Health

Summary

Mr C complained about the treatment provided to his late son (Mr A) who died during a hospital admission. Mr A was suffering from heart failure secondary to Friedreich's ataxia (an autosomal recessive genetic disease that causes difficulty walking, a loss of sensation in the arms and legs and impaired speech that worsens over time). After being administered calcium gluconate treatment for high potassium levels, Mr A vomited and collapsed with a cardiac arrythmia (irregular heartbeat) from which he could not be resuscitated. Mr C complained that the most junior doctor on the ward was given the responsibility of carrying out Mr A's treatment. He also complained that it had taken hours to carry out relevant tests on Mr A. The board acknowledged that a number of attempts were made to obtain blood for testing, spanning a period of several hours.

We took independent advice from a consultant cardiologist (doctor who deals with diseases and abnormalities of the heart). We found that there was no clinical need for Mr A's treatment to have involved more senior staff, noting that the challenging issue in this case was the emergency management of an elevated potassium level in a patient who was taking digoxin (a steroid used in small doses as a cardiac stimulant) medication with a higher than desirable blood level. While Mr A's blood potassium was at such a high level there was a risk of cardiac arrest at any time. We found that because of the metabolic complexity of the case and the excessive level of digoxin, full supportive measures should have been in place. In particular, we considered that there should have been continuous ECG (a test that records the electrical activity of the heart) monitoring. We were critical of the fact that there was no record of the junior doctor having discussed the complication of the excessive digoxin level with the cardiology registrar. We noted that the board had subsequently made changes to their protocol for treating hyperkalemia (high potassium level), to take into account concurrent treatment with digoxin.

We found that the apparent failure to recognise the complication of excessive digoxin, and the lack of continuous ECG monitoring, was unreasonable. We therefore upheld this complaint, while recognising that staff involved in Mr A's care were dealing with challenging circumstances.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failings identified in Mr A's treatment. In particular, the potential effects of intravenous calcium gluconate were not given due recognition. Bedside ECG monitoring should have been in place. 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 involved in delivering care and treatment, including clinicians, must document discussions which inform their decision-making.

Summary

Mr C complained about the care and treatment he received for back pain while in prison. He had previously been prescribed dihydrocodeine and found this effective. The board's treatment plan included physiotherapy, a transcutaneous electrical nerve stimulation (TENS) machine (method of pain relief involving the use of a mild electrical current), heat packs and non-steroidal anti-inflammatory drugs, but he complained that these were not effective. He had also been referred to a pain management clinic.

We took advice from an independent GP adviser. We considered the board's prescribing for Mr C's pain to be reasonable, along with the other supportive measures referred to above. We noted Mr C's wish to take dihydrocodeine for his pain, but highlighted that this is an opiate and that the prescribing of opiates in the prison setting leads to risk of misuse. The fact that the board's GPs chose not to prescribe dihydrocodeine, does not suggest that the care they have provided was below a reasonable standard. We considered that Mr C's treatment was in line with guidance on good medical practice, and therefore did not uphold this complaint.

Summary

Mrs C complained about the treatment she had received from the practice. She had reported in consultations that her right big toe was cold, blue and painful. The pain continued and she received additional painkillers. Blood tests revealed a low iron count and iron tablets were prescribed. The pain continued and Mrs C also reported pain in her leg at the groin which was diagnosed as a groin strain. Mrs C continued to report problems and a referral was made to the vascular (circulatory) service where it was found she had blood clots in her leg and groin which resulted in her requiring an amputation of a foot.

We took independent medical advice from a GP. We found that initially it was felt Mrs C had chilblains (a painful, itch/swelling on a hand or foot, caused by poor circulation in the skin when exposed to cold) which was not unreasonable given the presenting symptoms. However, when the symptoms persisted the practice should have considered an alternative diagnosis of critical ischaemia (limb threat due to peripheral artery disease) rather than continue with chilblains. We also found that the diagnosis of tendonitis (groin strain) was unreasonable as Mrs C had not sustained an injury and that safety netting advice should have been given to Mrs C when she was prescribed painkillers. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in staff considering an alternative diagnosis that Mrs C's foot problems were attributable to chilblains.
• Apologise to Mrs C for the failure to carry out an appropriate examination and assessment of Mrs C's reported groin problems. 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 be aware to consider alternative diagnoses where the symptoms, which were felt initially to be attributable to a named diagnosis, were persisting.
• Staff should carry out appropriate assessments in view of a patient's presenting symptoms.

Summary

Mr C complained about the treatment the practice provided to his mother (Mrs A). Mrs A was attended by a GP at home after it was reported she was having problems with her leg. At this time Mrs A was also receiving nursing care from district nurses. Mr C complained that the practice did not respond to a request from a district nurse for a further home visit the following day. Mrs A's condition worsened and she was admitted to hospital where she later died.

We took independent medical advice from a GP. We found that Mrs A's treatment by the practice was reasonable and found no failings in the treatment offered. We saw no evidence a district nurse requested a home visit by the practice. Therefore, we did not uphold Mr C's complaint.

