Health

Summary

Mrs C complained about the care and treatment provided to her late daughter (Ms A) by the practice. Ms A attended the practice complaining of severe leg pain and was diagnosed some time later with cancer. Mrs C complained that the practice failed to carry out the appropriate investigations in response to Ms A's symptoms and previous history of breast cancer.

We took independent advice from a GP. We found that Ms A's symptoms, which she discussed with the GP on the first two appointments, were not indicative that cancer was a likely diagnosis and the appropriate treatment was provided.

When Ms A began to complain of back pain, and it was noted that she had weight loss, we found that the practice acted appropriately by making an urgent referral for imaging and arranging for blood tests to be carried out. We concluded that the treatment provided was in line with national guidelines and we did not uphold the complaint.

Summary

Ms C complained about the care and treatment provided to her late father (Mr A) at the Royal Alexandra Hospital. Mr A had dementia and was admitted with drowsiness, fever, confusion, and crackles in the lung. Ms C felt that there was not sufficient screening for sepsis when Mr A was admitted, that he was not given appropriate pain relief, and that discharge was unreasonable. Ms C also raised concerns about the nursing care provided to Mr A.

We took independent advice from a consultant in acute and general medicine, and from a nurse. We found that Mr A was appropriately assessed when he was admitted to hospital, that his pain was managed appropriately, and that his discharge was reasonable. We did not uphold this aspect of Ms C's complaint.

In relation to nursing care, we found that whilst there were some areas of nursing care which were reasonable, there were a number of failings. Namely, we found that there was limited evidence of care planning being carried out appropriately, there was no 'Getting to Know Me' document completed (this document should be completed for all patients with dementia). We also considered that a non-verbal pain assessment tool should have been used, but noted that the board had acknowledged this. We upheld this aspect of Ms C's complaint.

Ms C further complained about communication and complaints handling. We found that there was a failure to appropriately communicate with Ms C when her father was in hospital, particularly as she was his power of attorney and next of kin, and we upheld this aspect of her complaint. We also found that in relation to complaint handling, there was confusion regarding whether Ms C's complaint was in fact feedback, and this resulted in a delay in acknowledging the complaint. We also found that the response was delayed and the reasons for this were not clear. We upheld this aspect of 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 nursing care and treatment; failing to communicate reasonably; and failing to handle Ms C's complaint reasonably. 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:

• Appropriate care planning should be carried out and should take into account the specific needs of patients with dementia.
• A 'Getting to Know Me' document should be completed on admission for all patients with dementia.
• Communication with relatives should be proactive, well documented, and should appropriately involve the input of power of attorneys and next of kin.

In relation to complaints handling, we recommended:

• Prompt action should be taken to determine whether someone is making a formal complaint.
• Complaint acknowledgement letters should be sent out as per the complaints handling procedure.
• Responses should be sent where possible within 20 days and without undue delay in line with the board's complaint handling procedure.

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 care and treatment provided to her late mother (Mrs A) was inadequate. Mrs A died following a short admission to hospital, following emergency surgery. Ms C was specifically concerned that Mrs A had been diagnosed correctly early in her admission to hospital, but that this had not been properly acted upon. Ms C also suggested that surgery should have been performed earlier and that this had contributed to Mrs A's death. Ms C said that the subsequent morbidity and mortality meetings investigating Mrs A's death had not been appropriately carried out, as they had not identified the reason for her admission correctly.

We took independent medical advice from a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). We found that Mrs A had been suffering from a condition which was difficult to diagnose and which shared symptoms with a number of conditions. Mrs A had been given a differential diagnosis, and although this included the condition she was suffering from, it was not accurate to say that she had been conclusively diagnosed early in her admission. We concluded that the process of diagnosis had followed the correct procedures, and that the test result which could most reliably diagnose her condition was inconclusive. Mrs A had undergone surgery within a reasonable timeframe. The morbidity and mortality meetings had reflected on the condition Mrs A had been suffering from, rather the reason her GP had referred her to hospital. We concluded that Mrs A's care and treatment had been reasonable and, therefore, did not uphold the complaint.

