Health

Summary

C complained about various aspects of the care and treatment that their parent (A) received from the board.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly) and from a nurse. We found that A was unreasonably discharged from Victoria Hospital when they had an infection, which may only have been partially treated, and that there may have been uncertainty about the effectiveness of the antibiotics A was receiving. We also found that A did not receive medical reviews when their delirium was active; that there should have been an earlier assessment of the possibility that A had a chest infection; that A was discharged from Queen Margaret Hospital to a care home without a prescription for stronger pain medication; and that no nursing transfer letter or discharge summary was provided to the care home when A was transferred from Queen Margaret Hospital.

We upheld C's complaint that the care and treatment provided to A was unreasonable.

C also complained about the board's communication. We found that there was a failure to discuss A's transfer arrangements, ongoing care (including palliative care) and medication with C prior to A's transfer to the care home. Therefore, we upheld this aspect of C's complain.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for: discharging A from Victoria Hospital, not carrying out a medical review of A, not carrying out an earlier assessment of the possibility that A had a chest infection, discharging A from Queen Margaret Hospital to the care home without a prescription for stronger pain medication, not providing a transfer letter or discharge summary to the care home when A was transferred, and for failing to discuss A's transfer arrangements, ongoing care (including palliative care) and medication prior to A's transfer to the care home. 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:

• Consideration should be given to the pain medication prescribed to patients who are approaching the end of their life and are being discharged from a hospital to a care home.
• Patients who are known to have delirium should receive regular medical reviews.
• Staff should discuss transfer arrangements, ongoing care (including palliative care) and medication with a patient's family when a patient is being transferred from hospital to a care home.
• Where a patient has been identified as potentially having a chest infection this should be assessed at the earliest opportunity.
• Where appropriate, the effectiveness of antibiotic treatment should be assessed prior to discharging a patient with an infection.

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 a failure on the part of the board to discuss their eye conditions and possible treatments before they were referred to another board for an operation.

We found that, whilst the referral to the other board was reasonable, the fact that C was not involved in a discussion, or advised about possible options for treatment prior to the referral, was unreasonable. Therefore, we upheld this aspect of the complaint.

C also complained about a failure on the part of the board to transfer all relevant medical information to the other board prior to the operation.

We found that it was reasonable practice for the board to state that the other board could contact them for relevant information if they considered it necessary to do so, given they had already met with C and had notes about their condition. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for (1) failing to explain to them why the doctor considered it necessary to refer them on to the other health board and (2) failing to send them a copy of the letter to their GP stating why the referral was being made. 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:

• To ensure patients receive information about why a referral has been made for them to see another clinician.

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 to the board on behalf of her son (Mr A), who had a diagnosis of autism. Mrs C was unhappy with aspects of the care and treatment provided to Mr A by the mental health service at Queen Margaret Hospital.

Mrs C firstly raised concern about the communication surrounding the prescription of a medication. The board upheld Mrs C's complaint and apologised that the information provided about the dose was not clear.We found that Mr A had taken a greater dose than intended; however, the dose taken was still within the safe limits of prescribing for this medication. We concluded that the board had taken reasonable action in light of the matter. We upheld the complaint but did not make recommendations.

Mrs C was also unhappy with the psychiatric care and treatment provided to Mr A more generally. We took independent advice from a consultant psychiatrist. We found that there was a reasonable level of assessment, treatment, and clinical management of Mr A during his consultations with the service. We did not uphold this complaint.

Finally, Mrs C raised concern about some of the language used in the board's complaint response. We considered that the use of one term or another was a matter of preference and we did not conclude that there were failings in the language used. However, we did consider that the time taken for the board to respond to Mrs C's complaint was excessive. On balance, we upheld this aspect of the complaint.

Recommendations

In relation to complaints handling, we recommended:

• In line with the NHS Scotland Complaints Handling Procedure, the person making the complaint should receive a full response to the complaint as soon as possible but not later than 20 working days, unless an extension is required. Delays in the investigation should be 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 has a family history of bowel cancer polyps (abnormal growths) on the colon and was admitted to hospital on several occasions over many months with abdominal pains and vomiting. C complained to the board that, despite their family and medical history, the board unreasonably delayed to perform a scan, which resulted in a delayed diagnosis of bowel cancer. C also complained that the board failed to accurately report on a scan, as a subsequent review identified the presence of cancer.

The board advised that a scan was not indicated when C first presented to hospital. They also advised that the initial report on the scan was adequate, and it was only when additional clinical information became available (blood test results), that a second review changed the diagnosis.