Summary

Miss C suffered from chronic osteoarthritis (a common form of arthritis that leads to pain, stiffness and swelling of the joints) in both of her hips and asked her GP to refer her to a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system) to be considered for hip replacement surgery. The consultant advised that they would not consider Miss C for surgery until her Body Mass Index (BMI, a measure for estimating human body fat) was reduced to an appropriate level. Miss C complained to the board that the consultant wrongly focused solely on her BMI and did not properly examine her or discuss her pain and mobility issues. Miss C requested a private referral for surgery from her GP and underwent hip replacement surgery on both of her hips.

The board explained that the consultant did not physically examine Miss C as there was no clinical reason to do so and that there are considerable risks and increased complication in patients who undergo surgery with a BMI greater than 40. Therefore, surgery is not recommended.

We took independent advice from an orthopaedic surgeon. We found that the board's approach to dealing with referrals of patients with a high BMI for hip replacement surgery was not sufficiently supported by the available guidance and it did not allow for individualised treatment. We also found that the board failed to carry out a thorough clinical assessment and that their reason for not offering Miss C a second opinion was not in line with the relevant guidance. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to carry out her hip replacement surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Reimburse Miss C for the cost of her first private hip replacement surgery on receipt of proof of the cost. The payment should be made by the date indicated. If payment is not made by that date, interest should be paid at the standard rate of interest applied by the courts from that date to the date of payment.

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

• The board should ensure that their approach in dealing with referrals of patients with a high BMI is flexible, in line with available guidance and adopts a holistic approach when deciding whether to carry out surgery.
• The board should ensure that patients with a high BMI who are seeking surgery are fully assessed.
• The board should remind staff of the General Medical Council guidance on consent and emphasise that the offer of a second opinion should not be limited to those occasions when the doctor is considering to offer treatment that they would not ordinarily do so.
• The board should ensure GP practices within their area are aware that patients can be re-referred if there is deterioration in their condition.

Summary

Mr C complained about the overall care and treatment given to his late father (Mr A) while he was a patient in Borders General Hospital.

Mr A was elderly and had a history of acute kidney injury and fluid overload. He was admitted to hospital with gastroenteritis (inflammation of the lining of the stomach). During his stay, clinicians experienced difficulty in getting his fluid balance right between heart failure and fluid overload, and his poor kidney function and fluid intake. When he was considered fit, Mr A was discharged home; however, he was admitted to hospital again the next day. After his second admission he was discharged home, and while the high risks of this were discussed, Mr A was keen to go home. He returned home but again required to be hospitalised the next day with increasing confusion and shortage of breath. Mr A's condition continued to deteriorate and a few days later he died. Mr C was unhappy with the medical and nursing care. He said that Mr A's condition was often unkempt and he had pressure ulcers.

We found that Mr A's medical care and treatment had been reasonable and given appropriately in response to his presenting symptoms. Both times he had been discharged, he was fit. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to nursing care, we found that Mr A's nursing notes were not of the required standard. Similarly, relevant standards in relation to the prevention and management of pressure ulcers were not followed by nursing staff. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to deliver Healthcare Improvement Scotland standards appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

• Nursing staff should be fully aware of, and apply, Healthcare Improvement Scotland standards for care of older people in hospital 2015.
• Nursing staff should be fully aware of, and apply, Healthcare Improvement Scotland standards for the prevention and management of pressure ulcers 2016.

When it was originally published on 19 June 2019, this case wrongly referred to Health Improvement Scotland. The correct name is Healthcare Improvement Scotland.

Summary

Mrs C complained about the board's handling of two extra contract referrals for out-of-area treatment for her ongoing health problems. Mrs C said that after her first referral to the extra contract referrals panel was granted, the board failed to offer any practical or financial assistance to make the trip to a hospital in England for treatment.

We found that there was no information on how the panel reached their decision on Mrs C's first extra contract referral, and key sections of the panel decision form were left blank or appeared to contain incorrect information. It was unclear what the panel took or did not take into account when making their decision not to support Mrs C with travel/accommodation costs, and there was some uncertainty in relation to the conditions of funding and whether the panel were approving an overnight stay as part of the request. We also found that there was no mention in the panel's decision letter of a patient's right of appeal regarding the extra contractual referral panel decision process. Therefore, we upheld this part of the complaint.

Mrs C also complained that the board unreasonably failed to deal with her complaint about the handling of the two extra contract referrals in accordance with their complaints procedure. We found that the board's handling of Mrs C's complaint was appropriate and we did not uphold this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to handle her first Extra Contractual Referral appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• The board should consider any application received from Mrs C now for travel and an overnight stay, taking into account any relevant policies such as their Travel Expenses Protocol.

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

• Decisions by the Extra Contractual Referral panel should be appropriately documented and relevant sections of the Panel Decision Form completed, making it clear what was taken into account when reaching their decision, including any consideration of their Travel Protocol, where appropriate.
• Notification of the Extra Contractual Referral panel's decision should include the right of appeal regarding the panel's decision process, in accordance with the Protocol.

