Health

Summary

Mrs C complained about the care of her child (Child A) in Ayrshire Central Hospital. In particular, she complained that Child A was prescribed antihistamine medication as a sleep aid, without proper instruction or explanation of potential side effects. A meeting was held but Mrs C did not consider that the board's subsequent written response reflected the detail of what was discussed. The full findings and decision outcome were not detailed or explained in the response. Neither was the action plan that the board had put in place. The response did not comply with the requirements of the NHS Complaint Handling Procedure and we referred the matter back to the board for further work.

Following the board's further response we investigated whether the actions in prescribing medication were reasonable and whether the board's handling of the complaint was unreasonable or not.

We took independent advice from a consultant paediatrician (consultant specialising in the medical care of children) and concluded that clinicians acted reasonably in assessing Child A for prescription medication. We did not uphold this aspect of the complaint, however, we provided feedback to the board that medical records should reflect all discussions regarding a patient's care and that those records should be legible.

With respect to the handling of the complaint, we found that the board unreasonably failed to respond to Mrs C's initial complaint, and also failed to provide adequate detail in their response following the involvement of our office. We identified that the board had failed to produce a report of their investigations, communicate whether the complaint was upheld or not, and did not keep Mrs C adequately updated as to their progress. We upheld the complaint and made recommendations with respect to ensuring that the board take actions to implement recommendations from a previous case we investigated.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adequately respond to the points of complaint originally raised, or those outlined in the complaint to our office, and for not updating Mrs C regarding the delays in responding. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets .

In relation to complaints handling, we recommended:

• The board should ensure the recommendations with respect to a previous complaint to our office, have been properly implemented and complaints handling is now compliant with their statutory responsibilities.

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 called an ambulance after finding his wife (Mrs A) in a concerning condition. The ambulance took longer to arrive than Mr C felt was reasonable, and he made further calls to the Scottish Ambulance Service (SAS) before it arrived.

When Mr C complained to SAS about this, their investigation concluded that the call had not been handled in line with their protocol and that, had protocol been correctly followed, a higher acuity may have been given to the call and an ambulance diverted from another call to respond. SAS apologised for the delay in the ambulance arriving and took steps to prevent a similar situation recurring. Mr C was dissatisfied and raised his complaints with us.

We found that there was an unreasonable delay in the ambulance arriving but found no evidence to determine whether a higher acuity would have been given or an ambulance diverted if the protocol had been followed correctly. We upheld the complaint but made no further recommendations.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) during two admissions to Ninewells Hospital. Mrs C complained about nursing care, medical treatment, surgical treatment, communication, and complaint handling.

During our investigation we took advice from a nurse, a consultant in acute medicine, a dermatologist (a specialist in diseases of the skin, hair and nails), a plastic surgeon, and a vascular surgeon (a clinician who treats disorders of the circulatory system).

In relation to nursing care, we found that there had been failings in relation to wound assessment and management; pressure ulcer prevention and management; mouth care; medication administration; adhering to fluid balance; and involving palliative care specialists. We were also concerned that the board's own investigation had not identified these failings. We upheld Mrs C's complaint about nursing care.

In relation to medical treatment, we found that many aspects of this were reasonable and that dermatology care was of a very good standard. However, we identified that there was a delay of around 12 hours in Mr A receiving antibiotics at one point and on this basis, we upheld this aspect of Mrs C's complaint.

We found that the surgical treatment provided to Mr A by both plastic and vascular surgery was reasonable and did not uphold this aspect of Mrs C's complaint.

With regard to communication, we found that the communication between the different teams and clinicians had been of a good standard. We also found that in general, there was good communication with Mr A and his family. However, at a point when Mr A's condition was deteriorating and it was unclear how much information he could understand and retain, there was a gap in communication with his family and we considered this to be unreasonable. We therefore upheld this aspect of Mrs C's complaint.

We considered the board's handling of Mrs C's complaint. We found that there were significant and unacceptable delays throughout the complaints process, and that communication from the board was reactive rather than proactive. We also found that there were a number of failures or delays in answering Mrs C and her family's questions. We considered the handling of Mrs C's complaints to have been unreasonable and we upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable nursing care to Mr A; failing to provide reasonable medical treatment to Mr A; failing to reasonably communicate in relation to Mr A's care and treatment; and failing to handle Mrs C's complaint in a reasonable and timely manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Wounds should be assessed and managed appropriately and timeously, and in line with relevant guidance.
• Pressure ulcer prevention and management should meet the Healthcare Improvement Standards for Pressure Ulcer Prevention 2016.
• Mouth care should be carried out frequently, especially in patients who are not eating or drinking well, and if problems develop they should be addressed in a timely manner.
• Medication should be administered in accordance with the Nursing and Midwifery Code and the board's own local policy on prescribing and administration of medication. Where medications are not administered reasons for this should be documented.
• Accurate fluid balance and adherence to fluid restriction should be a priority in patients who have renal failure.
• Patients such as Mr A should be reviewed by palliative care staff in a timely manner, and efforts should be made to make patients comfortable during the end of life period.
• Action should be taken in a timely manner when a patient develops a new fever, and antibiotics should be commenced promptly.
• It should be documented if a patient is able to understand and retain information, and if not, communication with relevant family members should take place and be documented.

