Health

Summary

C complained on behalf of their parent (A) about the care and treatment they received from the board following neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord). C complained that the board did not provide follow-up care to A and they were not referred to oncology (cancer specialists) for further treatment. C said that A required further surgery to treat recurrent disease a few years later as a result.

The board’s complaint response explained that an administrative error had occurred which had led to A not receiving follow-up care from neurosurgery or a referral to oncology. The administrative error had been managed via staff training to prevent it from happening again. In response to our enquiries the board confirmed that no internal review, such as a Serious Adverse Event Review (SAER), had taken place.

We took independent advice from a neurosurgery adviser. We found that it was unreasonable that A had not received the planned clinical follow-up after their surgery. It was also unreasonable that SAER or Duty of Candour guidance had not been followed in this case. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified in this report. 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:

• The board should initiate statutory duties and processes for learning when it becomes known that a potential harm has occurred. Including, but not limited to, Duty of Candour and adverse event review processes.

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

C complained about the standard of medical care and treatment provided by the board to their late sibling (A) during a long admission to hospital. A’s medical history was complex as they suffered from a number of life threatening conditions during their hospital admission and they were under the care of a number of specialities. It was not until after A died, when the post mortem was performed, that A’s cancer was identified.

C said that the various clinicians should have identified A’s cancer, and that communication was not reasonable. C also said clinicians did not manage A’s pain well which was unreasonable and very distressing for the family.

We took independent advice from specialists in urology (urinary system and male reproductive organs), cardiology (heart), radiology (imaging) and end of life care. We found that treatment decisions were reasonable, and that the board managed A’s pain in a reasonable way. We also found that it was reasonable for clinicians not to have diagnosed A with cancer. Therefore, we did not uphold C’s complaints.

However, there were aspects of communication that the board should consider improving and we provided this as feedback.

Summary

C complained on behalf of their late partner (A) who died from a stroke caused by a blood clot. A was admitted to hospital with seizures after collapsing at home and sustaining a head injury. A couple of days later A was identified to have had a stroke, and they died the next day. C complained that an MRI scan was not carried out in order to verify the cause of A’s seizures (a blood clot), in a timely manner to enable acute stroke interventions.

We took independent advice from a consultant in intensive care medicine and a consultant stroke physician. We found that receiving a CT head scan when A first presented was appropriate. A working diagnosis of seizure was reasonable at that time. We found that it was reasonable that time critical acute stroke interventions were not indicated, and therefore an MRI was not indicated. A repeat CT scan did not show any significant changes from the initial scan. We noted that an MRI scan at this point would have been unlikely to have altered A’s immediate management.

C was concerned that placing A in a medically induced coma masked the progression of the stroke, however, we found that this action was in keeping with guidelines. We considered that the clinical management of A was reasonable. Therefore, we did not uphold C’s complaint.

Summary

C complained about the decision to stop the anticoagulant (blood thinning) medication given to their late parent (A) and a lack of communication with the family around this decision. The practice instructed to stop the medication due to an unexplained bleed. Following this stoppage, A died from a stroke. A’s family contacted the practice to discuss their concerns about the medication but they were unable to speak to a clinician in a timely manner.

We took independent advice from a GP adviser. We found that there were clear indications for A to be on anticoagulant medication and that it was unreasonable that the medication was stopped without a replacement in place. The decision to stop the medication was not fully informed. We noted that the practice did not undertake timely blood tests or communicate with A’s family and the relevant specialists. We also found failings around the administration of blood tests.

The practice carried out a Significant Adverse Event Review (SAER), which we found was not in line with relevant national guidance. We upheld C’s complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings identified in this report. 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:

• Significant Adverse Event Reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward. SAERs should be held in line with relevant guidance.
• Appropriate blood tests should be carried out in line with relevant guidance when anticoagulant medication is stopped or replaced. Test results should be appropriately actioned.
• Contacts to the practice from patients or their carers should be adequately assessed to ensure that they are appropriately escalated and, where necessary, there is discussion with the appropriate member of staff, including clinicians.
• Patients should be fully assessed prior to the stopping of anticoagulation medication with appropriate consideration given to the risks. Full information should be sought, including where appropriate communication with relevant specialists and the family members prior to any decision being reached. Where this information is received in the GP’s absence, arrangements should be in place for this to be picked up by another clinician.

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

C complained about the care and treatment their parent (A) received during a hospital admission. C complained about the way episodes of agitation and aggression were managed by the board including in respect of administration of medicines; bruising to A during episodes of restraint and lack of dignity; a failure to manage their nutritional needs; and poor communication with A’s family.

The board’s response to C’s complaint advised that medication had been used to settle A when other measures had been unsuccessful. The board said that A’s weight loss had been recognised and a referral had been made to the dietician, however, they had been discharged from hospital before a review could take place. It was recognised that documentation including fluid and food intake charts were incomplete and steps would be taken to ensure improved compliance. The board considered there had been good communication with A’s family, however, they apologised for the lack of empathy reported by C, which staff would be asked to reflect on for future learning.

