Health

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) had received in Raigmore Hospital before her death. Mrs A had been referred to the hospital by her GP. The referral letter said she had fallen at home and referred to acute kidney injury. Mrs A fell on two occasions after being admitted to hospital. It was then identified nearly three weeks later that she had fractured her hip. Mrs A later died in the hospital.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the care and treatment provided to Mrs A in relation to her kidney function was reasonable and appropriate. In addition, she had not displayed sufficient pain or deformity that meant a hip fracture should have been considered. However, the nursing records indicated that Mrs A was at risk of falling, but there was inadequate information about what action would be taken to prevent any falls. We found that it was reasonable for staff to try to reduce Mrs A's agitation after her first fall by allowing her to walk with a member of staff, but it would have been more appropriate to have had two members of staff with her. Staff should also have told the family about the first fall when they contacted them about the second fall.

In view of these failings, we upheld Mrs C's complaint, although we noted that the board had already apologised to Mrs C and had taken a number of actions to try to prevent similar failings in the future.

Recommendations

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

• Nursing staff should ensure that the relevant nursing documentation is completed appropriately.

Summary

Mrs C complained about the standard of aftercare she received at Raigmore Hospital following hip surgery, both in terms of the orthopaedic care (treatment of diseases and injuries of the musculoskeletal system) and physiotherapy care (treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise). Mrs C said that her thigh should have been physically examined by the surgeon as she found out later that she had weakness in her thigh muscle and that physiotherapy staff did not provide treatment at two appointments she attended.

We took independent advice from a consultant orthopaedic surgeon and a physiotherapist. In terms of the orthopaedic care, we found that an x-ray was appropriately carried out which confirmed Mrs C's fracture was healing. We considered that there was no requirement to perform a physical examination of Mrs C's thigh and it would be accepted that she would have weakness with this type of injury and associated surgery. We noted that Mrs C also received support by way of a referral to the hip fracture service.

In terms of the physiotherapy care, we established that no specific referral had been made to the service in relation to Mrs C's hip. We considered that appropriate treatment was provided in response to the GP referral for carpal tunnel (a medical condition where there is pressure on a nerve in the wrist). Furthermore, reasonable action was taken by physiotherapy staff to refer Mrs C to the orthotic clinic (the branch of medicine that deals with the provision and use of artificial devices such as splints and braces) regarding her leg length discrepancy following hip surgery. We concluded that the aftercare was of a reasonable standard and did not uphold Mrs C's complaint.

Summary

Ms C, an MSP, complained on behalf of her constituent (Mr B). Mr B had concerns that his late mother (Mrs A) who suffered from COPD (a chronic inflammatory lung disease) had been discharged from Vale Of Leven Hospital. Mrs A was readmitted to hospital the day following discharge with pneumonia and died a few days later. Mr B felt that Mrs A should not have been discharged from hospital while she still had an infection.

We took independent advice from a consultant physician. We found that Mrs A was prone to suffering chest infections in view of her COPD. Prior to the hospital discharge there was evidence that Mrs A's health had improved and that there was no clinical need for her to remain in hospital. Arrangements were made for an appropriate care package to be in place at home and Mrs A was in agreement with this. Mrs A then quickly went on to develop a new infection, which could not be predicted, and she did not recover from it during her readmission to hospital. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment provided by the practice for his skin issues, sinus issues and headaches.

We took independent advice from a GP. We found that there was no evidence of any delay in Mr C being referred to the Plastic Surgery Unit at the board for his skin issues and that the care and prescriptions Mr C received for his sinus symptoms were reasonable. Mr C's symptoms were consistent with a working diagnosis of allergic rhinitis. There is no evidence of any delay in the treatment Mr C received or the management of his sinus symptoms. We found the assessment and management of Mr C's headache symptoms was reasonable. We did not uphold the complaint.

Summary

Mr C complained that the board unreasonably cancelled his nose operation and did not provide a reasonable explanation as to why. Mr C suffers from allergic rhinitis (inflammation of the inside of the nose caused by an allergen). Mr C said that the other treatments offered were not taken forward.

