Health

Summary

Ms C, who works for an advice and support agency, complained on behalf of Mr B about the care and treatment provided to his late wife (Mrs A) at Queen Elizabeth University Hospital. Ms C raised concerns about the medical and nursing care and treatment provided to Mrs A, about the decision to transfer Mrs A to another hospital, and that Mrs A's family were not advised of the transfer.

We took independent advice from a consultant physician/geriatrician (a medical doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the medical treatment provided to Mrs A was reasonable, and did not uphold this aspect of Ms C's complaint.

In relation to nursing care, we found that whilst many aspects were reasonable, there was a failure to swab Mrs A's leg ulcers on admission to the hospital and this was a breach of the board's standard operating procedure on

meticillin-resistant Staphylococcus aureus (MRSA - a type of bacteria that is resistant to several widely used antibiotics). Mrs A's leg ulcers were found to be MRSA positive when she transferred to another hospital. We upheld this aspect of Ms C's complaint. However, we were unable to conclude if this could have been avoided if Mrs A had been swabbed on admission.

We found that the decision to transfer Mrs A to another hospital was unreasonable given Mrs A's condition and we upheld this aspect of Ms C's complaint. However we found that her family were appropriately advised of this and did not uphold the complaint about communication of the transfer.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to swab Mrs A's leg ulcers for MRSA on admission and unreasonably transferring Mrs A to a different hospital. 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:

• The multidisciplinary team should satisfy themselves that a patient is suitable and fit before being transferred.
• Staff should follow the board's MRSA Standard Operating Procedure.

Summary

Mr C complained about the treatment he received at his dental practice. His dentist had said that he required a filling and the filling was performed by a dental therapist. Following the filling, Mr C experienced pain from the tooth and was told that a nerve had been damaged and that he would require either extraction or root canal treatment and then that he would require a crown. Mr C felt that the dental therapist had not carried out the filling in an appropriate manner. Mr C was also dissatisfied that when he made a formal complaint to the practice that he received responses from the dental therapist, head of practice and the dentist.

Summary

Ms C complained that the practice unreasonably failed to assess her child (Child A) before prescribing antidepressants; unreasonably failed to assess Child A before referring her to child and adolescent mental health services; unreasonably failed to include relevant information in the referral to child and adolescent mental health services; and unreasonably failed to give Ms C the appropriate information when she raised concerns about Child A.

In investigating Ms C's complaints, we took independent advice from a GP. We found that in relation to the prescription of antidepressants, this was a repeat prescription that should not have been issued. We found that Child A should have had a face-to-face assessment prior to antidepressants being re-prescribed. We found that this was an administration error as it should have been noted by the administrative staff who printed the repeat prescription that there had been a lengthy period of time since the last repeat prescription. We upheld this aspect of Ms C's complaint, however we considered that the actions already taken by the practice would address this issue.

In relation to the referral to child and adolescent mental health services, we found that this should not have been made without Child A's consent, and without a face-to-face assessment of Child A. Therefore, we upheld the complaints that there was an unreasonable failure to assess Child A and that the referral was unreasonable. However, in relation to the information that was included in the referral, we considered this to be reasonable. We found that appropriate action had been taken by the practice to address the failure to assess Child A in person prior to the referral being made, however, we made a recommendation to the practice in relation to consent.

We found that when Ms C raised concerns about Child A with the practice, they failed to tell her that Child A would need to be assessed in person. We upheld this aspect of Ms C's complaint.

Finally, we found that the practice's significant event review of the matters relating to this complaint was of a poor standard and lacked reflection. We made a recommendation to the practice to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for; failing to assess Child A before prescribing antidepressants; failing to assess Child A before referring them to the Young People's Department at Child and Adolescent Mental Health; making an unreasonable referral to the Young People's Department; failing to give Ms C the appropriate information when she raised concerns about Child A. 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:

• Patients should be informed of referrals and given the opportunity to object to any disclosure of information. This should be in line with General Medical Council guidance relating to consent and sharing information about young people, and ethical practice.
• Information should be given to parents/carers about the need to assess young people prior to referral where appropriate.

