Health

Summary

Mrs C complained about the treatment she received from the practice for an infection in her leg. Mrs C attended an out-of-hours surgery over the weekend prior to attending her local practice on the Monday. The practice adjusted Mrs C's medications and arranged a follow-up appointment with a nurse for wound dressing. Mrs C's leg grew worse and a GP was called to her home. The GP arranged for Mrs C's admission and further assessment at a hospital.

We took independent medical advice from a GP. We found that Mrs C's treatment by the practice was reasonable and found no failings in the treatment offered. Therefore, we did not uphold Mrs C's complaint.

Summary

Mr C complained about the care and treatment he received at the Royal Infirmary of Edinburgh. He attended A&E after experiencing pain in his back and leg. Mr C was assessed by the on-call orthopaedic (conditions involving the muscoskeletal system) doctor and an x-ray was performed. Following this, Mr C was admitted to an orthopaedic ward. He was then discharged four days following admission. Weeks later, Mr C returned to hospital and a hip x-ray was performed. Investigations over the following days identified that Mr C had a pathological hip fracture and advanced prostate cancer. Mr C underwent a hip replacement procedure and was referred to the uro-oncology (the diagnosis and treatments of tumors of urinary systems) service.

Mr C complained about the delay in accurately diagnosing his condition and that he was unreasonably discharged from hospital during the first admission. We took independent advice from a consultant orthopaedic surgeon. We were critical that the board were unable to provide the in-patient orthopaedic notes for Mr C's first admission, other than the summary of ward rounds.

We found that the investigations performed following Mr C's initial presentation to the board were inadequate. We found that a hip examination and hip x-ray should have been performed given the examination findings. We considered it was likely that the failings in this case led to a delay for hip replacement surgery, during which time Mr C continued to suffer pain from the condition. We upheld this aspect of Mr C's complaint.

In the absence of the orthopaedic records for the first in-patient admission, we noted that the board were unable to demonstrate that Mr C had been safely discharged. We concluded that the decision to discharge Mr C was unreasonable and we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to examine and investigate Mr C's hip during the admission and for the poor record-keeping. 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:

• An individual with thigh pain and an inability to weight bear should have a hip examination performed. An individual who is unable to do an active straight leg raise and is unable to weight bear should have a hip x-ray performed.
• Ensure clinical records are appropriately managed.

Summary

Mr C complained that the board had not provided him with appropriate care and treatment for pain in his knee and thigh.

We took independant advice from a GP. We found that appropriate investigations had been carried out into both issues, appropriate referrals to other services had been made, and pain had been managed in line with guidance. We did not uphold Mr C's complaint.

Summary

Mrs C attended hospital to undergo colonoscopy (a procedure to look at the lining of the large bowel) and gastroscopy (a procedure to look at the inside of the oesophagus and first part of the small intestine). The information booklet she had been given in advance indicated that she would be sedated. However, Mrs C said she was persuaded to go ahead without sedation which she found extremely painful. She said that she felt traumatised and violated. She complained to the board who said that the matter of sedation had been discussed with her and it was her decision to go ahead without it; staff had no recollection of her complaining of pain.

We took independent advice from a gastroenterologist and from a registered nurse. We found that the procedures concerned were ones where sedation would normally be given as the information booklet indicated. There was no evidence that medical staff had discussed the procedures with Mrs C and the associated consent forms had not been properly completed. Similarly, we found concerns about the nursing records and although at one point Mrs C was recorded as having a pain score of 2-3 (out of 4) she was not monitored or assessed further. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs 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/leaflets-and-guidance.

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

• Medical staff should fully discuss risks and record the risk and benefits of any medical procedures.
• Nursing staff should follow the Nursing and Midwifery Council (NMC) guidelines when completing records.
• Nursing staff should respond appropriately to pain score data.

Summary

Mr C complained about the nursing care and treatment his father (Mr A), who had dementia, received when he was admitted to University Hospital Monklands. He also complained that Mr A had been unfit for discharge on the day of his planned discharge. In addition, Mr C complained about the level of communication with Mr A's family from the board.

We took independent advice from a nursing adviser and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the nursing care Mr A received had been reasonable and we did not uphold this aspect of Mr C's complaint.

Mr A's planned date for discharge was modified due to his deteriorating health. We found that there had been a failure to assess Mr A's mental health and the possible presence for delirium prior to the original date for discharge, and as a result, the consultant geriatrician advised that staff could not be confident, or show, that Mr A had improved to a level where it was safe to consider discharge. We were particulary concerned that a dementia test was not carried out. We found that the board had unreasonably considered Mr A fit for discharge on the date of the planned discharge and upheld this aspect of Mr C's complaint.

