Health

Summary

Mrs C complained that the board unreasonably failed to make appropriate arrangements to deliver her baby by cesarean section (c-section) in line with her birth plan. Mrs C's waters broke two days before she was due to have her c- section at Wishaw General Hospital and she contacted the hospital for advice. Mrs C was told to return that evening and confirmed she still wished to have a c- section. After her arrival at hospital, Mrs C waited almost three hours before being clinically assessed. By the time she was examined she was 8cm dilated, and although staff started to prepare her for a c-section there was no theatre available and she progressed through labour, with her child eventually being delivered by forceps.

The board said that the department had been particularly busy, and that they had prioritised patients according to clinical need. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that there was no medical need to open a second theatre and that Mrs C and her baby has been appropriately monitored throughout the labour. However, Mrs C was on the 'red pathway' for her maternity care which highlights significant/obstetric risks and we found that there had been a delay in assessing her after her arrival at hospital. We considered that Mrs C should not have been left without adequate triage on her arrival at hospital. We upheld this aspect of Mrs C's complaint. However, we noted that the outcome may not have been different even if Mrs C had been examined sooner.

Mrs C also complained that the board's handling of her complaint was unreasonable. When Mrs C first raised her concerns with the board, she was offered a meeting with the consultant whose care she was under. At the end of the meeting the consultant suggested that Mrs C prepare a note setting out her account of what had happened. Mrs C understood she was making a formal complaint, but the consultant had actually asked for the account so that the Obstetric Risk Management Group could consider if a review of the case was required and identify any areas for learning. The misunderstanding came to light several months later, at which stage Mrs C was appropriately directed to the complaints process. Although we considered that the consultant had been acting in good faith, we were critical of the board's failure to identify Mrs C's concerns as a formal complaint. 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 delay in assessing her. The apology should recognise the impact of her birth experience on her daily life.
• Apologise to Mrs C for failing to identify her concerns about her treatment as a formal complaint. The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• Relevant staff should take a pro-active approach to triage, ensuring clinical questions are asked and documented.

In relation to complaints handling, we recommended:

• Staff should be confident in recognising complaints. In cases where there is any lack of clarity over whether concerns should be treated as a formal complaint, steps should be taken to ascertain and clearly record the wishes of the patient.

Summary

Mrs C complained about the medical and nursing care and treatment her late mother (Mrs A) received when she was admitted to Lorn and Islands Hospital. She also complained about the communication with her family and that the board had failed to handle her complaint in a reasonable way.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that it was difficult to provide an overall view about the medical care and treatment given to Mrs A due to the length and complexity of her admission. However, we found there had been a delay in diagnosing Mrs A's delirium and that she had a urine infection. We also found that the death certificate process was handled insensitively. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care given to Mrs A, we found no failings on the part of nursing staff regarding Mrs A's dehydration, dietary intake and her personal care. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to communication, we found that the nursing communication was reasonable. However, we found that there was a delay in medical staff communicating the results of a CT scan and the overall assessment of Mrs A's health to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint.

Finally, in relation to complaint handling, we found that the board had failed to comply with their complaints handling procedure and 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 failings in clinical care, communication and 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:

• Staff should be aware of the potential for elderly patients to have delirium. Staff should be careful and sensitive with the death certification process and junior doctors should have senior supervision of this process as set out in national guidance.
• Families or carers should be involved in identifying delirium. Results of CT scans and the overall assessment of a patient's health should be communicated timeously to families.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints handling process.

Summary

Mr C complained on behalf of his mother-in-law (Mrs B) about the care and treatment provided to her husband (Mr A) at Raigmore Hospital. Mr C complained that the board failed to manage Mr A's falls risk appropriately and failed to provide a reasonable standard of oral and nutritional care to Mr A.