In relation to complaints handling, we recommended:

• Significant event reviews should be robust and reflective.

Summary

Ms C complained about the board's assessment of a referral that was made for her child (Child A) to the child and adolescent mental health services. Ms C considered that it was clear from the referral that Child A had not been appropriately assessed by the GP and that the board had failed to appropriately risk assess the situation based on Child A's history of suicidal ideation and

self-harm. We took advice from a consultant in child and adolescent psychiatry. We found that the assessment and action taken when the board received the referral was reasonable and therefore we did not uphold this aspect of Ms C's complaint.

Ms C also complained about the board's handling of her complaint. We found that there were delays in responding and some information was not provided. We found that this was in part due to the complexity and scope of the investigation, however, we upheld this aspect of Ms C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• As far as possible, complaints should be responded to in a timely manner, and should be responded to in full. Where a complaint is complex or involves more than one service, a process for handling this should be determined from the outset.

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr A), who had chronic obstructive pulmonary disease (COPD) (a disease of the lungs in which the airways become narrowed) and a mental health condition.

Mrs C complained that the practice failed to admit Mr A to hospital in the months leading to his death. Mrs C had contacted the practice to raise concern about Mr A's physical health. Shortly following this, the GP attempted to carry out a home visit, but found no response on attendance at Mr A's property. A week later, Mr A was examined during a home visit by one of the board's out-of-hours doctors who initiated treatment for his COPD. At this time, Mr A had very low oxygen saturation and potential signs and symptoms of heart failure. A report of the out-of-hours consultation was sent to the practice. The practice arranged to visit Mr C again approximately ten days later, but when the GP attended Mr A refused an examination. The GP felt that the symptoms were likely due to COPD and treatment was commenced with a plan to review Mr A in ten days time. Mr A died on the date of the planned review, with the cause of death unknown.

We took independent advice from a GP adviser. We were unable to conclude that the practice reviewed the details of the out-of-hours report, which contained details of concerning symptoms, and used this to determine a working diagnosis and management plan at the penultimate home visit attempt. We considered that the practice's decision that that there was no clinical indication for hospital admission following the home visit was unreasonable. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to consider the details of the out-of-hours report and use this to determine a working diagnosis and management plan; and for the unreasonable decision that there was no clinical indication for hospital admission following a home visit. 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:

• When an acutely unwell patient refuses examination, a GP should consider what other evidence is available – including details of recent examinations and clinical history for background information – to assist clinical decision making and the management plan.

Summary

Mrs C complained about the care and treatment provided to her daughter (Miss A) when she was admitted to Aberdeen Royal Infirmary for abdominal pain, vomiting, and a high temperature. Mrs C felt that there was a delay in diagnosing Miss A with pelvic inflammatory disease (infection of the organs of the reproductive system).

We took independent advice from a general surgeon, a radiologist, and a gynaecologist (a doctor who specialises in the treatment of women's diseases, especially those of the reproductive organs). We found that the care and treatment provided to Miss A was reasonable and that it would not have been possible to diagnose her with pelvic inflammatory disease any earlier. We did not uphold this complaint.

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr A), who had chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed) and a mental ill health condition.

Mrs C firstly raised concern about a home visit by an out-of-hours doctor a number of weeks before Mr A's death. We took independent advice from a GP adviser. We found that the doctor who visited Mr A performed a reasonable assessment of him and we noted that the record-keeping was of a high standard. The records showed that Mr A had very low oxygen intake and potential signs and symptoms of heart failure. In view of the symptoms and the presentation described by the out-of-hours doctor, we considered that immediate hospital admission should have been arranged. We did not find evidence that this happened and we considered that this was unreasonable. We upheld this complaint.