In relation to communication, we found that the nursing communication was reasonable but the board had identified some failings. We also found failings in the medical communication in the initial part of Mr A's admission to the hospital. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and the family 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:

• Ensure older people in hospital have their cognitive status assessed and documented. Older people in hospital experiencing an episode of delirium should be assessed, treated, and managed appropriately.

Summary

Mr C complained about the care and treatment his mother (Mrs A) received at Lorn and Islands Hospital. Mrs A initially presented to the emergency department experiencing vomiting. Following assessment, Mrs A received antibiotics and was discharged home. Mrs A returned to the emergency department two days later again with vomiting symptoms. After further assessment was carried out, Mrs A was discharged home. Mrs A attended the hospital again approximately five days later and was admitted to a ward. During the admission, investigations were carried out which indicated that Mrs A had metastatic cancer (cancer that has spread to other parts of the body). Mrs A's condition deteriorated during the admission and she died from her illness. Mr C complained about the care and treatment his mother received as well as the way hospital staff communicated with the family.

We took independent advice from a consultant in general medicine and a registered nurse. We found that Mrs A was unreasonably discharged from the emergency department on two occasions without her symptoms being effectively managed. We also found that an incorrect diagnosis had been reached during the first presentation to the emergency department, whilst the second presentation was poorly documented. We noted that once Mrs A was admitted to the ward, there was an unreasonable delay in obtaining a CT scan (a scan that uses x-rays to create detailed images of the inside of the body) of Mrs A's chest/ abdomen. We upheld this aspect of Mr C's complaint.

In response to Mr C's complaint, the board apologised that inaccurate information was given to family members regarding the length of time to obtain test results. We also found that there was a lack of discussion between nurses, doctors and the family around the possibility of discharging Mrs A home and a lack of clarity with the family about this. We upheld this aspect of Mr C's complaint.

Finally, Mr C was also unhappy with the time that the board took to investigate and respond to his complaint. We found that the delay was unreasonable and we were critical of the board's communication surrounding the delay. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise to Mr C for the unreasonable decisions to discharge Mrs A on two occasions; the incorrect diagnosis of urinary tract infection; poor documentation of Mrs A's second hospital attendance; the unreasonable delay obtaining a chest/ abdomen CT; the lack of local multidisciplinary discussion around the possibility of discharge; and failing to provide a reason for the complaint handling delay and a revised timescale. 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:

• Clinicians should take time to observe whether a patient requiring anti-sickness medication needs this medication to be given from a route other than oral, or needs alternative anti-sickness medication to manage their symptoms.
• A diagnosis of urinary tract infection should be supported by presence of relevant symptoms and appropriate tests.
• Patient records should include documentation of a full assessment by the medical team; details of any subsequent discussions; and plans for follow-up.
• CT imaging should be performed timeously.
• Patients and families should receive realistic estimates for how long it will take for biopsy results to become available.
• Where possible, patients with a life limiting diagnosis and their families should be involved in discussions around their preferred place of end of life care and what would be required to facilitate this.

In relation to complaints handling, we recommended:

• Where the complaint investigation cannot be completed within 20 working days, the person making the complaint should be provided with an explanation for the delay and a revised timetable for the response.

Summary

Ms C complained that her partner (Mr A) had been misdiagnosed with brain cancer.

We took independent advice form a consultant clinical oncologist. We found that it was unreasonable for the board to have given Mr A the wrong information by misdiagnosing him with brain cancer. We accepted that this was likely a mistake or human error as a result of misreading Mr A's scan report. Following the discovery of the error, most of the action taken by the board was reasonable. We noted that the board apologised to Mr A and the consultant involved had reflected on this matter. However, we also found that the board failed to record on Datix (incident reporting system) or another similar reporting system that Mr A had been misdiagnosed with brain metastases. They also failed to carry out a serious adverse event review to consider whether there were any contributory factors that could be mitigated. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately record and carry out an appropriate review to ensure that there were no other contributory factors that could be mitigated. 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:

• Near misses and errors should be reported via Datix or another similar reporting mechanism and, if indicated, a Serious Adverse Event Analysis should be carried out.

