Health

Summary

Mr C complained that his wife (Ms A) contracted methicillin-resistant staphylococcus aureus (MRSA - a bacterial infection that is resistant to a number of widely used antibiotics) due to medical negligence in the Princes Royal Maternity Unit (PRMU), and of a subsequent delay in identifying and appropriately treating the infection. Mr C considered that Ms A contracted MRSA as a result of negligence following the birth of their child. He considered that there was a delay in medical staff diagnosing the infection and thereafter providing proper treatment. Ms A returned home, continuing to have difficulties, and had to receive treatment despite having been discharged from the PRMU.

We requested the relevant medical files and asked an independent medical adviser to consider the care and treatment provided to Ms A. The medical records evidenced that the treatment in hospital had been appropriate, with Ms A's observations being monitored appropriately and decisions taken to discharge her were reasonable in the circumstances. However, on re-admission it was apparent Ms A was suffering from an infection. We found that appropriate investigations were undertaken in a timely manner to identify the cause of Ms A's infection when her symptoms became apparent. The antibiotic treatment was revised when tests concluded the cause of the infection was MRSA. There was no evidence of medical negligence that resulted in the infection. We concluded that the diagnosis and treatment provided to Ms A was reasonable, and therefore did not uphold the complaint.

Summary

Ms C complained about the care she received from Queen Elizabeth University Hospital's maternity assessment unit (MAU) when she called for advice with heavy bleeding at 33 weeks of her pregnancy. She also complained about the treatment she received ten days later following her admission to the hospital, at which time her baby was stillborn.

In responding to the complaint, the board apologised that they could not account for Ms C's phone contact with the MAU because there was no record of the phone call.

We took independent advice from a consultant obstetrician (a specialist in pregnancy and childbirth) and gynaecologist (specialist in the female genital tract and its disorders). We considered that the record-keeping practice was of an unacceptable standard and that the advice Ms C had received was incorrect because she should have been asked to attend hospital to have a clinical assessment of her pregnancy, in line with national guidance. We also considered that it was likely that Ms C would have been admitted to hospital for monitoring but given her bleeding stopped, it was also likely she would have been discharged. Whilst we found that it was possible that follow-up with Ms C could have been earlier than when she was seen 10 days later, we considered that the large placental abruption (separation of the placenta from the inner wall of the uterus), which she had no obvious risk factors of, could not have been prevented or predicted. We upheld the complaint.

In terms of the treatment Ms C received at the hospital when she attended by emergency ambulance with heavy bleeding 10 days later, we considered that her initial management of her abruption was inadequate and not in accordance with national guidelines. However, we also considered that these failings were unlikely to have altered the outcome for Ms C's baby. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to fully assess and treat her on arrival to the maternity unit. 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 Maternity Assessment Service should maintain adequate records of phone consultations and advice given. Staff responding to patient phone queries should be aware of guidance on the management of significant antepartum haemorrhage.
• All staff attending patients with life threatening complications such as antepartum haemorrhage should be aware of national/local guidelines on emergency management of patient collapse.
• Staff handling complaints should ensure that the issues are fully investigated with action taken to address any failings identified.

Summary

Mrs C complained about the care and treatment she received from the board for her bunions (painful swellings on the first joint of the big toes). Mrs C complained that the board failed to advise her prior to her bunion surgery that permanent nerve damage or bone fracture were potential complications of the surgery. Mrs C said that if she had been advised of these potential outcomes, she would not have gone ahead with the operation.

We took independent medical advice on the case from a consultant orthopaedic and trauma surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that nerve damage and bone fracture were recognised complications of the surgery Mrs C had. We also found that the appropriate consenting process was carried out and the correct consent form was signed by Mrs C and the doctor who was to carry out her surgery. The consent form listed the complications of the procedure, including nerve damage and fracture. Therefore, we did not uphold this complaint.

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.