Mrs C also raised concern about the input of the Community Mental Health Team (CMHT) in the months leading up to Mr A's death and also felt that the board had reached inconsistent conclusions about whether Mr A was refusing assistance for his physical health in their respective adverse event review and complaint investigation. We took independent advice from a mental health nursing adviser. We found that the level of liaison between the CMHT and Mr A's GP was limited and ineffective, whilst we also identified shortcomings in the documentation. We did not consider that the board reached inconsistent conclusions in the adverse event review and complaint investigation; however, we considered that the board's investigations failed to give adequate consideration to the judgement that Mr A had capacity to make decisions about his physical health. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to offer and arrange hospital admission for Mr A following an assessment during a home visit; not giving adequate consideration to the judgement that he had capacity to make decisions about his physical health; and the limited CMHT liaison with the GP and the poor documentation of this. 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:

• Patients presenting with symptoms and signs of heart failure should receive investigations and treatment in line with national clinical guidelines.
• Where a member of a CMHT identifies concerns about a patient's physical health, they should liaise with the patient's GP in a systematic and effective way and this should be documented in the mental health records.

In relation to complaints handling, we recommended:

• Investigations should objectively evaluate the merits of clinical decisions made.

Summary

Mrs C complained about a number of issues with the care and treatment she received from the board. Mrs C had a complex medical history and had accessed a number of different services provided by the board.

Firstly, Mrs C raised concern that the board had not provided her with timely and appropriate maxillofacial (relating to the jaws and face) care and treatment. Mrs C was referred to the maxillofacial service for extraction of a tooth. After an initial consultation, Mrs C was listed to have the tooth extracted. At the subsequent consultation, a different doctor found that the tooth was vital and could be restored with further treatment. Mrs C was discharged from the service. Mrs C's general dental practitioner made a further referral to the service and after further consultations Mrs C's tooth was extracted. She felt that the board's actions had prolonged her pain. We took independent advice from a speciality doctor in oral and maxillofacial surgery. We considered that the care provided to Mrs C was reasonable. We did not uphold this complaint. However, we found evidence of issues with record-keeping in the service and we made a recommendation in relation to this.

Mrs C also raised concern that the board had not provided her with timely and appropriate orthopaedic (the branch of medicine involving the musculoskeletal system) care and treatment. Mrs C had a number of consultations in the orthopaedic service and was unhappy with the way clinicians investigated her orthopaedic condition and managed her care. In response to Mrs C's complaint, the board acknowledged that she had experienced delays and they described that they were reviewing the referral process to reduce delays. We took independent advice from a consultant orthopaedic surgeon. We found no medical failings in Mrs C's orthopaedic care, however, we noted that there was evidence of a significant delay in Mrs C being offered an appointment following a referral from her GP. We upheld this aspect of Mrs C's complaint.

Mrs C further complained that the board had not provided her with timely and appropriate physiotherapy treatment. She said that the self-management exercises recommended to her by the board were not helpful and she wanted to receive additional treatment, including hands-on therapy. In response to this complaint, the board said that the treatment provided had been appropriate. We took independent advice from a musculoskeletal outpatient physiotherapist. They said that it was standard practice to provide exercises to a patient to

self-manage chronic musculoskeletal pain, and hands-on treatment was of little long-term benefit in this situation. We considered that Mrs C received a reasonable standard of physiotherapy care and treatment and found no evidence of a delay in providing this. We did not uphold this aspect of Mrs C's complaint.

Mrs C was unhappy that the board failed to carry out timely and appropriate investigations into her facial/head pain symptoms. Mrs C had been reviewed by clinicians in a number of departments over a number of years in relation to this issue and she was unhappy with the investigations carried out and the lack of liaison between various specialties. We took independent advice from an oral surgeon with expertise in facial pain. We found that a number of appropriate investigations had been performed, yet there was limited evidence that appropriate haematology (related to blood disorders) investigations and investigation into temporomandibular disorder (a problem affecting the muscles and joints in the jaw area) were performed. We were also critical about the coordination of investigations between different disciplines and found that tests had not been carried out to exclude a specific type of headache. Therefore, we upheld this aspect of Mrs C's complaint.

