Health

Summary

C complained that the board failed to provide C with appropriate treatment for a shoulder fracture. C was admitted to hospital suffering from alcohol related seizures. It became apparent that C had also suffered a shoulder fracture. C was discharged 12 days later with an orthopaedic referral (specialists in the treatment of diseases and injuries of the musculoskeletal system) for the following week. C was then scheduled for surgery to realign the fracture. This was subsequently cancelled. When C was seen again the following week a different consultant determined that C’s fracture had now healed to the extent that surgery was no longer a viable option.

C complained that the shoulder is now misaligned, causing discomfort and a reduced range of motion affecting day-to-day life and their ability to work. C believes that opportunities were missed to prevent this outcome. The board’s response stated that C was initially too unwell for surgery, and that the cancelled procedure was because of an emergency admission that had to be prioritised. They also noted that there was reason to suspect that the injury was older than C had stated upon admission.

We took independent advice from an orthopaedic consultant. We found that there had been some challenges for the board in providing care and treatment to C. However, it had been evident from three days before C was initially discharged that the fracture was healing out of alignment. We also found that there was insufficient evidence on which to conclude that the injury was older than stated. We noted that various opportunities were missed for earlier surgical intervention and that there was a lack of ownership of C’s case from an orthopaedic perspective, contributing to a series of small delays which ultimately led to the window of opportunity for effective surgery passing. This amounted to unreasonable care and treatment. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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/information-leaflets.

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

• Discussions about patient care should be documented.
• Upper / lower limb expertise should be obtained promptly where this is appropriate. In addition, where patient care is being transferred, the board should ensure that there is effective communication and that delays are avoided / minimised.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their parent (A). A was admitted to hospital (Hospital 1) following a period of delirium which was a result of a urinary tract infection (UTI). They were treated with antibiotics but their delirium continued. A was transferred to another hospital for a period of rehabilitation (Hospital 2). C said that a nurse refused to take a urine test when A was showing symptoms of a further UTI, on the basis that A had no temperature. C also complained about a delay in prescribing antibiotics. A’s condition deteriorated again during their admission. C asked for a doctor to be called but they were told that no doctors were available. A deteriorated further that night and required admission to Hospital 1, where they died the following day.

C complained that A was denied access to a doctor. They also complained about communication and a lack of compassion from staff. A’s admission was during a time when visiting was restricted because of COVID-19 guidelines. C complained that staff should have allowed more frequent access to A when A was confused and distressed.

We took independent clinical advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s symptoms were not sufficiently clear to have merited a prescription of antibiotics sooner than they were prescribed. We noted that deterioration in older frail adults is often unpredictable and rapid, and found no failings in care and treatment provided to A. Based on the information available, we found no failings in communication, although we noted that the board had apologised to C already for certain communication failings. We found that staff were following the appropriate policies for visiting.

Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment that their adult grandchild (A) received from the board.

A received regular anti-psychotic medication from the board's mental health service. Separately, A suffered from episodes of paralysis, for which they attended A&E on numerous occasions. A died suddenly at home.

C complained that the board failed to recognise A was seriously unwell, with their episodes of paralysis wrongly being attributed to their mental health condition. On the day of A's death, A had fainted at the health centre after receiving their injection. C said that A attended A&E for assessment but was discharged without treatment.

The board’s response to C’s complaint advised that A had been fully assessed during each of their A&E attendances, with appropriate referral being made to neurology (specialists in the diagnosis and treatment of disorders of the nervous system) and advice sought from the mental health service. The board said that there was no evidence of A attending A&E on the day of their death so were unable to account for the hospital ID band that they had been wearing at the time. The board completed a Significant Adverse Event Review (SAER) in response to C's complaint.

We took independent advice from an A&E consultant and a consultant psychiatrist. We found that A received reasonable care from the board during their A&E attendances and confirmed that there was no record of A having attended A&E on the day of their death. We found that the management and review of A’s mental health was both reasonable and appropriate. Therefore, we did not uphold C's complaint.

We found that the board's complaint response was delayed following the conclusion of the SAER. Therefore, we made a recommendation on complaint handling in keeping with our powers to monitor and promote best practice.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to respond timeously to their complaint following completion of the SAER. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• In relation to complaints handling, we recommended
• Complaint responses should be issued in keeping with the timeframe given by the complaints handling procedure. Where a delay is necessary such as to allow completion of other review processes, the final complaint response should be issued as soon as it is practicably possible on conclusion of the other review process.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's spouse (A). A experienced urological symptoms including blood in their urine and a number of infections. After a number of investigations, A was diagnosed with bladder cancer which had spread to their prostate. A died a short time later.

C raised a number of complaints and we agreed to investigate four main concerns: that the board failed to provide a reasonable standard of urological treatment following insertion of a catheter, the delay in diagnosing A’s cancer; poor communication with B and A, and A’s poorly managed discharge from hospital.

We took independent advice from a consultant urologist.

