Health

Summary

Mr C complained about a number of concerns about the service and treatment he received while in the Golden Jubilee National Hospital. He was admitted to hospital in preparation for receiving a heart transplant.

Firstly, Mr C complained about the behaviour and attitude of hospital staff towards him during a grand ward round. He stated that they spoke to him in an aggressive and threatening manner. Although there was no evidence of what members of staff the board spoke to as part of their complaint investigation, we noted that Mr C's medical records contained an entry written by a member of staff not named in the complaint. This case note provided a different account from the one Mr C provided. We did not take a view on which account was the definitive one but concluded that there was not sufficient evidence to confirm Mr C's account. Therefore, we did not uphold this aspect of the complaint.

Mr C's second complaint was about the fact that all his teeth were removed in preparation for the transplant surgery. We took independent advice from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that, based on the medical records, it was appropriate for Mr C's teeth to be removed. This was because Mr C's records showed he had significant dental and gum disease. Following transplant, Mr C would have to take long-term immunosuppressant medication. As a result, such dental issues would present an on-going risk of potentially life-threatening infection. Therefore, the hospital's actions were appropriate, and we did not uphold this aspect of the complaint.

Mr C's third complaint was that the board did not investigate and respond to his complaint appropriately or reasonably. We found that there were some areas where the board's investigation and response to Mr C's complaint could have been improved. In particular, we highlighted a lack of records of who was spoken with as part of the complaint investigation. However, we did not consider there to be significant failings that would lead us to conclude that the board did not investigate Mr C's complaint reasonably or appropriately. Therefore, we did not uphold this aspect of the complaint.

Mr C's final complaint related to the board's decision to discontinue his treatment and to refer him elsewhere. This was done as the clinical team concluded that they could no longer provide safe and effective treatment to Mr C. We considered that the clinical team and the board acted appropriately and in line with relevant guidance. We also found that the clinical team's decision had been appropriately documented and justified. We recognised that this caused great upset and difficulty for Mr C. However, we did not consider their actions to be unreasonable. Therefore, we did not uphold this aspect of the complaint.

Summary

Miss C complained about the care and treatment which her late father (Mr A) received at Forth Valley Royal Hospital. Mr A, who had a number of pre-existing health conditions, had been admitted after a fall as his general health had deteriorated. He was in pain and died not long after the admission. The family felt that there had been a lack of investigations by staff into a diagnosis and that they failed to appropriately manage Mr A's pain control or provide him with a reasonable standard of nursing care.

We took independent advice from a consultant physician and from a senior nurse. We found that while Mr A received a reasonable level of overall care, the management of his pain could have been better in that the rationale behind the decisions to change/amend medication for pain relief were not clear. The level of communication between the staff and Mr A's family could also have been improved. We upheld this aspect of the complaint.

In regards to the nursing care, we found that, although there was evidence of good care at times, there was also a failure by nursing staff to fully record Mr A's pain score and other charts which would have evidenced whether appropriate care had been given. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings in managing Mr A’s pain control and in communication with the family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Apologise to Miss C for the failure to record whether action was taken to address Mr A’s pain; nutrition and fluid balance needs. 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:

• Staff should be aware of the importance of appropriately managing a patient’s pain control and ensuring that appropriate communication is given to family members.
• Staff should ensure that when action is taken to address patient needs that the appropriate records are completed in line with record-keeping guidelines.

Summary

Mrs C complained about the care and treatment her father (Mr A) received at Forth Valley Royal Hospital. Mr A had been admitted with sudden onset severe jaw pain, which was radiating to his chest and arms. He subsequently developed abdominal pain and a number of tests were carried out, including an abdominal ultrasound. On the following day, Mr A had a CT angiogram (a specialised scan using x-rays to look at the heart) of his aorta (the largest and main artery in the body). This confirmed a large aortic dissection (a tear) requiring urgent surgical intervention. Mr A was transferred to another board for this surgery. After the surgery, it was discovered that Mr A had suffered a spinal stroke. This left him paralysed and entirely reliant on carers.

We took independent advice from a GP, a radiologist (a specialist in the analysis of images of the body) and from a consultant cardiothoracic surgeon (a medical doctor who specialises in surgical procedures of the heart, lungs, oesophagus, and other organs in the chest.) We found that the ultrasound result should have been flagged up as highly significant and with greater urgency. Where a potential life-threatening abnormality emerges on a diagnostic test, every effort should be made to convey this result immediately to the clinical team involved. The failure to do so, in Mr A’s case, led to a delay in definitive diagnosis and potential treatment of the aortic dissection. We, therefore, upheld this aspect of Mrs C’s complaint. However, we found that earlier identification of the dissection and more timely surgery would not have necessarily changed the outcome for Mr A.

Mrs C also complained that the board had failed to comply with the relevant record-keeping guidance, as they had been unable to find some of Mr A’s clinical records. We found that the board had failed to follow their ‘Transportation of health records policy’ and we also upheld this aspect of Mrs C’s complaint.

Finally, Mrs C complained about the board’s response to her complaint. We found that in their response to her initial complaint, the board had failed to identify the major failing in Mr A’s treatment, which was the delay in highlighting the abdominal aortic dissection flap observed in the ultrasound examination. We also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in reporting the ultrasound result to the clinical team involved, and for the failings in relation to their handling of Mrs C's complaint. 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:

• All administrative, clerical and clinical staff who are involved in the transfer of medical records should follow the Board’s Transportation of Health Records Policy.

In relation to complaints handling, we recommended:

• The board should ensure that complaints are investigated appropriately and that, when requested, they provide further information about the action they have taken in response to any potential failings identified.