Summary

Ms C was suffering from, amongst other symptoms, back pain and was referred to a physiotherapist. Shortly after, a magnetic resonance imaging (MRI) scan of her back was taken. Months later Ms C was referred to a gynaecologist (medical specialism of the female genital tract and its disorders) who ordered a further MRI scan as her symptoms continued. When the radiologist reviewed this request, Ms C's previous MRI scan was also reviewed. This second review noted the abnormalities in Ms C's pelvis and documentation was added to their records at that point. A subsequent CT scan confirmed that Ms C had ovarian cancer, and she had an operation to remove two large tumours. However, it was only during an appointment with her consultant oncologist (cancer specialist) a year later that she learned that these tumours had been detected in the MRI scan taken years earlier.

We took independent advice from a medical adviser who specialises in radiology (the analysis of images of the body). We found that the report of the first MRI was unreasonable, because it failed to mention abnormalities in the pelvis and advise further investigations. This meant that there was, at the least, a missed opportunity to diagnose Ms C with ovarian cancer earlier. We also found that it would have been reasonable for the gynaecologist to have informed Ms C earlier about what happened. Instead, Ms C only found out after asking specifically how long the tumours had been present. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in the initial review of the scan and communication 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:

• Review what happened in light of the medical adviser's comments and address any systemic or training issues.
• Share the results of this investigation with the radiologist.
• Discuss the imaging at a learning discrepancy meeting.
• Share the results of this investigation with all relevant clinicians including the gynaecologist.

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 was diagnosed with prostate cancer and he understood from his surgeon that for the best outcome, he should travel to Germany for a specific procedure (nerve sparing radical prostatectomy - a surgical procedure that removes the prostate gland and pelvic lymph nodes while attempting to save the nerves that help cause penile erections). He subsequently travelled to Germany and underwent the mentioned procedure privately. He complained that the failure by the board to offer him the operation was unreasonable and he incurred significant financial cost as a result.

We took independent advice from a medical adviser. We found that Mr C had been advised by the surgeon that he would be a suitable candidate for the aforementioned procedure, but only if a specific type of biopsy procedure was available, which was not reasonable, and that the procedure was not available by the board, which is incorrect. We found no evidence that the three options that were available to Mr C on the NHS were explored with him by clinicians in a reasonable way. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr 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/informationleaflets.
• Reimburse Mr C for the direct costs of the operation he underwent privately on receipt of evidence of the costs. 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 all suitable patients are offered nerve-sparing surgery and that they are fully informed about all options, including the possibility for surgery with intra-operative frozen section within the UK.
• Ensure that the multidisciplinary team process is clear and well documented and that changes in staging are explained.

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 daughter (Miss A) that, when Miss A attended the Queen Elizabeth University Hospital on several occasions with groin pain and leg swelling, she did not receive appropriate treatment. Miss A was eventually admitted to hospital and was later diagnosed with secondary cancer.

Mrs C said the board unreasonably misdiagnosed Miss A's condition during her initial visit to A&E at the hospital. She said that they told Miss A she had strained her groin, when in fact she had a large blood clot there.

We took independent medical advice from a consultant in emergency medicine and from a consultant in general medicine. We found that although the diagnosis given at the time was incorrect, it was consistent with Miss A's recorded history and examination findings and was not unreasonable. We did not uphold this aspect of the complaint.

Mrs C said that the board unreasonably delayed in reaching a diagnosis of Miss A's condition. Her concerns included that it took several months of visits to the hospital before Miss A was admitted. We found that the clinicians who saw Miss A at the hospital could, and should, have exercised discretion and carried out further investigations of Miss A's condition at an earlier stage. We also found that the delay in Miss A being admitted to hospital and given a diagnosis, was unreasonable. Earlier investigation would almost certainly have identified the abnormal tissue causing Miss A's problem and led to the subsequent diagnosis of an underlying secondary cancer. While further early investigation might not have resulted in a different outcome, Miss A could have been spared the pain and anxiety caused by the delay in diagnosis of secondary cancer. Therefore, we upheld this aspect of the complaint.