In relation to complaints handling, we recommended:

• Complaints should be handled in a reasonable and timely manner, and in line with complaint handling guidance.
• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

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 board's neurology (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system) department had unreasonably delayed in diagnosing his epilepsy (a neurological disorder). Mr C was initially diagnosed with chronic fatigue syndrome (a medical condition of unknown cause, with fever, aching, and prolonged tiredness and depression) and said that he was referred to the neurology department on many occasions over a number of years but stayed with this diagnosis. Several years later, Mr C's diagnosis was changed to functional weakness and, several years after this, it was identified that he had epilepsy. Mr C considered that his epilepsy should have been identified earlier.

We took independent advice from a consultant neurologist. We found that it was unlikely that the symptoms Mr C initially had were due to epilepsy. He subsequently did develop symptoms that fitted epilepsy, but it was reasonable that it took some time to make a diagnosis, as his symptoms were relatively infrequent. We found that the sequence of investigations undertaken were reasonable and that there were no failings in Mr C's care and treatment. Therefore, we did not uphold this complaint.

Summary

Ms C attended Perth Royal Infirmary where she was treated for a suspected stroke. Her condition improved but she was found to have sustained brain damage, leaving her with ongoing communication difficulties. Ms C complained that her symptoms were misread, and that she was misdiagnosed and mistreated for a stroke. She considered that the treatment (thrombolysis injection to dissolve a suspected clot) contributed to her brain injury and resulting speech difficulties.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We considered that Ms C's symptoms, together with CT scan findings, supported the diagnosis of a stroke. We found that the treatment given was appropriate to the findings, and did not cause any direct side effects. Therefore, we did not uphold this aspect of Ms C's complaint.

Ms C also complained about a delay in responding to her complaint, and errors and inconsistencies in the response. The board had acknowledged that the response was delayed and apologised to Ms C. They told us that they had reminded staff of the need to ensure complainants are provided with updates if deadlines are not going to be met. We recognised the complexity of the complaint contributed to the delay and, on balance, considered that the response was reasonable and proportionate. However, we did not consider that the board fully explained the reasons for the delay to Ms C and found that they did not agree a revised target timescale as they are required to do. For this reason, we upheld this aspect of Ms C's complaint but made no further recommendations.

Summary

Mr C attended the Western General Hospital after he experienced seizures. They carried out scans, which showed a lesion (an abnormal growth) in his brain. Mr C complained that there was a delay in diagnosing that it was brain cancer, as medical staff initially thought that the lesion was an abscess (a collection of infected fluid). We took independent advice from a consultant oncologist (cancer specialist). We found it was reasonable that Mr C's lesion was thought to be an abscess, given the results of the scans and his medical history. We found that it was good practice that they also tested the lesion for cancer. We did not uphold this aspect of the complaint.

Mr C also complained that when cancer treatment options were discussed with him, he was not given appropriate support. In addition, he complained that there was a delay in telling him about fertility options before he started his cancer treatment. We found that Mr C had appropriate support from the multidisciplinary team and his family when treatment options were discussed with him. We also found that he was given appropriate written information about fertility options. Therefore, we did not uphold these aspects of the complaint.

Summary

Mrs C complained about the treatment provided to her husband (Mr A). Mrs C said that the board unreasonably removed Mr A's right kidney and ureter (the duct by which urine passes from the kidney to the bladder) on the basis of a diagnosis of cancer.

We took independent advice from consultants in urology (the medical specialism that deals with the male and female urinary tract, and the male reproductive organs) and pathology (the study of disease). We found that there were failings in relation to record-keeping which we drew to the board's attention. We also found that there had been a delay in the surgery being carried out which the board had apologised for. However, we found the investigations carried out which led to the diagnosis of cancer were reasonable. We also found that the biopsies (tissue samples) taken in this case were appropriately interpreted at the time and that a mistake had not been made. Therefore, we did not uphold the complaint.

