Health

Summary

Mrs C complained about the nursing care that her late mother (Mrs A) received at Broadford Hospital. Mrs C had a number of concerns about the board's record-keeping and also complained about the communication from the nursing staff. Mrs A was admitted to the hospital where a provisional diagnosis of urinary sepsis (blood infection) was made. Mrs A also developed a pressure ulcer while at the hospital.

We took independent advice from a nursing adviser. We found that:

• daily checks on Mrs A's Peripheral Vascular Catheter were not recorded.

• a “Getting to Know Me” document was not in place for Mrs A.

• a Short Term Care Plan was in place for Mrs A for more than 48 hours.

• Mrs A's urine output was not recorded on the Feed/Fluid Balance Chart when she was being treated for sepsis.

• no Active Care or Care Rounding Charts were in place for Mrs A.

• the board failed to provide reasonable pressure ulcer care to Mrs A and there was no evidence that the family were informed of Mrs A's pressure ulcer.

The board also identified some record-keeping failures during their own investigation of Mrs C's complaint and said that they had taken steps to address these. We asked the board to provide evidence of the action they had already taken.

In light of the above, we upheld Mrs C's complaints that the board failed to provide Mrs A with reasonable nursing care and that the board failed to communicate reasonably with Mrs A's family.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mrs A with reasonable nursing care during her admission to hospital. The apology should meet the standard 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:

• Daily checks on Peripheral Vascular Catheters should be carried out and recorded in accordance with relevant standards.
• The appropriate care plan should be in place in accordance with relevant guidance.
• Patient Feed/Fluid Balance Charts should be completed in line with policy and guidance.
• There should be appropriate assessment, monitoring, recording and communication regarding patients at risk of developing pressure ulcers in accordance with relevant policies and guidance.
• A “Getting to Know Me” document should be used to support person centred care for older people in hospital, especially if they are frail.
• Active Care or Care Rounding Charts should be used to evidence that patients have been asked about their care and comfort needs.

Summary

Mrs C complained about the care and treatment her late husband (Mr A) received at Raigmore Hospital. Mr A had a history of numerous medical conditions and was seen in the cardiology department (the branch of medicine that deals with diseases and abnormalities of the heart) due to a build up of fluid. It was decided that no cardiac intervention was needed and the plan was to see Mr A again in six months, however, six weeks later he developed an infection and required to be admitted to hospital. Mr A's kidney function also deteriorated and treatment was aimed at aiding his heart function and fluid balance. Mr A's condition continued to deteriorate and he later died. Mrs C complained that Mr A's renal and cardiology care was unreasonable.

We took independent advice from consultants in cardiology and renal medicine. We found that Mr A's condition was a complex one and it was difficult to balance his heart function and fluid balance. Mr A's deteriorating kidneys meant that he retained more fluid which put a greater strain on his heart and there was a precarious balance to be achieved between his body having too much fluid and too little. This took a great deal of clinical skill and overall, his care and treatment had been reasonable. However, we also found that there had been inadequate cardiology follow-up after Mr A had been discharged from hospital, although this did not impact on his care. Furthermore, Mrs C and Mr A were unaware, until just before Mr A died, that he was most unlikely to survive. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff failed unreasonably to respond to Mr A's attempts to complain about his care and treatment and appeared unaware of the board's complaints procedure. We found that Mrs C and Mr A experienced difficulties in pursuing a complaint and 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 failure to discuss Mr A's prognosis, to provide appropiate follow-up and for the lack of knowledge about the complaints process. 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:

• In patients with conditions that are likely to impact upon their prognosis, early discussion should be had with the patient and their family that is clear, unambiguous and documented.
• Cardiology patients should be appropriately followed-up/reviewed.
• All staff should be aware of the complaints process and able to advise accordingly.

Summary

Mr C complained about the way the practice handled his complaint.

We found that the practice failed to adhere to the NHS Scotland Model Complaints Handling Procedure (CHP). In particular they failed to acknowledge Mr C's complaint within three working days, failed to ensure that the complaint response detailed the right to bring the complaint to this office and failed to ensure that the complaint response addressed all the issues raised by Mr C. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to handle his 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.

In relation to complaints handling, we recommended:

• When responding to complaints the practice should follow their complaints handling procedure and all staff should be aware of this and the model CHP for the NHS.

Summary

Mr C complained about the care and treatment he received from the practice. In particular, Mr C complained that the practice did not perform more thorough examinations which he said resulted in a delay in him being diagnosed with cancer.

We took independent advice from a GP. We found that the practice failed to examine and document Mr C's sore throat at a consultation. Therefore, we upheld this aspect of Mr C's complaint. However, we found no evidence that the examination of Mr C's sore throat would have changed the practice's management plan for his symptoms or have an effect on his eventual diagnosis or clinical outcome.

Mr C also complained that the practice failed to handle his complaint reasonably. We found that there was an unreasonable delay in responding to Mr C's complaint and that the practice did not provide a copy of the Complaints Handling Procedure (CHP) to him promptly. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to examine his sore throat at a consultation, the delay in responding to his complaint and failing to provide the CHP promptly. 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 should receive full and appropriate examinations based on their reported symptoms and these should be documented.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model CHP. The model CHP and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Mrs C complained that the board unreasonably refused to offer her a consultation or further treatment to address her facial scarring. The board advised they would not offer Mrs C an appointment as they did not consider her facial scarring would be amenable to treatment.