Summary

Mr C complained about the psychiatric care andtreatment he received from the board, specifically that he disagreed with thediagnosis given to him and also that prescribed medication had caused unwanted psychological and physical problems . Mr C also had concerns that his medical recordsdid not hold an accurate account of his views in relation to his treatment anddiagnosis. We found his records did hold this information. We tookadvice from a psychiatric adviser and found that the care and treatmentprovided to Mr C had been appropriate and reasonable. We did not uphold Mr C'scomplaint.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) at Borders General Hospital. Mr A had a long history of health problems including arthritis (a disease causing painfulinflammation and stiffness of the joints) and chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) and he was admitted to hospital due to the severity of his tremors. Mr A had been taking regular doses of dihydrocodeine (DHC, an opioid painkiller) for several years for his arthritic pain. When he was admitted to hospital, Mr A's DHC was stopped and he suffered withdrawal symptoms. Mrs C complained that Mr A's medication was stopped for no reason. The board explained that there was no signature on the drug chart so they could not identify who stopped the medication and why but they had taken steps to address this failing.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the decision to stop the DHC was likely an error and we were satisfied the board had taken the appropriate steps to remind all junior doctors of the importance of documenting their decisions in the clinical notes. We upheld the complaint on the basis that it could not be identified why the medication was stopped and made a further recommendation in relation to complaint handling.

Mrs C also complained that Mr A was discharged from hospital when he was still very ill and that there was little consultation with the family and consideration of how they would manage at home. The board confirmed that Mr A was clinically well enough to be discharged home and that they delayed the discharge appropriately when Mr A's wife expressed concerns about how she would cope at home. We found that Mr A was medically fit for discharge and the process was appropriately managed. We did not uphold the complaint.

Recommendations

In relation to complaints handling, we recommended:

• Reasonable steps should be taken in future to identify relevant parties involved in complaint issues, to allow the issues to be thoroughly investigated, responded to in specific terms, and focussed learning to take place. This should be highlighted to all complaints handling staff.

Summary

Mrs C complained about the care of her late father (Mr A) at University Hospital Ayr. Mr A underwent surgery to remove bowel cancer and required further surgery due to a complication. He remained unwell thereafter and, due to his poor nutrition and weight loss, a decision was made to start nasogastric (NG) tube feeding (where a tube is placed through the nose into the stomach). However, the NG tube was mistakenly inserted into Mr A’s lungs instead of his stomach and this was not recognised prior to commencement of NG feeding. This error caused a severe deterioration in Mr A’s condition and he died just over a week later. The board carried out a Significant Adverse Event Review (SAER) and the Crown Office and Procurator Fiscal Service (COPFS) also looked into the circumstances of the death. As Mrs C was unhappy with the outcome of the board’s SAER and response to her subsequent complaint, she contacted the SPSO.

We took independent advice from a consultant gastroenterologist (a physician who specialises inthe diagnosis and treatment of disorders of the stomach and intestines)(a physician who specialises inthe diagnosis and treatment of disorders of the stomach and intestines). We considered that the board’s SAER process was reasonable and recommended appropriate policy changes to prevent a similar future recurrence. It was identified that there were some departures from existing policy but these did not contribute to Mr A’s death. These included record-keeping deficiencies and a failure to take all advised steps to obtain an aspirate (where a small amount of stomach content is sucked through the tube and the acidity checked to confirm correct placement of the tube). As the tube was incorrectly placed in this case, the further advised steps would have been unsuccessful anyway and an x-ray would still have been required. The significant failing was a consultant surgeon’s incorrect interpretation of the x-ray and consequent failure to identify the misplacement of the NG tube. This misinterpretation occurred out-of-hours when the consultant was in theatre preparing for surgery. The new policy position is that NG feeding will not be commenced overnight, and will only commence after a consultant radiologist has reviewed the x-ray and confirmed the correct placement of the tube.

We raised concerns that the board issued an initial death certificate which failed to record that Mr A died of aspiration pneumonia due to a misplaced NG feeding tube, when this was quite clear. COPFS subsequently amended the cause of death to include ‘misplaced NG tube and NG feed’. We upheld this complaint. While we were satisfied that appropriate steps had been taken to address the significant failing which contributed to Mr A’s death, we made some recommendations for the board to take additional steps.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the failure to issue a death certificate accurately recording that he died of aspiration pneumonia due to a misplaced NG feeding tube. 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 board should remind relevant medical staff that, when issuing a death certificate, careful consideration needs to be given to ensuring it accurately reflects the cause and circumstances of the death, regardless of how that might be viewed or interpreted.
• The board should inform the Ombudsman what steps were taken following the SAER, or what steps they intend to take now, to ensure future adherence to local policy regarding obtaining an aspirate and keeping records of the NG tube insertion process.

Summary

Ms C complained on behalf of her father (Mr A) that it was unreasonable for the practice to refuse Mr A a home visit. Mr A had been seen by the practice the day before and the next day a home visit was requested for him. The practice did not consider that a home visit was required and asked Mr A to attend, which he agreed to. Ms C said that Mr A required urgent medical attention and should have been seen at home.

We took independent medical advice and found that whilst there were differing accounts of what was discussed during the call requesting a home visit, there was no evidence in the medical records of clinical symptoms which were described during the call, nor in the notes from Mr A's appointment the previous day, which would have suggested a house call was required. We found that the practice's policy on home visits was reasonable and was applied appropriately in the circumstances. Therefore, we did not uphold this aspect of the complaint.

Ms C also complained that the practice's response to her complaint was unreasonable. We found that the practice failed to communicate with Ms C in line with their complaints handling procedure. Therefore, we upheld this aspect of the complaint. We noted that the practice had apologised for this but made a further recommendation for learning and improvement.

Recommendations

In relation to complaints handling, we recommended:

• All staff who handle complaints should be made aware of the findings of our investigation and reminded of the requirements of the complaints handling procedure.

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.