We took independent medical advice from an ear, nose and throat surgeon. We found that Mr C's treatment by the board was reasonable and found no failings in the treatment offered. Mr C was referred for alternative treatments as had been agreed with the surgeon. The proposed operation could have provided some limited benefit to Mr C, although it would have not stopped him requiring long- term medication to manage his allergic rhinitis. Therefore, we did not uphold Mr  C's complaint.

Summary

Mr C, an MP, complained on behalf of his constituent (Ms A) that her medical practice failed unreasonably to refer her to community mental health care services, and later dealt unreasonably with her complaint about this.

Ms A believed that her GP treated her differently after incorrect information was sent to the medical practice by a clinician. While the information was corrected and apologies were made, Ms A said that it had negatively effected her mental health. While Ms A said she requested on many occasions to be referred to a community mental health care service, she was not referred.

We took independent advice from a GP . We found that the advice given to Ms A had been reasonable and signposting to community mental health support services was appropriate in the circumstances.

Ms A also complained that a member of staff had unreasonably been involved in the complaints process. We found no evidence of this . The complaints were not upheld.

Summary

Ms C raised concern about a number of issues in relation to the Child and Adolescent Mental Health Service (the service) provided to her child (Child A) by the board. We took independent advice from a consultant child and adolescent psychiatrist (medical practitioner who specialises in the diagnosis and treatment of mental illness) and a registered mental nurse in a child and adolescent mental health service.

Ms C complained about the assessment and care provided to Child A and the way staff behaved to them both. We did not find evidence that staff within the service behaved inappropriately towards Ms C or Child A. We concluded that the assessment and intervention provided to Child A by the service was reasonable. We did not uphold this complaint.

Ms C also complained that the service failed to manage the sharing of confidential information appropriately. The board apologised to Ms C for failings in taking and recording consent for information sharing with the local authority and agreed to take action for learning and improvement. We identified a further instance where information was shared with the local authority without consent. We upheld this complaint and made recommendations in light of our findings.

Ms C was unhappy with the way that the board investigated her complaints and she raised concern that the investigating officer was not sufficiently independent. We did not find evidence that might indicate bias or partiality on the part of the investigating officer. However, we noted that the board reported inconsistent findings between two complaint responses. We felt that the board's failure to 'get it right first time' prolonged the complaints process. We upheld this complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Child A for sharing information with the Social Work Service without appropriate consent; and reporting inconsistent findings between the complaint responses. 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:

• Patient confidentiality should be maintained in line with Data Protection legislation. Where information is shared, this should be documented.

In relation to complaints handling, we recommended:

• An investigation should establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response that represents your final position. The investigation should 'get it right first time'.

Summary

Mrs C complained about the care and treatment her husband (Mr A) received at Inverclyde Royal Hospital and Royal Alexandra Hospital. Mr A was admitted with suspected empyema (pockets of infected fluid in the chest) and sepsis (a severe complication of infection). However, he was later found to have widespread cancer. After his discharge home, Mr A's condition worsened very quickly and he died the following week.

Mrs C complained that the board failed to provide Mr A with reasonable clinical care and treatment for his infection and/or sepsis. We took independent advice from a consultant respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs). We found that as Mr A was suspected to have empyema, there was a significant delay in carrying out his pleural tap (where a small needle or thin tube is used to remove excess fluid from around the lungs). This delay had been identified and acknowledged by the board. We upheld this aspect of Mrs C's complaint and made further recommendations in relation to this.

Mrs C also complained that the board failed to provide Mr A with reasonable nursing care in relation to pain management and nutrition. We took independent nursing advice. We did not find evidence of failings in how Mr A's pain was managed. However, we found that there was an unreasonable delay in carrying out Mr A's nutritional assessment and failings in how his fluid balance was recorded. We upheld this aspect of Mrs C's complaint.

Mrs C raised concerns about the board's communication with Mr A's family, in particular about his diagnosis of cancer. As the board acknowledged inadequacies in how the diagnosis was communicated, we upheld this aspect of the complaint. However, we found that the board had already taken appropriate action to address this and made no further recommendations.