We took independent advice from a plastic surgeon (a surgeon who repairs or reconstructs missing or damaged tissue and skin). We found that the board wrongly triaged (a process in which things are ranked in terms of importance or priority) Mrs C's referral according to the relevant protocol. We considered that Mrs C should have been offered an out-patient appointment to be assessed more fully. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to triage her referral appropriately and for the failure to offer her a face-to-face appointment with a consultant. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Offer Mrs C an out-patient appointment for her to see an appropriate consultant.

Summary

Mr C complained that the care and treatment he received from the dentist was unreasonable. Mr C had a lump on his tongue and was concerned that he was not referred to oral health or a dental hospital which he said resulted in there being a delay in him being diagnosed with oral cancer.

We took independent advice from a dental adviser. We found that the clinical examination carried out by the dentist was reasonable and, given that the dentist suspected that the lump on Mr C's tongue was a result of trauma, it was reasonable that a topical anaesthetic mouthwash was prescribed and an appointment was made to review Mr C. However, we also found that the dentist had not recorded in Mr C's medical record anything about:

• the history of Mr C's complaint, his past dental history, past medical history and social history.

• the diagnosis considered at the time.

As good record-keeping is an important part of a patient's care and treatment, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to take a full history of his symptoms and record the diagnosis considered. 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:

• Good record-keeping should include a full history of a patient's symptoms and a record of the diagnosis considered.

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received at Glasgow Royal Infirmary. Mr A had cancer and was seen at clinic and placed on the waiting list for surgery. However, Mr A began to rapidly lose weight and Mrs C tried to contact the consultant for advice. Mr A was referred for a dietetic assessment and was advised to take nutritional supplements. Mr A was still unable to stop the weight loss and Mrs C again tried to contact the consultant for advice. The consultant was not available and arrangements were made for Mr A to see another consultant at short notice. It was then discovered that Mr A's condition had deteriorated and that surgery was no longer an option. Mrs C felt that action should have been taken sooner to reassess Mr A and that a scan should have been arranged at the clinic appointment.

We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that there was no indication that a scan was required at the clinic appointment as a diagnosis had already been reached and Mr C did not report any new symptoms. It was appropriate that Mr A was then directed to a dietetic review in order to treat his poor nutritional intake so that he would be in appropriate health to undergo the planned surgery. There was no indication that a hospital admission was required at the time of the dietetic review. When Mr A saw another consultant, appropriate investigations were carried out although by that stage it was felt that he was no longer fit for the planned surgery. We did not uphold Mrs C's complaint. However, we did note that there was a failing in the passing of information from the secretarial staff to the clinical staff. This would not have affected the outcome and the board have already taken action to ensure that when clinicians are not available the matter should be escalated to another clinician.

Summary

Mrs C had surgery to remove her gallbladder at Queen Elizabeth University Hospital. Mrs C was experiencing severe pain following her surgery and it was subsequently discovered that bile was leaking into her abdomen. Mrs C underwent further procedures to resolve the bile leak. Mrs C complained about the medical treatment she received both during and after her surgery.

We took independent advice from a general surgical adviser. We found that the medical care Mrs C received during her surgery was reasonable and did not uphold this aspect of her complaint. However, we did find that there was an unreasonable delay in recognising that Mrs C's symptoms may have been caused by a bile leak. Therefore, we upheld Mrs C's complaint that the board failed to provide reasonable medical treatment after her surgery.

Mrs C also complained about the nursing care she received after her surgery. We took independent advice from a nursing adviser. We found that there was no pain assessment and care plan completed following her surgery. Therefore, 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 recognising her symptoms may have been caused by a bile leak and that there was no nursing pain assessment and care plan completed following her surgeries. 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:

• The possibility of a bile leak should be considered by medical staff in patients who do not recover as expected from laparoscopic cholecystectomy (gallbladder removal).
• Post-operative patients should have their pain assessed, recorded and treated by nursing staff in accordance with relevant guidance.

Summary

Mrs C complained about the treatment she received from the orthopaedic service (the service which deals with issues of the musculoskeletal system) at Glasgow Royal Infirmary. She had been referred there by her GP for a suspected torn cartilage. She said that the consultant reviewed her and suggested that she have a hip injection, arranged for her to have a scan and said that the matter would be reviewed. Mrs C then saw another doctor who suggested an alternative treatment plan. Mrs C felt that it was unreasonable that the consultant did not take any further action at the initial appointment.

We took independent advice from an orthopaedic consultant. We found that the consultant had carried out a reasonable assessment in view of Mrs C's reported symptoms and medical history, and that it was reasonable to suggest that she had a hip injection. The fact that another clinician arrived at a different diagnosis was also reasonable in the circumstances. We did not uphold the complaint.

Summary

Mr C was referred by his GP to the board's spinal service at Gartnavel General Hospital for assessment. The referral was vetted on receipt and considered appropriate for a virtual appointment. The appointment took place nine months after the referral was received. Mr C's referral was not considered appropriate for the spinal service and he was referred to the board's back pain service for physiotherapy. Mr C complained that he was unreasonably referred back to the physiotherapy service.

We took independent medical advice from a consultant orthopaedic surgeon (a  surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system). We found that the response to Mr C's referral was reasonable as the back pain service was the appropriate service for Mr C to be redirected to. We did not uphold Mr C's complaint. However, we noted that there was a delay in recognising that the referral should have gone to the back pain service in the first instance. The board's vetting system did not highlight that Mr  C's referral was not appropriate for the spinal service and we made a recommendation to the board in light of this.

Recommendations

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

• Have systems in place to ensure that inappropriate referrals are identified promptly.