Health

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.

Summary

Mr C complained about the clinical and nursing care and treatment given to his late mother (Mrs A) while she was a patient at Royal Alexandra Hospital. Mr C also complained that there was a failure to notify him of Mrs A's deteriorating condition.

We took independent advice from a nurse and a consultant physician. We found that falls assessments were not undertaken as they should have been and that Mrs A had not been provided with the walking frame that she required. We also found that Mr C was alerted neither to Mrs A's deteriorating condition nor to her fall and the injuries she suffered as a result. Similarly, Mr C appeared not to have been told of Mrs A's low sodium which was likely to have contributed to her fall and agitation. Therefore, we upheld these aspects of Mr C's complaint.

In relation to clinical treatment, we found the care to be reasonable. We did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to alert him to Mrs A's deteriorating condition and to her fall and injuries, as well as the failure to advise of her poor prognosis. 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 fall occurs, relatives should be alerted in a timely way. Similarly, they should be informed where a poor prognosis is anticipated.
• Medical staff require to communicate effectively with ward staff about the seriousness and risk of common metabolic problems.

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 us about the care provided to her late husband (Mr A) by the practice prior to him suffering a fatal heart attack. In particular, Mr A had reported chest pains three times over a three month period to his GP. The GP had felt the problems were related to a stomach problem, prescribed Gaviscon (medication for heartburn or indigestion) to Mr A and said they had ruled out a cardiac cause for the chest pain.

We took independent advice from a GP. We found that at the initial consultation it was reasonable that the GP had considered that Mr A's long standing stomach problem was responsible for his reported chest pain, and it was appropriate to prescribe medication. There was a question as to whether Mr A was taking the prescribed medication, which may have resolved the stomach problem, and that it was reasonable to pursue that line of enquiry in an effort to resolve the situation. We found that the GP had carried out an appropriate examination and did not uphold the complaint. We also noted that there was no evidence to suggest that had an earlier diagnosis been made, it would have prevented Mr A's sudden death.

Summary

Mr C complained about the treatment his mother (Mrs A) received at the practice. Mrs A suffered from chest pain and breathlessness and had concerns she had angina (a heart condition). Mr C complained that appropriate treatment and investigations were not carried out in a reasonable time-frame.

We took independent medical advice from a GP. We found that the practice unreasonably failed to carry out appropriate physical assessments during appointments. While the practice did not consider angina was a likely cause for Mrs A's health concerns, at the point where it was agreed to refer her, the practice used the incorrect referral pathway. They arranged for an electrocardiograph (ECG - test that records the electrical activity of the heart) followed by a routine referral to cardiology (the branch of medicine that deals with diseases and abnormalities of the heart), instead of the appropriate action of an urgent exercise tolerance test (or if the patient was not physically capable of doing this test then an urgent cardiology referral). We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to follow the correct referral pathway for investigation of angina. 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:

• The GP should be familiar with the appropriate referral pathway when investigating angina.

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 treatment his mother (Mrs A) received at Aberdeen Royal Infirmary. Mrs A was admitted to hospital to investigate heart concerns and was diagnosed with three vessel disease (a type of heart disease). An operation was carried out, but Mrs A died during the operation. Mr C was concerned about the board's response to Mrs A's reports of discomfort to nursing staff and the subsequent treatment she received. Mr C complained that the delay to take Mrs A's complaint seriously and call a doctor, contributed to her death.

We took independent medical advice from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that Mrs A was regularly assessed by both nursing and medical staff, and with the exception of the lack of ECGs on a particular date, appropriate actions were taken when she reported pain. The triple vessel bypass operation was initially successful, however, due to an uncommon complication which could not have been predicted, she died. We did not uphold this aspect of the complaint.

Mr C also complained that there were discrepancies between what he was told verbally by staff on the day after the operation and the written response to his complaint. We found that the board's response was an accurate account of events as documented in the medical records. However, while the board provided a reasonable explanation of the treatment provided to Mrs A, they did not reasonably reflect that there were two instances where ECGs were not carried out, which was out with normal process. On balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for inaccuracies in the complaint response. 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:

• Share the outcome of this investigation with relevant staff to ensure complaint responses are comprehensive and accurate.

