Health

Summary

Miss C complained about the antenatal care and treatment she received when she was pregnant with her child (Baby A). Miss C also complained that the board did not communicate reasonably with her about her antenatal care and treatment. At Miss C's 20 week anomaly scan it was identified that Baby A was measuring larger than expected. Baby A was born prematurely with severe and complex needs and died a few days later.

We took independent advice from a midwifery adviser and a sonography (the medical diagnostic imaging technique used to see internal organs, muscles, etc) adviser. We found that

No alternative arrangements were made for bloods to be obtained as requested by Miss C's GP during one of her antenatal appointments.

There were no records of:

one of Miss C's antenatal appointments

discussions that the midwife had with the sonographer and the consultant obstetrician (a doctor who specialises in pregnancy and childbirth)

the management plan, reason for changing the management plan and the details of what was communicated to Miss C.

The reason for not repeating the anomaly scan and requesting a growth scan instead was not explained to Miss C.

The sonographer did not seek medical advice regarding Baby A's measurements at the time of Miss C's 20 week scan or as soon as reasonably practicable.

The board identified that inappropriate comments were made to Miss C about Baby A's size.

The sonographer did not communicate Baby A's measurements to Miss C at the time of her 20 week anomaly scan.

Therefore, we upheld Miss C's complaints. We noted that the board had already apologised for some of these failings and had taken action to prevent these reoccurring. We asked the board for evidence of these actions and made further recommendations.

Miss C also complained that the board failed to handle her complaint reasonably. We found that the board did not inform Miss C at the earliest opportunity that a Significant Adverse Events Review would result in a delay in responding to her complaint or keep her updated as the review was progressing. We also found that the board failed to let Miss C know the outcome of the complaint investigation in writing. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failure to provide her with reasonable antenatal care and treatment, the failure to communicate reasonably with her and the failure to handle her complaint reasonably. 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:

• Bloods should be obtained as requested by GPs.
• Midwives should keep clear and accurate records in accordance with the Nursing and Midwifery Code: professional standards of practice and behaviour for nurses and midwives.
• Clear explanations should be given to expectant mothers about decisions to change the care they will be receiving.

In relation to complaints handling, we recommended:

• The board should ensure that they are adhering to the NHS Scotland Model Complaints Handling Procedure.

Summary

Mrs C complained about the out-of-hours care provided to her father (Mr A). Mr  A was seen at home by out-of-hours GPs and had been undergoing treatment for constipation in the days prior to this. The GPs considered that Mr A's reported symptoms were related to constipation. Mr A was later admitted to hospital where a catheter was fitted to drain retained urine from his bladder. Mrs C complained that the out-of-hours GPs had missed Mr A's urinary retention and prescribed inappropriate treatment as a result. The board acknowledged that an enema (a  procedure in which liquid or gas is injected into the rectum) that Mr A was prescribed was not appropriate and was unlikely to have been of any benefit in his case. This matter had been taken forwards with staff for reflection and learning.

We took independent advice from a GP. We found that there had been no indication that Mr A was suffering from urinary retention at the time he was seen and that the approach taken at the second out-of-hours visit was reasonable. However, we found that an enema had been inappropriate in Mr A's case and that a rectal examination should have been carried out during the first visit. On balance, we upheld Mrs C's complaint.

Recommendations

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

• Rectal examinations should be carried out when clinically indicated in patients presenting with unresolving constipation.

Summary

Mr C had been diagnosed with autistic spectrum disorder (a developmental disability that affects how a person communicates with, and relates to, other people) by the board's mental health service for children and young people (CAMHS). Shortly after discharge from CAMHS, Mr C attended A&E at St John's Hospital when he was in crisis. He was assessed by a psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness) who discharged him with follow-up with the GP. Mr C said that the assessment of risk and follow-up arrangements were not reasonable given his symptoms and circumstances at the time. Mr C also said that he had subsequently been diagnosed with psychosis (when someone perceives or interprets reality in a very different way from people around them) and that it was unreasonable that the psychiatrist did not consider this.