Mrs C also complained that the board unreasonably discharged Mr A home and without a suitable care package in place. We found it was reasonable Mr A was discharged home. However, we found that the board should have offered Mr A support at home given his diagnosis of widespread cancer. Therefore, we upheld this aspect of the complaint. We found that the board had appropriately apologised to Mrs C for this but we made a recommendation for further action.

Mrs C also raised concern that the board failed to send Mr A's medical records to another health board. The board accepted the medical records should have been sent and we upheld this aspect of the complaint. We found that the board had taken action to address this and made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in aspects of Mr A's nursing care. 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 suspected to have an empyema should receive timely pleural fluid sampling to clarify their diagnosis.
• Fluid balance charts should be completed fully for all patients, including those who are independent, or the reason why it is considered unnecessary should be clearly recorded.
• Patients diagnosed with cancer should be offered support from a specialist cancer nurse and/or community services.
• When a patient is discharged with cancer that cannot be treated, their GP should be informed so they can provide and/or arrange appropriate support.
• Patients should have a MUST (Malnutrition Screening Tool) assessment within 24 hours of their admission to hospital.

Summary

Miss C complained about the care and treatment she received at the Royal Alexandra Hospital. Miss C complained that staff failed to recognise that her waters had broken, that she was not allowed an epidural (anaesthetic introduced into the space around the spinal cord to produce loss of sensation below the waist) and that she was advised that she was not allowed gas and air as it was not available.

We took independent medical advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a midwife. We found no evidence in the records of Miss C's water breaking. However, we considered that the management of Miss C's analgesia (pain relief) as she awaited transfer to the obstetric unit for epidural was unreasonable as she should have been offered pain relief such as gas and air, further oral analgesia or injections of opiate analgesia. Therefore, we upheld this aspect of Miss C's complaint.

Miss C also complained that her baby (Baby A) was not fed or put in a nappy after delivery, did not go to special care and nobody checked on them when she was still in theatre. We found that appropriate steps were taken by the board to ensure that Baby A was cared for. Due to an emergency situation with Miss C, and as findings of Baby A's examination were normal, we found that it was reasonable for Baby A to be left with a family member. We also found that the delay in transferring Baby A to special care was not unreasonable, given that Miss C's care was the priority post-delivery. Therefore, we did not uphold this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failing in the provision of pain relief. 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:

• Appropriate pain relief should be provided to patients awaiting transfer to the obstetric unit for epidural.

Summary

Ms C complained about the care and treatment her late brother (Mr A) received at Glasgow Royal Infirmary. Mr A had previously suffered a brain injury and required to be managed under the Adults with Incapacity Act 2000. Mr A had difficulty swallowing and was considered unsafe for all food by mouth. Although Mr A required to undergo a number of investigative procedures, these could not be carried out due to his reluctance. Mr A also fell twice and after Ms C raised concerns with staff, he was later found to have broken his hip for which he required surgery. Before this could be carried out, Mr A suffered a heart attack and died a few days afterwards. Ms C complained that the gastroenterology (digestive system), nursing, orthopaedic (musculoskeletal system) and cardiology (heart and circulatory system) care and treatment Mr A received was unreasonable.

We took independent advice from consultants in acute care, orthopaedics and cardiology and from a registered nurse. We found that the team looking after Mr A struggled to balance the need to perform interventions with a desire not to treat him forcibly or against his will. We considered that the gastroenterology care Mr A received was reasonable. Mr A's cardiology treatment was also found to be reasonable. Therefore, we did not uphold these aspects of Ms C's complaint.

In relation to Mr A's nursing care, we found that he was not properly supervised and a number of nursing procedures were not correctly followed or recorded. In particular, despite being unsteady on his feet, he was sent for x-ray unsupervised and he fell. This incident was not recorded or followed-up as it should have been. After this fall, we found that the orthopaedic care was poor and there was a delay in planning the surgery required which was contrary to national guidelines. We considered the nursing care and orthopaedic care to be unreasonable and, therefore, we upheld these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to properly follow procedures, to keep full records and notes and for the delay in proposed surgery. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• All nursing records should be completed as appropriate in accordance with the requirements of the Nursing and Midwifery Council.
• Patients should undergo surgical intervention within 48 hours in line with national guidelines.