Summary

Mrs C's mother (Mrs A) was transferred to hospital by ambulance with low oxygen levels. Mrs C had a power of attorney (POA) in place, enabling her to make decisions on Mrs A's behalf. Mrs A was admitted to hospital and the following day medical professionals spoke with her regarding a 'do not attempt cardiopulmonary resuscitation' (DNACPR) agreement, without first consulting Mrs C. Mrs C complained to the board that it was inappropriate for medical professionals to speak with Mrs A regarding the DNACPR as she had dementia and did not understand what was being said. Mrs C also complained about the lack of knowledge of the POA that was in place. In their response, the board explained that it was a priority to complete a DNACPR given Mrs A's deteriorating condition, and it was appropriate in the circumstances to discuss this with her. The board said that they were aware of the POA and this was appropriately recorded in Mrs A's medical records.

Mrs C complained that the board's actions in implementing a DNACPR were unreasonable, that they unreasonably failed to clearly record in Mrs A's records that a POA was in place and that the handling of the complaint was unreasonable.

We took advice from an independent medical adviser. With respect to the actions in implementing the DNACPR, we found that given Mrs A's state of health on admission to hospital, it was appropriate for medical professionals to consider a DNACPR and discuss this with Mrs A. Whilst there were concerns about Mrs A's capacity, the records indicated that this was considered by medical professionals. It was reasonable for medical staff to decide DNACPR was required and that Mrs A had capacity at the time to be involved in the discussions. We did not uphold this complaint.

With respect to the complaint that the POA was not clearly recorded in the file, we found that at the time of Mrs C's complaint, the board were unable to locate a copy of the POA on file. Whilst the medical notes showed the medical professionals were aware of the POA in place, there was not a record kept on file at all times. On this basis, we concluded that the board failed to clearly record in the file that an active POA was in place. We upheld this complaint.

In relation to Mrs C's complaint, we found that the board failed to respond to the complaint within the 20 working day time-frame and failed to provide any explanation for the delay. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to keep her updated on the progress of her complaint, the delay in completing the investigation or to provide a revised timescale for response. 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 the board have been provided with a physical copy of a POA document, a copy should be kept in the relevant patient's medical records, in a prominent position, at all times.

In relation to complaints handling, we recommended:

• Complaints handling staff should be aware of the requirements of the Complaints Handling Procedure with respect to timescales for response and keeping complainants informed about their complaint.

Summary

Mr C complained about the treatment his wife (Mrs A) received from the board for breast cancer. Mrs A attended University Hospital Crosshouse where she was diagnosed with breast cancer and underwent chemotherapy (a treatment where medicine is used to kill cancerous cells), surgery and radiotherapy (a treatment using high-energy radiation). Mrs A was later diagnosed with metastatic breast cancer (cancer that spreads to other parts of the body) and died. Mr C complained that Mrs A did not receive appropriate treatment, that an alternative surgery would have provided a better outcome and that the treatment provided was experimental.

We took independent advice from a consultant clinical oncologist (cancer specialist). We found that Mrs A's treatment by the board was reasonable and found no failings in the treatment offered. Therefore, we did not uphold Mr C's complaint.

However, during the consideration of the complaint we found there were factual errors in the board's complaint response. We made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the errors identified in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mrs C complained on behalf of her daughter (Miss A) about the care and treatment she received for ongoing ear problems. Miss A had received care and treatment at Crosshouse Hospital over a number of years. Mrs C complained about information that was shared with her about Miss A at an Ear Nose and Throat (ENT) clinic consultation, specifically that Miss A might be putting fake blood in her ear; the decision to cancel another opinion; and the decision to discharge Miss A from the ENT service and refer her to mental health services. Mrs C also complained about the length of time it took the board to respond to her complaint.

We took independent advice from a consultant ENT surgeon. We considered that it was reasonable to consider the possibility of a psychological factor, cancel the third opinion, and refer Miss A to mental health services, on the basis that extensive investigations and treatments had not identified a physiological disorder. We also noted that Miss A had not been discharged from the ENT service but had been referred to mental health services. However, we found that there was no definitive evidence to clearly show that a fluid sample taken was in fact fake blood. In addition, we considered that the way in which the matter was approached with the family could have been more appropriately dealt with by mental health staff or at the very least their opinion should have been sought in the first instance. We considered that elements of Miss A's care and treatment were not handled reasonably and we upheld this aspect of Mrs C's complaint.

In relation to complaint handling, we found that the board had not responded to Mrs C's complaints correspondence within the 20 working day timescale. Mrs C was advised on two occasions that this may not be possible. We considered that this was reasonable given the board would have needed to review a number of years of care and treatment. However, we were critical that there were many occasions where Mrs C had to contact the board for updates after the 20 working day timescale had passed. On a number of occasions, the board did not proactively update Mrs C, as they should have done, with an expected timescale for the completion of their investigation. In addition, when they had suggested a revised timescale, this was not met. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A and the family for matters related to the fluid sample. 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 obtain speciality advice where appropriate and ensure that accurate information is shared with patients and their families.

In relation to complaints handling, we recommended:

• The board should have in place the necessary systems to ensure that complaints are handled in line with the NHS Scotland Model Complaints Handling Procedure, and that all staff responsible for dealing with complaints are aware of their responsibilities in this respect.