We took independent advice from a nursing adviser. We found that Mr A sustained seven falls during his admission, with the last fall resulting in him suffering a serious injury. The board had apologised for this and the lack of communication by their nursing team on some occasions, and we acknowledged the action that the board said they had taken to address this. However, we found that there were additional failings and an unreasonable level of care provided to Mr A not identified by the board. We noted that there appeared to have been a lack of action and a failure in record-keeping in relation to the management of Mr  A's falls risk. We considered that the supervision provided was unreasonable and highlighted that there was no person-centred care plan provided to record the management of Mr A's falls risk and interventions in place to reduce the risk of falls, or the level of observation he required. In addition, communication with Mr A's family was unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

In relation to Mr A's oral and nutritional care, the board accepted that this was not of an acceptable standard and apologised. We found that there were shortcomings in the assessment and management of Mr A's nutritional needs and in record-keeping. Although staff made urgent referrals to the dietician, Mr A did not appear to have been treated as a priority. We also found no evidence that Mr A's oral care needs were met. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B and her family for the unreasonable level of care provided to Mr A in relation to falls sustained by Mr A, his nutritional and oral care, record-keeping and communication with Mrs B and her family. 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 at high risk of falls should have their falls risk appropriately managed.
• Nursing records should be maintained in accordance with the nursing and midwifery code of practice.
• Patients should have their nutritional and oral care appropriately assessed and managed.
• There should be adequate communication with a patient's family and this should be appropriately documented.

Summary

Mr C complained that the practice failed to contact him to arrange a blood test. Mr C's GP had referred him to the plastic surgery department who wrote back to the practice to request blood tests. The practice failed to contact Mr C to arrange the blood tests and he complained that this caused a delay in him receiving further treatment. Mr C also complained that the practice's handling of his complaint was unreasonable.

We took independent advice from a GP. We found that the practice failed to contact Mr C to arrange the blood tests and upheld this aspect of his complaint. However, we noted that this failing was likely an administrative oversight and was not due to a lack of clinical skill. The practice acknowledged this failing and apologised.

In relation to complaint handling, we found that the practice referred Mr C to our office appropriately and responded within the required timescales. Therefore, we did not uphold this aspect of Mr C's complaint.

Summary

Mr C complained about the treatment he received at Glasgow Royal Infirmary. He had attended as a day case for an Endoscopic Ultrasound Scan (EUS, a minimally invasive procedure to assess digestive and lung diseases) where a biopsy was taken. On the way home after the procedure Mr C became unwell and was taken to another hospital where he was diagnosed with acute pancreatitis (inflammation of the pancreas). He was admitted for treatment and further deteriorated, and it was found he had ruptured his spleen which then had to be removed. Mr C felt that the EUS had not been carried out appropriately and that it had caused his health problems.

We took independent medical advice from a consultant surgeon. We found that the EUS had been performed appropriately but unfortunately Mr C had developed pancreatitis which is a rare but recognised complication of the procedure and there was no evidence of any failings during the procedure. Similarly, Mr C then developed a further rare complication of pancreatitis where his spleen ruptured which is usually as a result of infection or severe inflammation. We did not uphold the complaint.

Summary

Ms C complained about the care and treatment she received from the practice regarding a flu vaccination and that the practice did not provide her with an appointment when she called them. Ms C was subsequently diagnosed with Idiopathic Thrombocytopenic Purpura (ITP, a disorder that can lead to easy or excessive bruising and bleeding. The bleeding results from unusually low levels of platelets (the cells that help blood clot)) which she considered was linked to the flu vaccination she received.

We took independent advice from a GP. We found that the care and treatment Ms C received was reasonable and that she was not informed about the risk of ITP because it is not a recognised side effect of the flu vaccination.

We also found that there was no record of Ms C's call to the practice to book an appointment. We considered that it was reasonable that there was no record of this call in Ms C's medical record. In the circumstances we did not have sufficient evidence to determine whether Ms C should have been offered an appointment or that the care provided by the GP Practice was unreasonable.

We did not uphold Ms C's complaints.

Summary

Ms C complained about the care and treatment she received at the GP out-of-hours service at Gartnavel General Hospital when she attended with a rash and bruising on her legs. We took independent advice from a GP. We found that the examination carried out within the out-of-hours service was reasonable and it was reasonable that Ms C was referred to the Immediate Assessment Unit (IAU) rather than A&E. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the care and treatment she received within the IAU at Queen Elizabeth University Hospital. We took independent advice from a consultant in acute medicine. While most of the care and treatment that Ms C received was appropriate, we found that it was unreasonable that Ms C was not assessed for signs of bleeding when an initial low platelet (cells that help blood clot) result became available. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to carry out an assessment for signs of bleeding when the initial low platelet result became available. 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 with a low platelet count should be assessed for signs of bleeding.