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 that his child (Child A) received for jaundice (a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels. Bilirubin is the reddish yellow pigment made during the normal breakdown of red blood cells) in the days following their birth. In particular, Mr C was concerned that Child A did not receive a blood transfusion and received UV phototherapy instead.

We took independent advice from a midwife and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). We found that the care and treatment provided to Child A was reasonable and in accordance with relevant guidelines. We also found that, as Child A's bilirubin level responded well to the phototherapy treatment, it was reasonable that they did not receive a blood transfusion. We did not uphold this aspect of Mr C's complaint.

Mr C also complained about the way in which the board handled his complaint. We found that the board failed to provide a revised timescale for when Mr C could expect to receive a response to his complaint. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide a revised timescale for when he could expect to receive a response to his 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:

• 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 that the care and treatment given to his late wife (Mrs A) by the board was unreasonable. Mrs A had a history of rheumatoid arthritis (an inflammatory disorder that mainly affects flexible joints) and was later investigated for possible heart disease. The investigations proved negative. However, a year later she was admitted to hospital again and found to have severe problems with the functioning of her heart valves. Heart surgery was considered, but Mrs A developed sepsis and multiple organ failure which increased the risks associated with surgery. However, it was considered that Mrs A would not survive without an operation, which went ahead. After Mrs A was discharged home, she picked up a serious infection and suffered a stoke. She died a few months later.

We took independent advice from a cardiologist (a doctor who specialises in the heart and blood vessels). We found that it was extremely unusual for a patient's heart condition to deteriorate so rapidly and that this could not have been foreseen; there had been no delay in treating Mrs A's symptoms or in diagnosing her heart problems. Mrs A's health was such that surgery was always going to be risky for her, but there had been no delay undertaking it. Afterwards, the serious infection from which Mrs A suffered had a significant associated mortality rate and her health continued to deteriorate despite her treatment. Therefore, we did not uphold the complaint.

Summary

Mrs C complained about the care and treatment her daughter (Miss A) received from the board's out-of-hours GP service on two separate occasions, and from Aberdeen Royal Infirmary during two separate admissions. Mrs C believed that the out-of-hours service had not properly assessed Miss A and should have admitted her to hospital. Miss A underwent an appendectomy (appendix removal surgery) during the first hospital admission and then required to have a further operation for a pelvic abscess which is a recognised complication of appendicitis. Miss A was also found to have Crohn's disease (an inflammatory bowel condition) which further complicated matters. Mrs C believed that it took a long time for staff to decide what to do when Miss A was readmitted to Aberdeen Royal Infirmary, that an unusual antibiotic was administered, and that the medical staff tried too many times to insert cannulas.

We took independent advice from a GP and a consultant in general and colorectal (bowel) surgery. We found that the care in relation to the out-of-hours service was of a reasonable standard, because there were clear records made by both GPs of a detailed history being taken, appropriate examination performed, observations taken and tests carried out, with advice given on what to do if Miss A's condition worsened. We also took into account that appendicitis is not always a straightforward diagnosis to make and that other conditions, such as kidney infection, can mimic this. We did not uphold this aspect of the complaint.

In relation to the first hospital admission, we found that whilst the timing of antibiotic treatment and surgery were slightly outside national guidelines, we did not consider these delays to be unreasonable. Nevertheless, although it was reasonable to discharge Miss A on antibiotic treatment and arrange for blood tests some days later, we were critical that this safety-netting measure was not appropriate. We considered that arrangements should have been made for follow-up review within 48 to 72 hours, given Miss A's c-reactive protein (a marker of inflammation) had risen again and that she had a fever. Therefore, we upheld this aspect of the complaint.

In relation to the second hospital admission, we found that the choice of antibiotic treatment was reasonable. In addition, we considered that the problems with cannulation, whilst distressing for Miss A, was not because of sub-standard care, and that the time taken to perform another operation was reasonable given the fact that re-operating is a major undertaking; and there had been an outbreak of flu at Aberdeen Royal Infirmary, which resulted in Miss A being transferred to another hospital. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Miss A for failing to put in place an appropriate safety netting measure at the time of the first discharge from 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:

• Surgical staff should arrange appropriate follow-up review post-discharge where relevant to ensure robust safety measures are in place.

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.