Summary

Ms C complained about the care and treatment she received following a total abdominal hysterectomy (surgery to remove the womb). The day after the surgery, Ms C began to feel unwell and experienced severe pain in the lower right-hand side of her abdomen. Ms C requested help from a nurse and was advised that her symptoms could have been wind. Based on this, the nurse gave her some peppermint water. After the pain persisted, Ms C asked to be seen by a doctor. Ms C was given pain relief and monitored throughout the night. The following day, Ms C's haemoglobin level dropped and she required surgery to treat a rectus sheath haematoma (internal bleeding). Ms C felt that the hospital should have identified earlier that she was bleeding internally. She also complained about the nursing care she received while in hospital, especially in relation to one particular nurse who Ms C felt displayed inappropriate attitude and behaviour.

We took independent advice from a consultant gynaecologist and a nurse. We found that it was not unreasonable for the rectus sheath haematoma not to be identified or addressed earlier. We considered that the board's actions, including their post-operative treatment plans for Ms C's care, were reasonable. Therefore, we did not uphold this complaint.

In relation to nursing care, we found that it was not unreasonable for nursing staff to have suggested Ms C's pain was caused by wind and there was nothing in the medical records to suggest nursing staff unreasonably delayed contacting a doctor. We noted that the medical records indicate that there was some conflict or difficulty in the communication between Ms C and nursing staff. However, we did not consider what was recorded in the records to be unreasonable or a cause for concern. We acknowledged that Ms C's account differed from what was recorded in the medical records and that we had no reason to doubt what she had told us. However, we concluded that we would not be able to reach a conclusive view on the interactions between Ms C and the nursing staff, as there was no evidence that the nursing care provided was inappropriate or unreasonable. We did not uphold this complaint.

Summary

Miss C complained about the care and treatment she received from the Princess Royal Maternity Hospital. She raised concerns about the general anaesthetic she was given during her emergency caesarean section, which she said was given the wrong way round and jeopardised her ability to breathe, risking both her and her baby's lives.

We took independent advice from a consultant anaesthetist who covers obstetric (medical specialism for pregnancy and childbirth) theatres as part of their elective and emergency work. We found that the sequence of drug administration in Miss C's case was wrong and could have caused Miss C difficulty breathing, but the awareness of this would have lasted for only a few seconds at most. There was no risk to Miss C's baby from this drug error and the risk to Miss C was limited to the unpleasant experience she suffered, but there would not have been any risk to her life. Given the failing in the administration of the drugs, we upheld this part of Miss C's complaint.

The board acknowledged their failing in this case and took appropriate remedial action on this matter. However, we made one recommendation for further action by the board.

Miss C also complained that she developed a chest infection and contracted Clostridium Difficile (bacteria that can infect the bowel and cause diarrhoea) whilst in hospital. We did not identify any failings by the board in these areas. We did not uphold this part of Miss C's complaint.

Recommendations

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

• Consideration should be given to the supply of pre-filled syringes of suxamethonium, as raised by the board's departmental morbidity and mortality meeting.

Summary

Mr C complained that the board failed to carry out a Significant Clinical Incident (SCI) investigation reasonably. Mr C's late partner (Ms A) underwent a hernia repair operation (an operation to correct a hernia, which is a bulging of internal organs or tissues through the wall that contains them) at a private hospital and later found this surgery had perforated her bowel. This perforation was successfully repaired with further surgery at Glasgow Royal Infirmary, however, Ms A continued to deteriorate and died shortly afterwards. The board carried out a SCI investigation which highlighted a number of failings in Ms A's care and several recommendations were made to improve practice going forwards. Mr C was unhappy with this report and complained to the board. Mr C remained unhappy with their response and brought his complaint to us.

We took independent advice from a consultant surgeon. We found that the scope of the SCI investigation was reasonable and that it had identified many of the issues with Ms A's care. However, there were some areas where the recommendations either did not address, or did not fully address, the failings. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the SCI process did not fully address all the failings in care and treatment provided to Ms 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:

• Emergency transfers from a hospital with no facility to manage full emergency assessment/emergency surgery to a hospital where optimal care can be provided, should be regarded as 'blue light', especially in the presence of sepsis.
• Surgical admissions of this type should be discussed with a more senior clinician (senior trainee or higher) to ensure management and treatments are optimised.
• All emergency cases should be assessed for sepsis on the Sepsis Six pathway and prompt management plans be put in place as necessary, including prompt administration of antibiotics.
• There should be standardisation of communication using an appropriate tool such as SBAR (Situation, Background, Assessment, Recommendation).