Mrs C also raised concerns about the Significant Adverse Event Review (SAER) which had been carried out. We found that the SAER carried out was reasonable. We found that a comprehensive review of the case was carried out, and failings in the consenting process were recognised. We also found that there had been a thorough external review of the pathology slides and recommendations made for improvements. We did not uphold the complaint.

Summary

Mr C complained that the board failed to provide reasonable care and treatment for his foot, and that the board did not respond to his complaint appropriately.

Mr C underwent surgery to address a bunion (a type of bony lump that forms on the side of the foot) at St John's Hospital. Mr C experienced problems after his operation, and had further surgery on the same area approximately four years later. At this time, Mr C was noted to have septic arthritis (inflammation of a joint caused by a bacterial infection) and a procedure was performed to wash out the joint and remove infected tissue. Mr C's problems continued to persist, and he required further surgery the following year.

We took independent advice from a consultant podiatric surgeon (a clinician who diagnoses and treats abnormalities of the foot). We noted that Mr C had presented with a foot that was difficult to correct surgically. While there was a lack of correction after the initial surgery, we did not conclude that this was an unreasonable failing by the board. Mr C also had concerns about the second procedure. We concluded that this had been performed reasonably. However, we noted that Mr C's foot wound had been slow to heal following the procedure and he had received extensive antibiotic treatment. In these circumstances, a post-operative x-ray should have been performed to determine whether there was evidence of spreading infection. An x-ray was not performed and we concluded that this was unreasonable. On balance, we upheld this aspect of the complaint.

Finally, Mr C raised concerns about the board's handling of his complaint, stating he had anticipated a more compassionate response. We found that the board's complaint response acknowledged the problems Mr C experienced appropriately. We also noted the board had not complied with the timescale under their Complaints Handling Procedure. Therefore, we upheld this aspect of the complaint. We noted that the board had acknowledged this failing and we made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to perform an x-ray following the second surgical procedure. 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 receives joint washout and debridement treatment, an x-ray should be considered to establish if the infection has spread.

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 that her mother (Ms A) received at University Hospital Hairmyres. Ms A attended the hospital with back and chest pain, and her blood count was found to be low. The cause of Ms A's low blood count was suspected to be an internal bleed. Ms C was concerned about the investigations carried out to identify the cause of Ms A's low blood count and that Ms A was discharged home without a final diagnosis.

We took independent advice from a consultant hepatologist (specialist treating the liver, gallbladder and pancreas) & gastroenterologist (treatment of the stomach and intestines). We found that the clinical approach used to identify the source of Ms A's bleeding was reasonable. In particular, plans were made for Ms A to have an endoscopy (procedure using an instrument to give a view of the body's internal parts) and a colonoscopy (procedure where a flexible fibre-optic instrument is inserted through the anus in order to examine the colon) on an

out-patient basis. We found that it was reasonable for the board to discharge Ms A and that it would not have been possible for the board to make a final diagnosis during Ms A's admission. We did not uphold Ms C's complaint.

Summary

Mr C complained about the care and treatment provided to him by the board in relation to a pacemaker implantation (a device that generates electrical impulses delivered by electrodes to contract the heart muscles and regulate the heart). After Mr C had his pacemaker implanted, he attended hospital on several occasions as he was aware of having palpitations (noticeably rapid, strong or irregular heartbeat). Some months after implantation, it was found that Mr C had a heart failure as a result of the pacemaker. Mr C raised concern that it took several months to detect the heart failure and take action on this.

We took independent advice from a cardiologist (a medical specialist who diagnoses and treats disorders of the heart). We found that the monitoring of Mr C's pacemaker was reasonable, and that no problems were identified during this monitoring. We found that Mr C was not experiencing any symptoms of heart failure and therefore there would have been no reason for the board to suspect this. We determined that the finding of heart failure was incidental, and when identified it was acted upon in a timely and appropriate manner.

We noted that the risk of heart failure was not outlined on the consent form for Mr C's pacemaker implantation and that this was technically a failing. However, we found that national practice does not currently reflect that this risk is not routinely included anywhere on consent forms in the NHS at this point. Therefore, while we considered that it may be good practice to raise the risk of heart failure when taking consent for pacemaker implantation, as the risk is not one that is nationally recognised or currently reflected in practice and guidance, we did not consider this to be a failing of the board with regards to required actions and reasonableness. We did not uphold this aspect of Mr C's complaint.

Mr C also complained about the board's communication with him regarding his pacemaker and heart failure. We found that communication was prompt and covered all issues reasonably. We did not uphold this aspect of Mr C's complaint.