nursing monitoring records.

Mr C complained about the care and treatment provided to Mrs A during the admission and that there was a delay in transferring her when her condition deteriorated.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment ofdiseases and injuries of the musculoskeletal system) and from a registered nurse. We found that medical staff managed Mrs A's condition in a reasonable manner. In particular, there were regular reviews, reasonable investigations were arranged and treatment was responsive to her condition. We did not identify any delay in the board transferring Mrs A when her condition deteriorated. We also found that the nursing care provided was reasonable. We noted that there was evidence of appropriate care planning, monitoring and interventions. We did not uphold these aspects of the complaint.

Finally, Mr C complained that the board did not communicate reasonably with Mrs B about Mrs A's care. The board upheld this complaint and outlined improvement work. We were satisfied that the board had taken appropriate action. We upheld this complaint but made no recommendations.

Summary

Mr C complained about the care and treatment he received at Ninewells Hospital after he ruptured his Achilles tendon. After he was reviewed by a consultant, conservative (non-operative) treatment of his injury was initiated. After a number of reviews, Mr C was discharged. He requested a further review as he was concerned about the progress of his recovery but no further action was taken following this review.

Months after his initial injury, Mr C re-ruptured his Achilles tendon. He was reviewed the following day and it was decided that surgery was necessary. There was a delay in surgery taking place, partly due to the surgeon being on annual leave. When Mr C attended the hospital to receive surgery, he remained on the ward all day before being told in the evening that surgery would not be required. He then underwent surgery two days later.

Mr C complained to us about the care and treatment he received for his initial injury, including the fact that he did not receive physiotherapy after his cast was removed. He also complained about what he considered to be unreasonable delays and communication after he re-ruptured his Achilles tendon.

We took independent advice from an adviser with a background as a trauma and orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the board had failed to provide reasonable or appropriate care and treatment to Mr C following his initial injury. Although conservative treatment was appropriate for this kind of injury, we did not consider that other treatment options were fully discussed with Mr C. In addition to this, we concluded that it was unreasonable for an appropriate form of physiotherapy not to be suggested or discussed with Mr C. We highlighted that there was no evidence to suggest that this contributed to Mr C re-rupturing his Achilles tendon. However, we concluded that there were failings in Mr C's care and treatment that had had a negative impact on his patient journey. Therefore, we upheld this aspect of the complaint.

In respect of the complaint about delays and communication, we found that the timescale for Mr C receiving surgery was reasonable. However, we considered that the internal communication and communication with Mr C on the day he was initially due to receive surgery was unreasonable. The records show that he remained on the ward, while fasting, from early in the morning until the evening. However, at some point during the day, his surgery was cancelled due to there being more urgent emergency cases. This information was not relayed to staff on the ward, despite them making enquiries. We did not consider the fact that the surgery was cancelled to be unreasonable, as it is understandable that emergency cases may have to take priority at short notice. However, when it was known that the surgery was cancelled, this should have been relayed to the ward as soon as possible. The fact that this did not happen resulted in further frustration and anxiety for Mr C. As a result of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably failing to fully discuss treatment options with him, discharging him without discussing physiotherapy or a home exercise programme and for keeping him in hospital despite the fact that the surgery had been cancelled earlier that day. The apology should meet the standards setout in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Where appropriate, a range of treatment options should be openly discussed with the patient and a shared decision-making approach taken.
• The board should reflect on what happened and ensure that appropriate follow-up actions are considered when a patient is discharged following an Achilles tendon rupture. This includes discussing relevant physiotherapy and home exercise options with the patient.
• Reflect on how this situation happened and consider whether there are any improvements that can be put in place to help prevent a similar situation from occurring 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

Mrs C complained on behalf of her late relative (Mrs A) about the information given to Mrs A by doctors prior to her death in hospital. Mrs C was unhappy that Mrs A was told that she was dying, and that she was asked where she wanted to be when she died. We found that on one occasion Mrs A asked for information about her prognosis and she was provided with an honest response. We also found there was evidence of a further discussion with Mrs A regarding her future care when it was disclosed to her that she was dying. The General Medical Council (GMC) guidance states that a doctor must answer patients' questions honestly. It also states that information necessary for making decisions should not be withheld even if another relative asks the doctor to do this, unless the doctor considers that this would cause the patient serious harm. It was recorded that Mrs A had capacity and that she required to be involved in discussions about her future care. We found that the doctors were required to make Mrs A aware of her situation in order to obtain her consent. We did not uphold this aspect of the complaint.

Mrs C also complained about a failure to address her complaint about an item of hers that went missing in the hospital. We did not uphold this complaint on the basis that the board had initially logged the complaint. Although the board delayed in addressing the complaint they proceeded to apologise for the fact that it had not it had been addressed sooner.

Summary

Ms C complained about the way in which the board handled her complaint and what she considered to be inaccurate information in their response. Ms C highlighted a section of the response where the board detailed two tests they claimed were previously carried out. Ms C stated that these tests did not, in fact, take place. We reviewed the relevant medical records and were satisfied it was reasonable for the board to state that one of the tests took place. However, there was no evidence of the other test taking place and we concluded that the evidence provided by Ms C supported her account of cancelling the appointment for this test before it took place. It was not clear to us why this inaccurate information was included in the board's response, along with a statement that the results were normal. Therefore, we upheld this aspect of the complaint.

