Health

Summary

Mr C complained about the care and treatment his mother (Mrs A) received at Lorn and Islands Hospital. Mrs A initially presented to the emergency department experiencing vomiting. Following assessment, Mrs A received antibiotics and was discharged home. Mrs A returned to the emergency department two days later again with vomiting symptoms. After further assessment was carried out, Mrs A was discharged home. Mrs A attended the hospital again approximately five days later and was admitted to a ward. During the admission, investigations were carried out which indicated that Mrs A had metastatic cancer (cancer that has spread to other parts of the body). Mrs A's condition deteriorated during the admission and she died from her illness. Mr C complained about the care and treatment his mother received as well as the way hospital staff communicated with the family.

We took independent advice from a consultant in general medicine and a registered nurse. We found that Mrs A was unreasonably discharged from the emergency department on two occasions without her symptoms being effectively managed. We also found that an incorrect diagnosis had been reached during the first presentation to the emergency department, whilst the second presentation was poorly documented. We noted that once Mrs A was admitted to the ward, there was an unreasonable delay in obtaining a CT scan (a scan that uses x-rays to create detailed images of the inside of the body) of Mrs A's chest/ abdomen. We upheld this aspect of Mr C's complaint.

In response to Mr C's complaint, the board apologised that inaccurate information was given to family members regarding the length of time to obtain test results. We also found that there was a lack of discussion between nurses, doctors and the family around the possibility of discharging Mrs A home and a lack of clarity with the family about this. We upheld this aspect of Mr C's complaint.

Finally, Mr C was also unhappy with the time that the board took to investigate and respond to his complaint. We found that the delay was unreasonable and we were critical of the board's communication surrounding the delay. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise to Mr C for the unreasonable decisions to discharge Mrs A on two occasions; the incorrect diagnosis of urinary tract infection; poor documentation of Mrs A's second hospital attendance; the unreasonable delay obtaining a chest/ abdomen CT; the lack of local multidisciplinary discussion around the possibility of discharge; and failing to provide a reason for the complaint handling delay and a revised timescale. 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:

• Clinicians should take time to observe whether a patient requiring anti-sickness medication needs this medication to be given from a route other than oral, or needs alternative anti-sickness medication to manage their symptoms.
• A diagnosis of urinary tract infection should be supported by presence of relevant symptoms and appropriate tests.
• Patient records should include documentation of a full assessment by the medical team; details of any subsequent discussions; and plans for follow-up.
• CT imaging should be performed timeously.
• Patients and families should receive realistic estimates for how long it will take for biopsy results to become available.
• Where possible, patients with a life limiting diagnosis and their families should be involved in discussions around their preferred place of end of life care and what would be required to facilitate this.

In relation to complaints handling, we recommended:

• Where the complaint investigation cannot be completed within 20 working days, the person making the complaint should be provided with an explanation for the delay and a revised timetable for the response.

Summary

Ms C complained that her partner (Mr A) had been misdiagnosed with brain cancer.

We took independent advice form a consultant clinical oncologist. We found that it was unreasonable for the board to have given Mr A the wrong information by misdiagnosing him with brain cancer. We accepted that this was likely a mistake or human error as a result of misreading Mr A's scan report. Following the discovery of the error, most of the action taken by the board was reasonable. We noted that the board apologised to Mr A and the consultant involved had reflected on this matter. However, we also found that the board failed to record on Datix (incident reporting system) or another similar reporting system that Mr A had been misdiagnosed with brain metastases. They also failed to carry out a serious adverse event review to consider whether there were any contributory factors that could be mitigated. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately record and carry out an appropriate review to ensure that there were no other contributory factors that could be mitigated. 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:

• Near misses and errors should be reported via Datix or another similar reporting mechanism and, if indicated, a Serious Adverse Event Analysis should be carried out.

Summary

Ms C complained about the care and treatment she received following a total abdominal hysterectomy (surgery to remove the womb). The day after the surgery, Ms C began to feel unwell and experienced severe pain in the lower right-hand side of her abdomen. Ms C requested help from a nurse and was advised that her symptoms could have been wind. Based on this, the nurse gave her some peppermint water. After the pain persisted, Ms C asked to be seen by a doctor. Ms C was given pain relief and monitored throughout the night. The following day, Ms C's haemoglobin level dropped and she required surgery to treat a rectus sheath haematoma (internal bleeding). Ms C felt that the hospital should have identified earlier that she was bleeding internally. She also complained about the nursing care she received while in hospital, especially in relation to one particular nurse who Ms C felt displayed inappropriate attitude and behaviour.