C raised concerns that A’s catheter had to be refitted a number of times, which was difficult to do and caused A pain and discomfort. The board explained that a catheter is commonly fitted after surgery and a permanent catheter was fitted due to A’s past urology history and difficulty in emptying their bladder. We found that whilst it was reasonable to insert a catheter, the reasoning behind the decision was poorly documented and that as A required a number of emergency admissions for catheter related issues, the board should have considered an emergency cystoscopy (a procedure that uses a tube to examine the bladder and the urethra) and TURP (transurethral resection of the prostate) and they failed to do this.

Whilst it is agreed that A’s case was complex and a number of investigations were required, we found that there was a delay in arranging a diagnostic cystoscopy following an emergency admission, a breach of the waiting time target for cancer referrals and a failure to recognise the significance of paraaortic lymphadenopathy (lymph nodes of an abnormal size) which contributed to the delay in diagnosis of A’s cancer. We accepted that had this delay been avoided, A’s outcome likely would have been the same, although their quality of life would have been improved.

With regards to communication, we did not identify any issue with the volume or frequency of communication with A. However we concluded that important medical details were overlooked or not explained clearly, such as A’s urological diagnosis and overall management plans.

Our investigation also concluded that whilst it was appropriate to discharge A home due to their condition being manageable with pain relief and antibiotics, there was a failure to ensure adequate pain relief would be available to A.

We upheld all four complaints and made appropriate recommendations for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• That A’s case be reviewed at the local Morbidity & Mortality meeting with a view to identifying opportunities that were missed to progress A’s diagnosis and ways of ensuring similar delays do not affect future patients.
• That the board review the record keeping in A’s case and take steps to ensure their junior doctors and trainees are receiving adequate training in good medical record keeping and that senior clinicians are reminded of their responsibility to maintain sufficiently detailed records of discussions with patients and relatives.
• That the senior staff involved in A’s care be asked to reflect on the way that bad news was delivered on this occasion, and in general, with a view to ensuring they do so in as inclusive and compassionate a way as possible and with reference to the MDU guidance on breaking bad news.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided by the board in the lead up to the delivery of their twin babies. One of the twins (A) was stillborn.

C complained that the board failed to provide reasonable care and treatment during C’s pregnancy. We took independent advice from a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system). We found that while many aspects of the care and treatment were reasonable, the omission of some key measurements and tests was unreasonable and did not accord with guidelines. This impacted on clinicians being able to reach a fully evidenced position on what care was appropriate. Therefore, we upheld this part of C's complaint.

C complained that the board failed to reasonably communicate the risks and options available to them. We found that the records indicated that the board reasonably communicated with C in relation to the risks and options available to them. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to reasonably investigate C’s concerns. We found that many aspects of the reviews which were carried out were reasonable. However, we found that the reviews failed to identify that the significance of the lack of the measurements being taken was unreasonable, leading to a delay in identifying learning that could be taken forward. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings as identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informati on-leaflets.

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

• Where adverse event(s) occur the review should be thorough and identify all relevant learning from the event.
• Where it is considered that there are growth issues in relation to a fetus, appropriate investigations and tests, including measuring the pulsatility index as required, should be carried out in line with relevant national guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate.

C complained about the care that they received from the board during two hospital admissions. In particular, that staff were unprofessional and unempathetic and became impatient and abrupt when C was unable to do as staff asked.

We took independent advice from a senior nurse. We found that there was a lack of communication and understanding of C’s cognitive impairment which resulted in staff not fully understanding the issues C was dealing with on a daily basis and the challenges their diagnosis presents. There was also a lack of appropriate care planning and a failure to complete all documentation and risk assessments. This led to a failure to provide reasonable emotional and psychological care to C whilst an inpatient, a poor patient experience for C and anxiety over future hospital care. Therefore, we upheld C's complaint.

In addition, we also found that the board’s response to C’s complaint was poor and did not demonstrate the learning or improvement required.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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/information-leaflets.

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

• Documentation and communications regarding care needs should be highlighted at admission, with all relevant risk assessments completed reflecting accurate assessment and planning of care needs. Care plans should be person-centred to incorporate patients who have a cognitive impairment.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures (www.spso.org.uk/the-model-complaints-handling-procedures). The board should fully investigate and address the issues raised and appropriately identify and action learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that their late parent (A) received whilst in hospital. A was admitted to hospital with light headedness, dizziness, and pain in the hip and leg. C had concerns about the board’s failure to consider A’s previous medical history, decisions made during surgery, communication, care provided, and what was recorded on the death certificate.

The board said that investigations into A's blood loss found no issues and that they planned to discharge A. However, due to further bleeding A was not discharged and required emergency surgery. A was made aware of the risks associated with the surgery. This operation was successful, however, a further procedure was required to remove a section of A's bowel. Due to further changes in A’s condition, the board moved A to palliative care.

