Health

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.

Summary

Mr C complained to us about the care and treatment provided to his son (Mr A) by the board in the community. Mr A had been diagnosed with paranoid schizophrenia (a serious mental health condition that causes disordered ideas, beliefs and experience), complicated by drug misuse. The conditions of Mr A's treatment were set out in a compulsory treatment order. We took independent advice from a mental health nurse.

Mr C complained that Mr A received an inadequate level of support and that restrictive measures should have been put in place when Mr A failed to comply with his treatment plan. We found that Mr A's care plan was reasonable. We found that the board demonstrated good practice by encouraging Mr A to comply with his treatment plan rather than immediately resorting to more restrictive measures. We found that the board did admit Mr A to hospital when it was the only practical way to stabilise his condition. We did not uphold this aspect of the complaint.

Mr C complained that there was a failure to take the circumstances of Mr A's family into account and to ease the strain they were experiencing. He also complained there was a failure to communicate effectively with the family. We found that the board acted appropriately by referring Mr C to social work for a carer's assessment. We found there was no obligation for the board to carry out their own assessment of the family's needs as carers. We also found that the board's communication with the family was reasonable. Therefore, we did not uphold these aspects of the complaint.

Summary

Mr C complained about the nursing care provided to his late mother (Mrs A) while she was a patient at Borders General Hospital. Mr C said Mrs A had told him that a nurse had pulled out her nephrostomy tube (a thin plastic tube passed from the back, through the skin and then into the kidney) and that it had not been reinserted properly. As a result of the failure to properly reinsert the tube, Mr C felt Mrs A's condition deteriorated until her death.

We took independent advice from an adviser and found that, had the tube been displaced, it would have to be reinserted in a sterile environment such as a theatre which would not normally be a procedure carried out by nursing staff. In addition, there was no entry in the nursing records which indicated that there was a problem with the tube and when Mrs A was subsequently transferred to another hospital the tube was seen to be working appropriately. We did not uphold the complaint.

Summary

Ms C complained on behalf of her child (Child A). After being assessed at a gender identity clinic, Child A was diagnosed with transsexualism and it was recommended that they be prescribed Sustanon (a hormone injection). The gender identity clinic wrote to Child A's GP to ask for arrangements to be made for Sustanon to be prescribed and administered. However, the practice advised that they would not prescribe or administer the medication for an initial period. Instead, they considered it appropriate for the gender identity clinic to prescribe the medication and make arrangements for it to be administered until Child A was stabilised, at which point the practice would take over. The practice stated that this decision was due to a lack of professional knowledge in this area and concerns about the GP's indemnity cover as Sustanon is classed as an unlicensed medication for this purpose. Ms C complained that the practice unreasonably declined to prescribe the medication and that they failed to communicate reasonably. Ms C stated that no GPs had been in contact to discuss the situation and there had been a lack of clarity about the practice's decision-making.

We took independent advice from an adviser with a background in general practice. We found that General Medical Council guidance supported the practice's position that they should not prescribe medication or initiate treatment if they do not consider themselves professionally competent to do so. We considered it appropriate, and in line with relevant guidance, for the practice to refer the matter back to the gender identity clinic for them to arrange treatment. In addition to this, we were satisfied that the reasons provided by the practice to Ms C were valid considerations for the practice to take into account. Therefore, we did not uphold this aspect of Ms C's complaint.

In relation to communication, we considered that it would have been helpful if a GP from the practice contacted Ms C or Child A to discuss their concerns. However, we noted that the practice's position was accurately conveyed by the practice manager. On balance, we considered the practice's communication to be reasonable. Therefore, we did not uphold this aspect of Ms C's complaint.

Summary

Mrs C complained on behalf of her husband (Mr A). Mrs C said Mr A had undergone an operation on his heart, which they had believed would be routine and uncomplicated. Mr A suffered serious complications during the surgery, resulting in a long period of recuperation and life altering consequences. Mrs C said they accepted that what had happened was a recognised risk of the surgery, however, she complained that Mr A had not been provided with adequate information during the consent process. Mrs C felt her complaint had been poorly handled, and although the board had apologised to Mr A, Mrs C was unhappy with this response.

We took independent medical advice. We found that Mr A was not provided with sufficient information during the complaints process. The advice also stated that the board needed to ensure that consent was taken early enough to allow patients to consider properly the potential complications and risks associate with their surgery. We found that the board's response to the complaint was reasonable in terms of practical solutions to the failings identified, but that they had not fully accepted responsibility for the failings, which devalued the apologies they offered. We upheld both aspects of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to obtain his informed consent. 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:

• Ensure the boards consent process allows (where practical) for a reasonable period of time between consent being given and a surgical procedure being undertaken.

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

Mrs C complained that the Scottish Ambulance Service (SAS) delayed in sending an ambulance for her husband (Mr A). Mr A's GP requested an ambulance within two hours as Mr A was experiencing vomiting and diarrhoea and was delirious. The ambulance did not arrive until almost eight hours later. SAS explained that there was an unexpected increase in the volume of calls that day, and that there was no missed opportunity to allocate an ambulance. SAS acknowledged that their delay in sending an ambulance was unreasonable.

We took independent advice from a consultant paramedic. We found that there was no missed opportunity to send an ambulance. However, we found that on one occasion the SAS call handler failed to use the correct interrogation system. We also found that SAS failed to carry out a clinical triage which would have involved Mrs C receiving a call from a clinical adviser who would have assessed Mr A's symptoms in more detail. This failing was acknowledged by SAS and was due to the high demand on the service. We upheld Mrs C's complaint and made a recommendation for learning and improvement.

Recommendations

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

• SAS should ensure that call handlers have absolute clarity on 999 call made by/on behalf of urgent patients to ensure correct interrogation system is used consistently.

Summary

Miss C complained to us that the medical practice had failed to provide her with appropriate care and treatment. She had attended the practice for a medical certificate following her recent attendance at A&E where she was diagnosed with a fractured finger and had her fingers strapped. Miss C said that the practice failed to manage her care appropriately in liaising with hospital staff and delayed making a referral to the hand clinic.

Summary

Mr C complained that his stoma reversal surgery (a surgery to reconnect the bowel) was delayed because of his mental health.

We took independent advice from a consultant colorectal (bowel) surgeon. We found that the surgeon acted unreasonably in failing to seek specialist advice from the mental health team when initally considering Mr C for surgery. In addition, we found that the surgeon did not respond when advice from the mental health team was offered. Mr C's maximum waiting time for treatment under the requirements of the Patients Rights (Scotland) Act 2011 was exceeded by ten months. There was no evidence that consideration was given by the board to arranging treatment by another provider or if any decision was made that this would not be an efficient and effective use of healthcare resources. We concluded that there was an unreasonable delay in the stoma reversal surgery going ahead, and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings this investigation has identified. 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:

• Staff should work together with other members of the healthcare team in a professional and supportive manner to maintain continuity of patient care.
• The board should take all reasonably practicable steps to ensure that it complies with the Treatment Time Guarantee.
• Where the board is not able to meet the Treatment Time Guarantee, they should consider arranging treatment by an alternative provider (as required by the Patient Rights Act and Regulations).