We took independent advice from a consultant colorectal (bowel) surgeon. We found that there was insufficient consideration given to C's own medical history and that an x-ray taken was not appropriately followed up or acted upon. We concluded that there were several missed opportunities to perform a scan or colonoscopy (an examination of the bowel with a camera on a flexible tube) when C had attended hospital. We upheld this aspect of the complaint.

However, we concluded that the initial report on the scan was adequate. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take proper account of their medical history and for failing to carry out a CT scan when they first presented to hospital. 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 consultant with overall care for the patient should receive feedback from the case in a supportive way and the feedback is used for reflection as part of their annual appraisal.
• This case should be discussed as a delayed diagnosis and be reported and investigated as an incident in the organisation.

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

Miss C complained about a number of aspects of the care and treatment her mother (Mrs A) received at Victoria Hospital.

We took independent medical advice from three advisers – a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a consultant gynaecologist (a doctor who specialises in the female reproductive system) and a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus).

Miss C said that a radiologist failed to identify the thickened area in part of her mother's bowel on a CT scan. We found that an opportunity was missed at the time of the reporting of Mrs A's CT scan to identify a tumour in this area, in addition to making the new diagnosis of an ovarian tumour. However, given the limited sensitivity and specificity of unprepared CT scan for bowel tumours, we consider this not to be unreasonable.

Miss C complained that there was a delay in Mrs A's hysterectomy (surgical removal of the uterus) taking place which she said was due to the gynaecologist's leave delaying Mrs A's case being discussed at the multi-disciplinary team meeting. We found that Mrs A was referred for her case to be discussed at the next gynaecology multi-disciplinary team meeting the day after she was admitted to hospital. This was then processed in accordance with the department's normal procedures and Mrs A's case was discussed at the next available multi-disciplinary team meeting. We considered that the consultant gynaecologist's leave was not relevant to Mrs A's care and did not delay it in any way.

Miss C said that following the results of Mrs A's CT scan and the suspicion of cancer, the board should have carried out Mrs A's colonoscopy (examination of the bowel with a camera on a flexible tube) and PET scan while she was still in hospital. We found that Mrs A's colonoscopy was carried out within appropriate timescales, taking into consideration the risks from her previous surgery, her potential pain/discomfort and the likely success of the procedure. We found that Mrs A's PET scan was also carried out within a reasonable time, allowing for tissue healing and resolution of infection to take place following Mrs A's surgery, and in order to produce meaningful results to assist clinical decision-making and patient management. The timescales for these procedures would have had no impact on the treatment provided.

We did not uphold this complaint.

Summary

Ms C complained to us about the time she waited for a psychology appointment from the board. While she waited, Ms C went back to see her GP because she felt her condition had worsened. Several months after her referral to the board, Ms C had a telephone assessment with a psychologist to assess her needs. Some months after that, Ms C was offered a psychology appointment. The board apologised to Ms C for the delay and explained that they were taking steps to reduce their wait times.

We took independent advice from a psychologist. We found that there was an unreasonable delay in carrying out Ms C's telephone assessment. We found that it was unclear why there was such a delay, as it was a relatively routine referral. We found that the delay meant the psychology service was unaware of the worsening in Ms C's condition and they missed the opportunity to offer her an earlier psychology appointment. We found this led to an unreasonable delay in offering Ms C a psychology appointment and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms 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, who are on the psychology wait list, should be assessed promptly. This would allow the board to identify high-risk patients or identify where there is some other need for urgent treatment (e.g. pregnancy) and help the service to identify appropriate treatment options. It would also enable patients to be given timely information about sources of support/guidance while they wait to be seen; and give the patient reassurance and motivation.

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 mother (Mrs A) whose hip fracture was not diagnosed until approximately nine weeks into her hospital admission, following a fall at home and a further fall during her first night in hospital. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that Mrs A's hip fracture should have been diagnosed within one week of her admission as there was enough information present to indicate she had a fractured hip and more detailed assessments should have been carried out during this time. Therefore, we upheld this aspect of the complaint.

Mrs C also complained that the board did not take reasonable falls prevention measures as Mrs A fell during her first night of hospital, despite having been admitted post-fall, and with a history of falls. We took independent advice from a nursing adviser. We found that there was no evidence that a falls risk assessment was carried out when Mrs A was admitted to the Combined Assessment Unit and there was no evidence of falls prevention measures being put in place at this time, which was unreasonable. Therefore, we also upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in Mrs A's care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.

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

• Nurses should keep clear and accurate records relevant to their practice, in line with the Nursing and Midwifery Council code.
• Falls risk assessments should be undertaken on patients when indicated.
• When the need for further assessment is identified by therapy staff, this should be notified to appropriate parties and actioned.