We took independent advice from a consultant in intensive care and acute medicine, a general surgery consultant and a registered nurse. We found that A's care and treatment was reasonable. However, A's medical history was recorded incorrectly by medical staff, affecting the treatment plan, investigations, and diagnosis. We found that A's operations were carried out reasonably. However, the surgical team failed to examine A in person when consulted which was unreasonable. Overall, we considered that the care and treatment provided to A was unreasonable and upheld this part of C's complaint.

In relation to nursing care, we found that the care and treatment provided to A was reasonable. We also found that A's death certificate was not completed incorrectly. Therefore, we did not uphold these part's of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to take an accurate medical history on admission, there was a missed opportunity for the vascular team to identify the correct diagnosis during their review of A, the failure to consider a diagnosis of aorto-enteric fistula earlier, and particularly, once the CT scan findings were available, and the failure of the surgery team to review A in-person. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Accurate medical history should be established by clinicians and investigations, including CT scans, that are carried out should be critically reviewed when considering diagnosis alongside the history. Medical records should be viewed to establish/confirm the correct medical history.
• When asked, the surgical team should fully review the presentation and history of the patient. Where necessary the patient should be seen in-person.
• When a specialist review is requested such as vascular, the specialist team should fully review the presentation and history of the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained to the board about various aspects of the board’s care and treatment of their partner (A) and their communication with C and A during an inpatient admission covering the end of A’s pregnancy and the birth of their child (B) by caesarean section. The board accepted that a number of areas of communication had not been reasonable and apologised for this. The board explained what action would be taken to address these areas for improvement. The board also accepted that in a few specific cases, A had not received reasonable care but indicated that they considered A’s care and treatment had been reasonable overall. In response to a specific complaint from C, the board stated that A had not had sepsis (blood infection) or been treated for it during their admission. A few months later, however, the board wrote to C and stated that their labour had been complicated by sepsis.

We took independent advice from an appropriately qualified midwife. We found that, overall, A and B received good care and appropriate standards of treatment that were in line with relevant professional standards. Given this, and that reasonable actions to minimise recurrence were taken in relation to areas where the board had accepted care was not of an acceptable standard, and where communication could have been improved, we did not uphold the complaint that the board had not provided reasonable care and treatment to A.

We found that A had had sepsis during their admission and receive prompt and appropriate care. However, we considered that the board’s repeated altering of their position on whether A had sepsis, both minimised A’s experience and, potentially risked inadequate care and treatment responses being provided to patients with suspected sepsis in the future. We upheld the complaint that the board’s response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that their response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Relevant board staff have a clear understanding of the symptoms and diagnosis of sepsis and the actions to take in treating sepsis and suspected sepsis.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C was concerned about a number of issues regarding their care and treatment, and that of their child (A), during their pregnancy, A’s birth and afterwards. C raised complaints with the board and were dissatisfied by their response. The board’s response accepted that there had been issues with aspects of the boards complaint handling and a number of issues with their communication, but did not indicate that the board considered that there had been any issues with C or A’s care or treatment.

We took independent advice from qualified advisers with experience of obstetrics, neonatology and midwifery (the medical specialisms for pregnancy, childbirth etc.). We found that, overall, C and A had received reasonable care and treatment from the board and that, where areas for improvement around communication had been identified, reasonable actions had been taken to address these. We did not uphold these part's of C's complaint. We noted that the board had accepted that C had been assigned to an incorrect consultant’s waiting list for a post-birth debrief and upheld this complaint. We also noted that the board had appropriately apologised to C for this. However, we considered that the board should have taken steps to minimise the possibility of a similar situation recurring in the future.

In considering the board’s response to C’s complaints, we found that there were specific areas where the board’s response and actions could have been improved. However, taking into account those areas for improvement in complaints handling the board had identified, the apologies provided to C and the specific circumstances of the time C raised their complaints, overall the board responded reasonably to C’s complaint. We did not uphold this part of C's complaint.

Recommendations

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

• Steps are taken to minimise the possibility of patients being assigned to incorrect consultant’s waiting lists for post-birth debriefs.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C’s spouse (A) presented to A&E with neck pain. A was discharged home as it was noted that they were on a waiting list for an MRI scan, following an urgent referral by their GP to orthopaedics (area involving the musculoskeletal system). A was admitted to hospital four days later and advised that they were terminally ill with bladder cancer which had spread to the spine. A later died. C complained to the board that A&E did not consult orthopaedics or arrange further testing when A presented with continuing pain despite prescribed medication. The board’s response indicated that A was appropriately assessed by the A&E doctors and as A was waiting on an MRI, the discharge letter to the GP advised to follow up with the hospital where the MRI was being organised. The board said that the GP was best placed to expedite further care with the relevant team.

We took independent advice from a consultant in emergency medicine. We found that A&E carried out an appropriate assessment, including consideration of any red flags which warranted further investigation or onward referral. We found that as A had already been referred to the spinal team and had an MRI ordered it was reasonable not to investigate A further. We found that the board acted in accordance with NICE guidance in how they managed A’s care and treatment, which was reasonable. Therefore, we did not uphold the complaint.