We took independent advice from one of our medical advisers. We found that the standard of psychiatric care and treatment provided in relation to the assessment and follow-up arrangements were reasonable. In particular, the symptoms that Mr C presented with at the time were not consistent with a diagnosis of psychosis, and while it was possible that his presentation was an early sign or symptom prior to the development of psychotic symptoms at a later date, there was no evidence that this could have been predicted or anticipated. We did not uphold Mr C's complaint.

Summary

Mrs C complained about the care and treatment that was provided to her late father (Mr A) by the practice on two occasions. Mr A was initially suffering with urinary problems and later, with symptoms of heart failure. Mrs C was concerned that there had been a failure to identify urinary retention as the cause of his symptoms and that, when he was seen by a GP registrar (trainee GP), a few months later, they attributed a seizure-like episode to medication changes, when he was actually suffering from aspiration pneumonia (a complication of pulmonary aspiration. Pulmonary aspiration is when you inhale food, stomach acid, or saliva into your lungs).

We took independent advice from a GP. We found that there had been no unreasonable failure to diagnose urinary retention and that Mr A's symptoms were more consistent with urinary infection when he was seen by the practice. Therefore, we did not uphold this aspect of Mrs C's complaint.

We found that, when Mr A was seen by the GP registrar, the relevant guidance for diagnosis of heart failure had not been followed. We found that it was not possible to rule out the medication changes as a cause of the seizure-like episode and there was no indication in the medical records that Mr A was suffering from aspiration pneumonia at the time he was seen by the GP registrar. We upheld this aspect of Mrs C's complaint as the issue around diagnosis of heart failure had not been identified as a training issue for the GP registrar.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in the management of Mr A's suspected heart failure. 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:

• Suspected heart failure should be managed in line with national guidance. Where this is not considered appropriate, a clear rationale for alternative action should be recorded.
• Issues with care and treatment provided by GP registrars should be taken forwards as part of the training process. Clear information should be available on a daily basis so GP registrars know who to approach for help and supervision.

Summary

Mr C complained that the board failed to ensure their mental health service for children and young people (CAMHS) provided a reasonable standard of care and treatment. Mr C said that he had a diagnosis of autistic spectrum disorder (a  developmental disability that affects how a person communicates with, and relates to, other people) from CAMHS but that they failed to explore potential mental health conditions during the period in question or provide appropriate treatment.

We took independent advice from a specialist in the services provided by CAMHS practitioners. We found that in many respects the CAMHS practitioners who assessed Mr C provided a reasonable standard of care and treatment in relation to diagnosis, management and referrals. We also took into account that it appeared Mr C refused to meet with senior staff to discuss his concerns. However, we found that Mr C's case was complex and he experienced considerable difficulties which had a significant impact on him. We also found that there were missed opportunities to engage with Mr C and to consider further referrals to ensure his mental health needs were met. Therefore, we upheld Mr  C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the missed opportunities to engage with him and to consider further referrals to ensure his mental health needs were met. 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:

• Relevant CAMHS practitoners should reflect on this complaint and its findings.

Summary

Mrs C, an advice and support worker, complained on behalf of her client (Mrs A) regarding the treatment she received from the domiciliary podiatry service (area of medicine that treats disorders of the foot, ankle and lower limb). Mrs A complained that the podiatrists failed to review her on a regular basis and that they did not appropriately treat her foot blisters, cuts or check her foot pulses.

We took independent advice from a podiatry manager. We found that the records indicated that the podiatrists reviewed Mrs A on a regular basis based on her presenting symptoms. When she requested an emergency appointment this was arranged within an appropriate timescale. We found that the podiatrists provided appropriate treatment in view of Mrs A's presenting symptoms and that her foot pulses were checked on an annual basis in line with national guidance. We did not uphold Mrs C's complaint.

Summary

Ms C complained that the treatment she received at Dumfries and Galloway Royal Infirmary was unreasonable. Ms C underwent a small bowel resection (removal of part of the small intestine) and since then had experienced significant pain. Ms C said that the treatment options were restricted for her and that her symptoms were being ignored.