Summary

Mrs C complained that the practice failed to provide her late aunt (Ms A) with appropriate care and treatment. Ms A visited the practice on three occasions and was later admitted to hospital where she was diagnosed with septicaemia (blood poisoning), multi-organ failure and metastatic gastric (stomach) cancer. Mrs C complained that the practice failed to reasonably investigate Ms A's symptoms. Mrs C also complained that the practice failed to respond to her complaint in a reasonable way.

The practice acknowledged that there were shortcomings in record-keeping and checking observations. The practice apologised and took action to address these issues.

We took independent advice from an adviser in general practice medicine. We found that the investigation and treatment decisions provided to Ms A at each of the three consultations were of a reasonable standard and that an emergency admission to hospital by ambulance was not required given the circumstances. We considered that the standard of medical care and treatment provided to Ms A was reasonable. We also found that the practice responded to Mrs C's complaint in a reasonable way. Therefore, we did not uphold Mrs C's complaints.

Summary

Ms C complained about the care and treatment provided to her late husband (Mr  A) by the board in relation to treatment of his cancer. Ms C raised concerns that after a scan which showed progression of Mr A's cancer, neither the radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) nor oncologist (a doctor who specialises in the treatment and management of cancer) involved in his care contacted him to discuss this with him. Ms C said that Mr A did not discover that his cancer had progressed until he contacted his GP several month later. Ms C also complained that when Mr A was having palliative chemotherapy (a treatment for terminal cancer to prolong survival and minimise suffering, but which cannot cure the disease) the oncologist failed to identify or investigate his low haemoglobin (a protein in the blood that carries oxygen).

We took independent advice from a consultant oncologist. We found that it was reasonable that Mr A's low haemoglobin was not identified as he had not been reporting unusual symptoms. However, we found that the failure to contact Mr A to discuss his scan results was unreasonable. We determined that this was due to a miscommunication between the oncologist and radiologist and that the radiologist had changed their practices as a result of this complaint. However, we upheld Ms C's complaint and made a further recommendation to the board regarding this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the breakdown in communication which resulted in neither the oncologist nor radiologist contacting Mr A to discuss the scan results. 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:

• When two or more specialists are involved in a patient's care, it should be clear who is going to contact them to discuss their ongoing treatment, and this contact should be made in a timely manner.

Summary

Ms C, a support and advocacy worker, complained on behalf of her client (Ms A) about the care and treatment Ms A received at Queen Elizabeth University Hospital following an operation. Ms A also considered that she had not received a transparent account of events of her post-operative care.

We took independent advice from a nurse. We found that Ms A had issues with urine retention after surgery. Ms A reported not feeling well and this was responded to by nursing staff; however, no attempt was made to catheterise (a  process that involves inserting a tube to the patient's urethra to allow urine to drain freely from the bladder for collection) Ms A, prompt her to self-catheterise or to take a bladder scan. We also noted there were inadequate records of Ms A's fluid balance.

Ms A also had issues with the surgical stockings she was required to wear after her operation, as she found these to be too tight. We noted that according to the Scottish Intercollegiate Guidelines Network (SIGN) guideline 122 a lack of mobility after surgery put a patient at risk of venous thromboembolism (a blood clot that starts in a vein) and devices such as surgical stockings should be worn unless there are specific reasons why these should not be used. We noted that there was no record of an assessment being carried out and we considered this should have been documented. However, as there was no evidence in the notes to raise concerns about the fit of the stockings, it was reasonable that these were worn.

In relation to the board's response to Ms A's complaint, we found that the board did not provide a full, objective and proportionate response.

We upheld both of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to perform a bladder scan and/or prompt Ms A to self-catheterise, failing to keep adequate records and for failing to provide Ms A with a full and objective response to her complaint. The apology should meet the standards set out in theSPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Nurses should have clear guidelines to ensure a consistent approach to the indicators patients should achieve during an assessment period or a trial of voiding post catheter removal.
• Assessment of the suitability of surgical socks recorded prior to application and regular review of these should be documented as part of ongoing care planning.

In relation to complaints handling, we recommended:

• The board should follow their complaints handling procedure and issue appropriate responses.