Ms C also complained that the board's response contained inaccurate information about whether she had been diagnosed with a type of anaemia (a condition in which there is a deficiency of red cells in the blood). We found that Ms C had previously received the diagnosis. The diagnosis was subsequently questioned by other medical professionals. However, there was no evidence to confirm that this had ever been fully clarified to Ms C. Furthermore, the medical records show that the initial diagnosis, whether correct or not, continued to inform subsequent consultations. In light of this, we upheld this aspect of the complaint.

Finally, Ms C complained about the board's failure to respond to her correspondence within an appropriate timescale. We considered her complaint itself to have been handled appropriately. However, we considered the board's handling of her post-complaint correspondence to be unreasonable. Although we considered that the board's complaint and feedback team were not the most appropriate place for Ms C to direct some of her enquiries, it still would have been reasonable to expect the board to respond in a clear and timely fashion. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for providing inaccurate information in their stage two response about a test being carried out; providing an inaccurate or incomplete account of Ms C's diagnosis history in relation to pernicious anaemia in their stage two response; and for failing to respond to Ms C's correspondence within an appropriate timescale after they issued their stage two response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide clarification, as far as is possible, about whether or not Ms C's symptoms and test results support a diagnosis of pernicious anaemia. If necessary, carry out appropriate tests to allow such clarification to be provided.

In relation to complaints handling, we recommended:

• Stage two complaint responses should contain accurate information and establish all the facts relevant to the points made in the complaint. The board should explore how and why the stage two response contained inaccurate information.

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

Ms C complained that the board failed to diagnose a ruptured Achilles tendon when she attended Western General Hospital. We took independent advice from a consultant physician in acute internal medicine. We found that given the specific test for excluding a ruptured Achilles tendon was carried out, which resulted in a negative finding, it was reasonable that the ruptured Achilles tendon was not diagnosed. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the care and treatment she received at the Edinburgh Royal Infirmary after the ruptured Achilles tendon had been diagnosed. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the care and treatment provided to Ms C was reasonable and did not uphold this aspect of her complaint.

Ms C complained that the board failed to communicate reasonably with her. We found that there was no record of any detailed discussion with Ms C prior to her surgeries about the risks or benefits of the proposed operations, the alternatives to surgery or the varying degrees of success and the possibility that her condition could be made worse. The board had a document for recording fasting and insulin instructions for diabetic patients but this was not completed in Ms C's case. Therefore, we upheld Ms C's complaint that the board's communication with her was unreasonable.

Ms C complained about the way that that the board handled her complaint. We found that Ms C's complaint was not acknowledged within three working days. There was also a delay in responding to Ms C's complaint and the board did not proactively keep her updated about the reason for the delay in responding to her complaint and provide a revised timescale for when she could expect to receive a response. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to record a detailed discussion with her prior to her surgeries about the risk or benefits of the proposed operations, failing to acknowledge Ms C's complaint within three working days and for failing to keep her updated about the reason for the delay in responding to the complaint or providing a revised timescale for the response. 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 given full information about the risks and benefits of proposed operations, including the alternatives to surgery, and these discussions should be documented in line with relevant guidance.
• Diabetic patients should be given fasting and/or insulin instructions prior to surgery and these instructions should be recorded.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

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

Mr C complained about the antenatal care which his wife (Mrs A) received at the Royal Infirmary of Edinburgh. Mr C felt that Mrs A was not appropriately monitored by the community midwives, that they had been difficult to contact for advice when Mrs A started to suffer from swollen legs, and that she went on to develop pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine) which required an emergency hospital admission.

We took independent advice from a midwife and found that Mrs A's antenatal care was shared between the community midwives and her GP practice. Mrs A was appropriately monitored during the antenatal period although the nursing documentation could have been clearer. We also found that appropriate advice was given that Mrs A should take paracetamol for her swollen legs and to seek further advice if the symptoms did not improve. Appropriate contact details were contained in Mrs A's nursing records. There was also no indication from the nursing records that Mrs A had reported symptoms which were suggestive of pre-eclampsia. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment he received in relation to a coronary artery bypass graft (a surgical procedure used to treat coronary heart disease) at the Royal Infirmary of Edinburgh.

We took independent advice from a consultant cardiologist (a specialist in diseases and abnormalities of the heart). We found that Mr C was identified as having ostial left anterior descending artery disease (a narrowing in the blood vessels of the heart) and that the initial choice of treatment for this, bypass surgery, was reasonable. Mr C then had an uncommon but recognised complication of bypass surgery. We found that the decision to perform a second procedure to implant a stent (a small tube used to keep passageways open) was reasonable. We also noted that there was no reason to believe that performing a stent procedure earlier would have translated to any clinical benefit for Mr C. We considered that the clinical care Mr C received was reasonable and did not uphold this aspect of his complaint.