Mrs C also said that the board failed to deal with her complaint about Miss A's care and treatment appropriately. We found that the board had delayed in responding to Mrs C's complaint, failed to provide her with any updates and that, following repeated contact by Mrs C's MSP's office, a full response was eventually forthcoming. This was contrary to the board's complaint handling procedure and we, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Miss A for the delay in admitting Miss A to Queen Elizabeth University Hospital and investigating and diagnosing her condition at an earlier stage; and for failing to provide Mrs C with appropriate updates on her 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:

• In future cases of this type, staff should admit patients to Queen Elizabeth University Hospital and carry out further investigations at an earlier stage, in order to reach a diagnose within a reasonable timeframe.

In relation to complaints handling, we recommended:

• Where the board needs longer than the 20-day timescale to issue a full response, they must explain the reasons to the complainant, and agree with them a revised timescale whenever possible, in accordance with the board's complaints policy and procedure.

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 did not provide reasonable care and treatment to her late brother (Mr A) at Inverclyde Royal Hospital and that the board's staff had failed to communicate adequately with her about Mr A. Mr A, who was terminally ill, died in the hospital days after his admission.

We took independent advice from a consultant in acute medicine and from a senior nurse. We found that there were failings in the care provided to Mr A when he was in A&E. There were failures to recognise and respond to Mr A's high blood glucose levels, to perform an electrocardiogram (ECG) as part of initial investigations on admission and to address his pain. We noted the board has acknowledged the failing to address Mr A's pain needs and has taken appropriate steps to improve this area of care.

We found that when Mr A was transferred to another ward, there was a failure to recognise and treat sepsis (blood infection) early enough or adequately for Mr A as a patient with an impaired immune system. We noted, in particular, that Mr A's profound and rapid deterioration may have been avoided with earlier, more aggressive input. Finally, there were a number of record-keeping failures, which meant it was unclear to know exactly what had happened with respect to Mr A's deterioration and the ward move. Therefore, we considered that the board did not provide reasonable clinical treatment to Mr A and upheld this aspect of the complaint.

In relation to Mr A's nursing care during his assessment in A&E, we identified failures to check Mr A's blood glucose levels and to address his pain relief while he was there. The nursing care received after Mr A's ward move was found to be of a reasonable standard. In view of the failings in relation to the nursing assessment in A&E, on balance, we considered that the board did not provide reasonable nursing care to Mr A and upheld this aspect of the complaint.

We noted that the board acknowledged that there were shortcomings in communication, and have offered an apology to Mrs C.

The principal issue our investigation identified was that there was a failure by haematologists (medical specialists of blood and its disorders) to discuss the rapid progression of Mr A's leukaemia with him and his family and that he would be for palliation (care to make you more comfortable, not cure) only. This contributed to the shock Mr A's deterioration had on his family. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and her family for a failure to check blood glucose and carry out an electrocardiogram test; a failure to recognise and treat sepsis; failures in record-keeping; and a failure to discuss the rapid progression of the leukaemia. 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 with diabetes should have their blood glucose checked on admission and regularly during their in-patient stay. Patients presenting with an abnormal heart rate should have an ECG on admission (as part of initial investigations). Patients who are in pain should have their pain needs addressed prior to transfer out of A&E. Patients who are immunosuppressed should be reviewed for sepsis early and frequently and have appropriate therapy commenced. Deteriorating patients should not be transferred between wards unless the move is intended to improve the management of that patient's deterioration/underlying condition. Staff should maintain reasonable medical records, consistent with General Medical Council guidance. Time and the band of nurse should be documented in the patient's records. Staff should communicate with a patient and relatives where it is clear that the patient is deteriorating and only palliative care is to be provided.

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 (Ms A) had received from the practice before Ms A completed suicide.

She complained that the practice failed to identify that her mother had a personality disorder. We took independent advice from a GP adviser. We found that it had been reasonable for the practice not to diagnose that Ms A had a personality disorder. We did not uphold this aspect of the complaint.

Ms C also complained that the practice failed to manage Ms A's anti-depressants and that they had failed to take appropriate action when she stockpiled medication. We found that the practice had acted reasonably in relation to these matters and did not uphold these aspects of the complaint.

Ms C then complained that the practice had failed to call her back, after she had contacted them to raise concerns about her mother's behaviour. We found that there was no evidence that Ms C requested or was promised a follow-up call by the practice. In view of this, we found that it was reasonable that the practice did not call her back. We did not uphold this aspect of the complaint.