We took independent advice from a senior nurse adviser and a consultant geriatrician (specialist in medicine of the elderly). We found that there were aspects of A’s care which were reasonably managed particularly in relation to the way episodes of agitation and aggression had been managed on the ward. We found there were aspects of A’s care which were unreasonably managed particularly in relation to management of their nutritional needs, record keeping and communication.

On balance, we considered the board failed to provide a reasonable standard of care and treatment to A and we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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:

• The board should ensure effective communication with family members, particularly in circumstances where Adults With Incapacity is 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.

Summary

C complained about the standard of surgery and post-operative care that they received when they had an elective operation for a long standing hernia (when part of an organ protrudes through your muscle wall). During the procedure the bowel was punctured resulting in an injury and transfer to another hospital.

C said that the small hernia was manageable without an operation, and complained that they had not been told about all the risks and about inadequate care post-surgery.

We took independent advice from a consultant general and colorectal surgeon. We found that it was reasonable to offer C an elective repair of the hernia and for this operation be to done by the consultant surgeon. However, more regard should have been given to whether C was at an increased risk due to their BMI. We found that the board failed to provide informed consent at an appropriate time which meant that the risks of surgery were not effectively communicated to C. We also found that the consent process for C did not meet published guidelines. Therefore we upheld this complaint.

We found that post surgery, recognition and escalation to start Patient Controlled Analgesia was appropriate, and that C responded well to this pain relief. The timing of the CT scan was reasonable. Following escalation to clinical care specialists and treatment, C was transferred for further care which was also reasonable. We therefore did not uphold this complaint.

We provided feedback that consideration should be given to the preoperative risk assessment being carried out at consultant level and that referral to specialist weight management is available for patients who require incisional hernia repairs electively.

Recommendations

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

• Relevant staff should be aware of the required consent procedure and to ensure that the consent discussions are appropriately timed in advance of surgery and documented.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

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

C raised concerns about the care and treatment provided to their sibling (A). A underwent a series of hospital admissions, suffering from bleeding from their bladder, following radiotherapy. During these admissions, the majority of communication between the board and the family was with A’s partner (B). A was initially expected to recover from the radiotherapy but was admitted and discharged repeatedly, with some readmissions happening a matter of hours after A was discharged. A continued to deteriorate and died in hospital.

C believed that A was not provided with an adequate standard of urological or nursing care. They felt that A was not provided with appropriate treatment and that they were not reviewed properly by other medical specialties, given the complexity of their case. C was also concerned that A was not provided with adequate nursing care. C believed that the board had not acknowledged systemic failings which impacted on A’s care, wellbeing and adversely affected the outcome of their treatment.

We took independent advice from a consultant urologist and a registered nurse. We found that A’s urology care fell below a reasonable standard, as did their nursing care and we upheld these aspects of the complaint.

We found that A was reviewed appropriately by other medical specialties and this aspect of C’s complaint was not upheld.

Finally, the opportunity to perform surgery on A was missed and this contributed to A’s deterioration. It was not possible, however, to determine whether A would have survived if their care had been different. The board failed to transfer A to a different consultant or offer a second opinion when this was requested and they failed to communicate reasonably with A’s family about their care. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise separately to C & B for the failures in A’s care. 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:

• Improved management of long-term or complex patients, with clear communication between different medical specialties. The board should review the management approach to long-term complex patients, focusing on the shared care arrangements between differing specialties.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring, when requested as part of their care plan.
• A review of whether urology patients can be provided with a dedicated ward, or part of a ward.
• Consultant care transfer and second opinion requests should be managed reasonably and transparently.
• Patients should receive adequate nutritional support to support their treatment and recovery. The board should develop an action plan, reviewing A's case and identifying learning for the staff involved in A's care.
• Patients admitted to hospital should receive reasonable medical care including being offered appropriate treatment options, nutrition, and review after transfer from HDU. Clinical correspondence should be completed to an appropriate standard.
• Patients admitted to hospital should receive appropriate nursing care including appropriate recording of their patient centred care plan.
• Patients admitted to hospital should receive appropriate nursing care including recording and management of wounds or pressure injuries.
• Decisions on surgery should be explained to the patient whenever possible, allowing the patient or their family to make informed decisions about their treatment.

In relation to complaints handling, we recommended:

• Complaint responses should be clear and written in plain English whenever possible. Where clinical terms or technical language is used, this should be clearly explained in the body of the letter.

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

C complained that the board failed to provide their parent (A) with reasonable care and treatment when they attended the A&E with symptoms including a loss of sight in one eye. C raised concerns about the delay in assessing A and failures by staff to reasonably diagnose and treat A. C also said that the board failed to reasonably communicate and provide A and C with sufficient information after A was taken to a cubicle, to provide A with appropriate personal care, to adequately record information about A’s care and treatment and to follow the relevant policies and procedures in providing care and treatment to A.

