Health

Summary

Mrs C complained to us that she had unreasonably been removed from the ear, nose and throat in-patient waiting list because she had cancelled three planned admissions. Mrs C felt that the board had not listened to her reasons for the cancellations as some were outwith her control.

We took independent advice and considered the guidance around removing patients from the in-patient waiting lists. We found that from a clinical perspective, there was no life-threatening reason for Mrs C to have remained on the waiting list and from a procedural aspect, staff had followed the guidance on removing a patient from the waiting list after three cancelled appointments. We did not uphold the complaint. However, we established that Mrs C had been reinstated to the waiting list and would be offered one further appointment.

Summary

Mr C complained about the treatment he received when he attended an out-of-hours service (OOHS) GP at Peterhead Hospital. Mr C said that he had collapsed at home and was taken to the OOHS where the GP performed a cursory examination and sent Mr C home. Mr C was subsequently admitted to hospital the following day and treated as an in-patient for a week.

We took independent clinical advice from an GP. We found that the OOHS GP had carried out an appropriate examination after taking into account a report from the paramedic who brought Mr C into the OOHS along with a history provided by Mr C. It was reasonable to have reached a diagnosis that Mr C had taken a reaction to the medication which had previously been prescribed by his GP and that there was no clinical indication for a hospital admission at that time. The OOHS GP could not have predicted that Mr C would then go on to develop a chest infection. We did not uphold the complaint.

Summary

Ms C, an advocate, complained on behalf of her client (Mr A) about the care and treatment he received following a referral to the board's musculoskeletal (MSK) hub (a specialist physiotherapy service) and following his referral to neurosurgery (branch of medicine concerned with the brain and other nerve tissue). Mr A was experiencing shooting pains down his legs.

We took independent advice from a specialist musculoskeletal physiotherapist and a consultant neurosurgeon. We found that it was reasonable for a physiotherapist to assess Mr A initially and then refer him directly to the MSK hub when there was no improvement in his condition. We also found that the MSK hub appropriately assessed Mr A in accordance with relevant guidelines and referred Mr A for an MRI scan at the appropriate time.

We found that it was reasonable for neurosurgery to send Mr A back to the MSK hub because a further period of conservative management of his symptoms might have been successful and might have avoided the need for an operation. We did not uphold Ms C's complaints.

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.