Finally, Mrs C was dissatisfied with the way the board handled her complaints. While we acknowledged that Mrs C's complaint was exceptionally complex, we did not find evidence that the board provided a clear timescale within which they aimed to respond to Mrs C. We considered that the delays in complaint handling were unreasonable and also noted that in once instance, the board did not appropriately acknowledge one of Mrs C's complaints or inform her of her right to complain to us. 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 the unreasonable delay in providing an appointment to her, not investigating her orofacial pain reasonably, failures in record-keeping, and the delays in complaint handling. 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:

• Where multiple specialties are involved in investigating a clinical issue, the care should be well coordinated with effective communication between disciplines.
• Neurology staff should be mindful of the possibility of neurovascular and migrainous causes in patient's presenting with complex orofacial pain.
• Patient care should be documented in line with the requirements within the General Medical Council and General Dental Council standards. Temporomandibular joint disorder should be managed in line with contemporary clinical guidance.

In relation to complaints handling, we recommended:

• Complaints should be handled in accordance with the NHS Complaints Handling Procedure.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) while he was a patient at Forth Valley Royal Hospital. Mr A had a history of cancer and his condition was investigated. His results were in keeping with alcoholic hepatitis. Mr C had abnormal liver function results and changes had occurred in his brain as a consequence of his liver disease. He had lost a lot of weight and went on to develop influenza A (a highly contagious viral infection of the respiratory passages).

Mrs C complained that when she visited Mr A in hospital he was often unkempt and dirty. He also experienced an unwitnessed fall but Mrs C said that he was not properly assessed after this. Mrs C felt that Mr A's condition was allowed to deteriorate, and after developing sepsis he died.

We took independent nursing and gastroenterology (medicine of the digestive system and its disorders) advice. We found that on admission, nursing staff failed to complete a Malnutrition Universal Screening Tool (MUST) which, had they done so, would have alerted staff to his malnutrition and prompted further steps (for example referral to a dietician). A falls assessment should also have been carried out earlier in his admission and then regularly after that, particularly after his fall. However, while we found no evidence that he had not been nursed in a dignified way, we found that there had been failures in Mr A's medical care, there was poor documentation and monitoring of his liver disease, insufficient investigation of his fall, and a full sepsis screen had not been carried out. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to properly carry out a MUST and falls assessments and for failings in medical care.

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

• A MUST assessments should be carried out on admission.
• Falls assessments for patients similar to Mr A should be carried out on admission and thereafter at least on a weekly basis.
• Patients admitted with moderate liver impairment who have a mortality of over one in four should be treated in the correct ward by the correct team as a matter of priority.
• All relevant documentation should be completed appropriately and as required.
• Full assessment and investigation should be made after a fall, particularly when the fall occurs in a patient with liver failure, into the possible reasons for the fall.
• Medical teams should be aware of the high risk of mortality of patients admitted with decompensated liver disease, including the risk of sepsis.

Summary

Mrs C complained to us that nursing staff failed to document her concerns appropriately at a pre-operative assessment before she had a wisdom tooth surgically removed. She said that she told them that she was extremely anxious and that it was agreed that she would be taken first on the list for surgery. However, when she attended hospital to have the surgery, she was not first on the list and this made her extremely distressed.

We took independent advice from a nursing adviser. We found that there had been a failure to document the concerns Mrs C raised at the pre-operative assessment and that this had made her extremely anxious on the day of the surgery. We upheld this complaint.

Mrs C also complained that nursing staff had been rude and dismissive about her concerns when she attended the hospital for the surgery. We did not find any evidence to support this aspect of her complaint and we did not uphold the complaint.

Mrs C complained that she had not been given adequate pain relief after the surgery. We found that the board had not documented Mrs C's request for stronger pain relief at the pre-operative assessment and upheld this complaint.

Finally, Mrs C complained that she had been discharged from hospital without antibiotics. We took independent advice from a dental adviser. We found that it had been standard practice and reasonable to discharge her without antibiotics. We did not uphold this complaint.

Recommendations

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

• The documentation that is completed at a pre-operative assessment should include a section for any concerns raised at that assessment.
• Pain relief medication prescribed should be appropriately recorded. All medicines on discharge should be clearly and accurately recorded on discharge documentation.