We took independent advice from a consultant neurologist and a nurse. We found that there was an unreasonable delay in A being assessed by a doctor. We also found that there was poor record keeping in A’s medical and nursing records, which showed the level of care and observation A had received was unreasonable. We found that, had A’s observations been recorded as required, it was possible that a deterioration in A’s condition would have been picked up sooner. Consequently, we found that the care and treatment provided to A in the A&E was unreasonable. We, therefore, upheld this part of C’s complaint.

C also complained that, after A was transferred to the high dependency unit, a consultant neurologist failed to sensitively explain to them about A’s diagnosis and prognosis. We found that adequate and appropriate information was conveyed to C by the consultant neurologist and the communication between them had been clinically appropriate and satisfactory. It was not possible to determine whether or not the consultant neurologist had failed to explain this sensitively. We did not, therefore, uphold this part of C’s complaint.

C further complained that a senior research nurse failed to take reasonable steps to contact them regarding a stroke research study. We found that there was a failure to take reasonable steps to contact C regarding the stroke research study. We, therefore, upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. 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:

• A significant adverse event review should be carried out.
• Basic observations should be carried out to the frequency required for the presenting condition of the patient to allow any deterioration in the patient to be identified timely and acted on as soon as possible. Records should be accurate and reflect the care and interventions carried out to the standard required by the Nursing and Midwifery Council.
• Where a patient safety incident occurs, a datix should be completed. There should also be evidence of reflection and learning for the staff involved in relation to such incidents.

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

C complained about the care and treatment provided to their adult child (A) by the board. A had received care from mental health services for several years prior to their death by suicide. C complained that the board failed to reasonably share information with A’s family and failed to involve family in A’s care. C also complained about the board’s adverse event review process, and their complaint handling.

We took independent advice from a consultant psychiatrist. We found that the board had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable.

The board told us that records were kept briefer than they would normally, because A was an employee of the NHS and was concerned about their records being kept confidential. We did not consider this to be a reasonable position to take, as all patients, including those who are NHS staff, should be confident that their records will be kept confidential. We considered it unreasonable that the board had not addressed this concern. We upheld C’s complaint about information sharing and involvement of family.

In relation to the adverse event review process, we found that the board had not appropriately taken account of C’s view on the scope of, and information to be contained within the review, and because it did not identify the failings in care. We upheld this aspect of the complaint.

Finally, we considered the board’s handling of C’s complaint to be unreasonable. This was because answers to multiple questions about care and treatment were responded to using generic and repetitive phrasing, the complaint response contained several inaccuracies and C was not made aware that some aspects of the complaint could only be responded to by another organisation until the final complaint response,. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings with regard to information sharing and involvement of A’s family, the adverse event review process and the complaint handling and response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Adverse event review teams should be open to the requests of family when making decisions about scope and information contained in the final report. Adverse Event Reviews should be a reflective and learning process that appropriately consider events in sufficient detail to ensure failings and any appropriate learning and practice improvements are identified.
• Patients who are also employees of the NHS should have confidence that records will be confidential.
• Records should be comprehensive and completed in line with professional standards. In particular, mental health services should seek to discuss involving family in care planning and risk assessment. These discussions and outcomes of such should be documented and revisited regularly.

In relation to complaints handling, we recommended:

• Where some aspects of a complaint cannot be responded to by the board, the board should coordinate responses or make the complainant aware that they need to approach another organisation at the earliest possible point. Complaint responses should attempt to address individual concerns, or explain why that is not possible. Complaint responses should be 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

C complained about the care and treatment provided to their late parent (A) who was diagnosed with lung cancer. C considered that there had been missed opportunities to diagnose A earlier, and that as a result A was denied appropriate care which may have affected their outcome. C also complained that the cause of death determined by the board was inconsistent with A’s diagnosis. Additionally, C complained that the cause of death was amended at a later date, which caused them to doubt the accuracy of the board’s conclusions.

In their complaints response, the board stated that X-rays conducted earlier in the year had been reviewed and that radiologists were in agreement that A’s disease could not have been identified earlier. The board had also apologised that the cause of death had initially been determined to be hospital acquired pneumonia, and that this had now been corrected to community acquired pneumonia with lung cancer as the major contributing cause.

We took independent advice from an experienced respiratory consultant. We found that it was not unreasonable that A’s cancer had not been detected on earlier X-rays. However, a decision to downgrade a GP’s referral from ‘urgent suspicion of lung cancer’ to ‘new urgent’ created delays in investigations of approximately four weeks, and likely longer had A not been admitted to hospital unrelated to the referral. Further delays of around three weeks were also apparent between the final investigation and the final multidisciplinary team (MDT) discussion. We also found that it was unlikely that there would have been a different outcome for A due to the nature of A’s illness. As such. we upheld C’s complaint.

Regarding the cause of death, we found that the cause of death had been correctly identified in line with the available information and that whether the pneumonia had been hospital or community acquired was a technicality that was less significant than the overall conclusions. Based on this, on balance, we did not uphold this aspect of the complaint that there had been inaccurate or misleading information provided.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. 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:

• There should be a robust system in place for triaging respiratory referrals, which should only be downgraded when there is a clear clinical reason to do so. All patients with suspected cancer undergoing investigations should be appropriately tracked to prevent delays.

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.