Ms C complained that the practice had failed to take action when Ms A reported abuse of her children. We did not find any evidence in the practice's records that Ms A had reported physical abuse of her children. However, we considered that there was evidence of emotional abuse by Ms A to her children and that social work input should have been arranged in relation to this. We upheld this aspect of Ms C's complaint.

Finally, Ms C complained that the practice had unreasonably failed to deal with her complaint appropriately. We found that the practice had made a reasonable attempt to respond to the issues raised. It was also reasonable that one of the GPs named in the complaint carried out the investigation, given the size of the practice. That said, we found that the practice had unreasonably failed to provide updates on the investigation or information about when they expected to issue a final response. In view of 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 their failure to ensure that social work input was arranged and for failing to keep her updated on the complaint. 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:

• GPs should be familiar with the indications of emotional abuse in children and the referral mechanisms in place for social work assessment.

In relation to complaints handling, we recommended:

• When there is a delay in responding to a complaint, the practice should tell the person making the complaint about the reasons for the delay and when they can expect a response.

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 about the care and treatment provided to her late father (Mr A) during an admission to Glasgow Royal Infirmary. At the time, Mr A had a long standing cardiac and respiratory (heart and lung) illness and was admitted with a chest infection, shortness of breath, confusion and hallucinations.

We took independent advice from a consultant in respiratory medicine. We found that many aspects of the care provided were reasonable. However, we found no evidence that an inhaler review had been appropriately performed or planned. On balance, we upheld this aspect of Mrs C's complaint.

Mrs C also had concerns about the nursing care provided to Mr A, and the way in which his discharge was handled. We took independent advice on these matters from a registered nurse. We found that the dietary monitoring performed was reasonable and we found no failings in the way nurses interacted with Mr A. We concluded that the nursing care provided was reasonable. Similarly, we were not critical about the way Mr A's discharge was handled. We found no evidence of unreasonable failings and concluded that the handling of the discharge was reasonable. We did not uphold these complaints.

Finally, Mrs C complained about the way her complaint was investigated by the board. We did not find failings in the way the board investigated or responded to the complaints raised. However, we found that the board did not update Mrs C about the delay in responding to her, in accordance with the NHS Scotland Complaints Handling Procedure. On balance, we upheld this aspect of the complaint but noted that the board had already apologised for this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that an inhaler review was not performed during the admission or planned. 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:

• Where a patient suffers repeat significant disabling breathlessness attributable to chronic obstructive pulmonary disease, inhaler assessment and medication review should be undertaken or planned.

In relation to complaints handling, we recommended:

• Where a complaint response cannot be provided within 20 working days, the person making the complaint should be updated on the reason for the delay and be given a revised timescale for completion. Delays in 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

Ms C complained about the care and treatment her late mother (Ms A) had received at Glasgow Royal Infirmary. Ms A had been admitted to the hospital after taking a mixed overdose, including opiate-based painkilling medication. She was given naloxone (a drug that can reverse the effects of opioids). On the following morning, Ms A had a respiratory arrest and was transferred to the high-dependency unit, where her naloxone was increased. She was reviewed by the liaison psychiatry department several days later and was discharged home.

We took independent advice from a consultant psychiatrist. We found that, although the hospital had delayed in issuing the final discharge letter, the care and treatment provided to Ms A had been reasonable. We did not uphold this aspect of the complaint.

Ms C also complained that the board's communication with her family had been unreasonable. We found that there was a lack of consistency in Ms A's records in relation to communication with her family. It was not recorded who was present, who had a discussion with the family or what was discussed. We found that this was unreasonable and we upheld this complaint.

Ms C further complained that the board had provided inaccurate information to her about their review of Ms A's treatment. We did not consider that the response from the board to Ms C had been inaccurate or that that it misinformed her. We did not uphold this aspect of the complaint.

Finally, Ms C complained that the board's response to her complaint had been unreasonable. After the board had issued their initial response to Ms C's complaint, an MSP wrote to them again on behalf of Ms C. In response to this, the board agreed that a further review by a clinician in a separate part of the board would be carried out. However, they delayed in informing Ms C of this and in then carrying out the further review. In view of this, we also upheld this aspect of Ms C's complaint.

The board said they had taken action to address these failings, so we asked for evidence of this, but made no further recommendations.