We took independent advice from a consultant gynaecologist and a nurse. We found that it was not unreasonable for the rectus sheath haematoma not to be identified or addressed earlier. We considered that the board's actions, including their post-operative treatment plans for Ms C's care, were reasonable. Therefore, we did not uphold this complaint.

In relation to nursing care, we found that it was not unreasonable for nursing staff to have suggested Ms C's pain was caused by wind and there was nothing in the medical records to suggest nursing staff unreasonably delayed contacting a doctor. We noted that the medical records indicate that there was some conflict or difficulty in the communication between Ms C and nursing staff. However, we did not consider what was recorded in the records to be unreasonable or a cause for concern. We acknowledged that Ms C's account differed from what was recorded in the medical records and that we had no reason to doubt what she had told us. However, we concluded that we would not be able to reach a conclusive view on the interactions between Ms C and the nursing staff, as there was no evidence that the nursing care provided was inappropriate or unreasonable. We did not uphold this complaint.

Summary

Miss C complained about the care and treatment she received from the Princess Royal Maternity Hospital. She raised concerns about the general anaesthetic she was given during her emergency caesarean section, which she said was given the wrong way round and jeopardised her ability to breathe, risking both her and her baby's lives.

We took independent advice from a consultant anaesthetist who covers obstetric (medical specialism for pregnancy and childbirth) theatres as part of their elective and emergency work. We found that the sequence of drug administration in Miss C's case was wrong and could have caused Miss C difficulty breathing, but the awareness of this would have lasted for only a few seconds at most. There was no risk to Miss C's baby from this drug error and the risk to Miss C was limited to the unpleasant experience she suffered, but there would not have been any risk to her life. Given the failing in the administration of the drugs, we upheld this part of Miss C's complaint.

The board acknowledged their failing in this case and took appropriate remedial action on this matter. However, we made one recommendation for further action by the board.

Miss C also complained that she developed a chest infection and contracted Clostridium Difficile (bacteria that can infect the bowel and cause diarrhoea) whilst in hospital. We did not identify any failings by the board in these areas. We did not uphold this part of Miss C's complaint.

Recommendations

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

• Consideration should be given to the supply of pre-filled syringes of suxamethonium, as raised by the board's departmental morbidity and mortality meeting.

Summary

Mr C complained that the board failed to carry out a Significant Clinical Incident (SCI) investigation reasonably. Mr C's late partner (Ms A) underwent a hernia repair operation (an operation to correct a hernia, which is a bulging of internal organs or tissues through the wall that contains them) at a private hospital and later found this surgery had perforated her bowel. This perforation was successfully repaired with further surgery at Glasgow Royal Infirmary, however, Ms A continued to deteriorate and died shortly afterwards. The board carried out a SCI investigation which highlighted a number of failings in Ms A's care and several recommendations were made to improve practice going forwards. Mr C was unhappy with this report and complained to the board. Mr C remained unhappy with their response and brought his complaint to us.

We took independent advice from a consultant surgeon. We found that the scope of the SCI investigation was reasonable and that it had identified many of the issues with Ms A's care. However, there were some areas where the recommendations either did not address, or did not fully address, the failings. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the SCI process did not fully address all the failings in care and treatment provided to Ms A. 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:

• Emergency transfers from a hospital with no facility to manage full emergency assessment/emergency surgery to a hospital where optimal care can be provided, should be regarded as 'blue light', especially in the presence of sepsis.
• Surgical admissions of this type should be discussed with a more senior clinician (senior trainee or higher) to ensure management and treatments are optimised.
• All emergency cases should be assessed for sepsis on the Sepsis Six pathway and prompt management plans be put in place as necessary, including prompt administration of antibiotics.
• There should be standardisation of communication using an appropriate tool such as SBAR (Situation, Background, Assessment, Recommendation).

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.