Mr C also complained about aspects of his nursing care during his hospital admission when the stent procedure was performed. We took advice from a consultant nurse in cardiology. We found that Mr C was not prescribed appropriate pain relief and that there was contradictory evidence in the records around the management of his pain. Mr C's pain should have been managed better and the failure to do so was unreasonable. We also identified failings in record-keeping, in particular, a failure to complete care documentation, around communication with Mr C and his family, and his discharge from hospital. We considered that the nursing care Mr C received was unreasonable and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing provide him with reasonable pain relief, failures in record-keeping, and failing to provide him with reasonable nursing care. 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 who are in pain should have their pain needs addressed as soon as possible. Following a surgical procedure, patients pain needs should be proactively addressed even though they are waiting to be clerked into the ward. Nursing staff should ensure the documentation of a patient's care following a surgical intervention should be completed. Nursing staff should maintain reasonable records, consistent with the Nursing and Midwifery Code of Conduct.

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

Ms C complained about the care and treatment her late mother (Mrs A) received at the Royal Infirmary of Edinburgh. When Mrs A was admitted, it was recorded that she had known lung cancer and she was initially treated for pneumonia (inflammation of the lungs). It was subsequently planned that Mrs A would be discharged, but a CT scan showed that she had an accumulation of blood in her abdominal muscle. Mrs A later had a fall. She was monitored overnight, but died the following day.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the medical treatment provided to Mrs A had been reasonable. We did not uphold this aspect of the complaint.

Ms C also complained about the nursing care provided to Mrs A. We took independent advice from a nursing adviser. We found that there was no evidence of any failings that had led to Mrs A's fall in the hospital or that a specific injury sustained in the fall led directly to her death. A robust post falls assessment was also undertaken after the event, which did not indicate any specific injury.

Overall, the nursing care provided to Mrs A had been reasonable. However, there were gaps in the nursing notes provided. There was also a lack of evidence of communication with Mrs A's family. In addition, the board's response to Ms C's complaint did not address many of the points she had raised. Given these failings, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to provide evidence that nursing staff communicated with her appropriately. 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:

• Nursing staff should maintain records in line with the Nursing and Midwifery Council's guidance on record-keeping.

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

Mr C complained about the care and treatment his late wife (Mrs A) received from the practice during a number of attendances.

We took independent advice from GP adviser. We found that the care provided to Mrs A by the practice, when she presented with a swelling in her groin and a lump on her breast, to be reasonable.

Mrs A had also attended the practice with a swelling in her neck. We found that there was a failure by the practice to document a full history relating to the neck swelling, how long it was there for, and to consider further investigation of the swelling and safety netting. We considered this to be below a reasonable standard and upheld this aspect of Mr C's complaint. However, we also acknowledged that by the time Mrs A presented with the swelling in her groin, she already had incurable cancer. While earlier referral for investigation of the neck swelling could have possibly led to an earlier diagnosis, it was unlikely to have changed Mrs A's overall outcome.

Mr C also complained that Mrs A had been treated in an unsympathetic and dismissive manner by the practice, and said that he and Mrs A were unaware that she had suspected heart failure. Our investigation found no evidence of this.

Mr C also complained about the way in which the practice had responded to his complaint. We found that the practice responded to Mr C within a reasonable time, and did not identify any inaccurate information in their response. We also acknowledged that the practice had offered to meet with Mr C. 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 failure to document a full history relating to Mrs A's neck swelling; how long it was there for; or to consider further investigation of the neck swelling and safety netting. 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:

• Relevant staff should ensure they review and are aware of General Medical Council Good Medical practice guidance and the Scottish cancer referral guidelines on Head and Neck Cancers.

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

Mrs C, an advocate, complained on behalf of her client (Mrs B) about the medical and nursing care that Mrs B's late husband (Mr A) received at Wishaw General Hospital.

Mrs B was concerned that a urine sample was not taken around the time Mr A was admitted to hospital; that sepsis may not have been treated properly; that staff did not recognise the severity of a fall Mr A sustained; and an opiate painkiller was not given at a particular time. Mrs B was also concerned that; no falls assessment was carried out and wheelchair transportation was inappropriate after Mr A's second fall; record-keeping regarding a fall was contradictory and did not capture the severity; intravenous paracetamol should have been given instead of oral paracetamol; and Mr A's blood pressure and heart rate were not properly monitored.

We took independent advice from a GP consultant and from a registered nurse. We found that there was a failure to take a urine sample which the board had accepted and apologised for. However, overall we did not identify any significant failings in Mr A's medical care and did not uphold this aspect of the complaint.

However, we found that it was unreasonable that Mr A was not transported by trolley to have his scan carried out and that there was a failure to escalate his worsening blood pressure reading to medical staff. Therefore, we upheld the complaint that Mr A's nursing care was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to escalate Mr A's blood pressure reading to medical staff; and for not transporting Mr A by trolley for his scan. 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:

• Nursing staff should comply with the board's policy on deteriorating patients and NEWS escalation.
• Nursing staff should ensure that appropriate consideration is given to a patient's transportation following falls.

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.