We took independent advice from a colorectal and general surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that Ms  C's medical circumstances were very complex, and from the medical notes it was clear that treatment options were not straightforward and came with many risks. We found no evidence that appropriate treatment was withheld from Ms C. We also found that the medical care Ms C received was reasonable, appropriate investigations had been made and there was careful consideration of her care with appropriate discussions and follow-up appointments arranged for further treatment. Therefore, we did not uphold Ms C's complaint.

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) when he was admitted to Hairmyres Hospital with a suspected chest infection. Mr A was fed via a Percutaneous Endoscopic Gastrostomy (PEG, a tube into the patients's stomach through the abdominal wall) and early in the morning, on the day after his admission, Mr A's PEG became detached. While it appeared that nurses noticed this, it was not reported until a ward round later that day. By then, the entry tract had closed and the feeding tube was unable to be reinserted.

Subsequently, there were difficulties in ensuring Mr A's nutrition and there were numerous failed attempts to re-establish his feeding. After ten days, Mr A's family requested that he be transferred to another hospital to have a PEG surgically inserted but the procedure had to be stopped. Mr A died shortly afterwards. Mr  C complained that staff failed to act when the PEG had become detached.

We took independent advice from a consultant in general medicine. We found that the board's guidance stated that if a gastronomy feeding tube fell out, it should be replaced as soon as practicable, preferably within two hours. However, this did not happen and staff were initially unaware of the need to reinstate the PEG within a particular time frame. We also found that there was a lack of coordination and planning around the repeated failure to obtain a consistent route of feeding and there was a lack of communication about how unwell Mr A was. Although the outcome for Mr A may have been the same, we considered that his recovery was compromised by a level of care that fell below what could have been expected. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to provide Mr A with a reasonable level of care in that his PEG tube was not quickly replaced and that there was a failure to initiate alternative methods of feeding. 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 and adhere to the board's policy on Enteral Tube Feeding, Best Practice Statement for Adults. Patients in a similar situation should receive a timely and feeding regime commenced and timely consideration of transfer. Record-keeping by doctors should meet General Medical Council standards.

Summary

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided by the board in relation to a respiratory (breathing) condition. Ms C complained that Ms A had been unreasonably discharged from the care of a lung specialist when the specialist left the board. She also raised concerns about the medical and nursing care provided when Ms A was admitted to Hairmyres Hospital. Finally, Ms C complained that the follow-up Ms A received at Monklands Hospital was unreasonable and that the board's response to the subsequent complaint was unreasonable.

We took independent advice from a respiratory consultant. We found that as Ms  A's condition was stable, it was reasonable to discharge her when the lung specialist left the board. The discharge letter provided advice to Ms A's GP that if her symptoms progressed, she should be re-referred as a new patient. We also found no failings in the medical care and treatment that Ms A received either as an in-patient or in follow-up as an out-patient. Therefore, we did not uphold these parts of Ms C's complaint.

We took independent advice from a nursing adviser in relation to Ms A's concerns about nursing staff. We found that the nursing care that was provided to Ms A was reasonable. We did not uphold this part of Ms C's complaint.

Finally, we found that the response to Ms A's complaint was reasonable and considered that it addressed the points listed in her original complaint. Therefore, we did not uphold this part of Ms C's complaint.

Summary

Mr C complained about the medical care and treatment his late mother (Mrs A) received at Hairmyres Hospital. In particular, Mr C complained that a biopsy was not carried out and that the board had failed to give Mrs A an appointment for a ring pessary (a device used to support the uterus, vagina, bladder or rectum) change.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that there had been no indication to carry out a biopsy when Mrs A attended the hospital following a referral from her GP. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to Mr C's concern that Mrs A had not been given an appointment for a ring pessary change, we found that the board had initially advised Mr C that this was as a result of a system failure. However, they later clarified that this was not the case. We found that the failure to attend an appointment for a ring pessary change was not caused by a failing on the part of the board and we did not uphold this aspect of Mr C's complaint. However we were concerned that incorrect information had initially been given to Mr C about this matter and made a recommendation to the board.

Recommendations

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and issues raised should be thoroughly investigated.