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 that the board failed to discharge her late husband (Mr A) in a reasonable way. After a period of admission to Borders General Hospital, staff planned Mr A's discharge which was discussed with Mrs C. Mrs C said that staff unreasonably failed to fully consider her concerns about Mr A's discharge and to record these in Mr A's clinical records in a reasonable way. As a result, the couple struggled to cope when Mr A was discharged home and he was readmitted to hospital the following week.

We took independent advice from a nurse. We found that while the decision to discharge Mr A was reasonable, staff communication did not meet Mrs C or Mr A's needs. It would have been reasonable for staff to have fully discussed (and recorded) their concerns about discharge with Mrs C and the consultant responsible for Mr A's care during his hospital admission beforehand. We also found that Mrs C's concerns about Mr A's discharge home were not recorded and the board gave inaccurate information during the complaint process about a meeting Mrs C had with staff. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in communication. 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:

• Feedback the findings of our investigation in relation to communication to relevant staff for them to reflect on.

In relation to complaints handling, we recommended:

• Feedback the findings of our investigation in relation to complaints handling to relevant staff for them to reflect on.

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 care and treatment they received at Borders General Hospital was unreasonable, including that they should not have been admitted; that they were not advised of the side effects of their medication; and that staff did not adequately explain what the medication was to treat.

We took independent advice from an adviser qualified in psychiatry. We found that it was appropriate for C to be admitted to hospital for assessment and treatment. While we found that there was no evidence of a specific discussion with C regarding the potential side-effects of their medication, we considered that the board's acknowledgement and apology for this in their letter to C to be a reasonable response. We found that, overall, there was good evidence of engagement and dialogue with C regarding their treatment plan and medication, and that the board's prescribing and administering of medication was reasonable. As a result, we did not uphold the complaint.

Summary

Mrs C was listed for a procedure to decompress a nerve in her foot. This procedure was agreed by a consultant but they resigned so Mrs C was transferred to another consultant (consultant 2) whose preferred treatment was non-surgical. Mrs C expressed concern at the treatment proposed for her so she met with a third consultant (consultant 3). It was agreed that she would be listed for surgery. Mrs C understood the procedure would involve removal of a bone spur (bony lumps that grow on the bones of the spine or around the joints) along with decompression of the deep peroneal nerve (a nerve that runs from the leg to the top of the foot). After surgery, Mrs C became aware that the procedure carried out by consultant 3 involved only the removal of the bone spur. Mrs C complained that the board unreasonably changed the original treatment plan agreed for her and that they inappropriately failed to carry out the procedure she consented to. She also complained that the board unreasonably failed to arrange a follow-up appointment with a different consultant.

We took advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that consultant 2's preferred treatment was reasonable although we did note that pre-operative investigation was limited with no apparent x-rays being arranged until Mrs C was seen by consultant 3. We found that consultants can have differing opinions in relation to proposed treatment and therefore, it was reasonable to change the original treatment plan for Mrs C given her care was transferred between different consultants. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to consent for the surgery, we found that the consent form signed by Mrs C and the letter issued by consultant 3 confirming the proposed surgery did not match the surgery she received. It may have been the case that removing the bone spur released pressure on the nerve anyway but this should have been explained clearly to Mrs C. We found that whilst the procedure may have been clinically appropriate, the communication surrounding the procedure was unclear and inconsistent so we upheld this aspect of the complaint.

In relation to arranging a follow-up appointment for Mrs C with a different consultant, we saw evidence that Mrs C had clearly communicated that she was unhappy with the response provided to her complaint and she asked that her follow-up appointments be with someone else other than consultant 3. We saw evidence that consultant 3 wrote to Mrs C offering to facilitate her receiving an opinion from someone else. Mrs C said she did not receive that letter. The board told Mrs C that because she did not have an open referral, she should return to her GP to discuss further treatment options.

We found that it would have been reasonable for the board, as part of its handling of Mrs C's complaint, to offer her the opportunity to meet with a different consultant. Doing so would have demonstrated a willingness to try to better understand and resolve Mrs C's ongoing concerns about her surgery. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to clearly and consistently communicate with her in relation to her surgery and for not offering her the opportunity to meet with a different orthopaedic consultant as part of their final complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Clearly communicate to Mrs C details of the surgery including the procedure consented to and the procedure actually carried out detailing whether that involved decompression of the deep peroneal nerve.
• Consider offering Mrs C the opportunity to meet with an orthopaedic consultant to discuss her concerns about the surgery.

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.