Health

Summary

Mrs C complained about the palliative care and treatment that her father (Mr A) received at Queen Elizabeth University Hospital. Mr A was later transferred to a hospice where he died. Mrs C was concerned about the types and doses of medication prescribed to Mr A and the board's communication with the family about Mr A's condition and the medication he was receiving.

We took independent advice from a consultant in palliative medicine. We found that the majority of the palliative care and treatment that Mr A received was reasonable. However, we found that the handover between the hospital and the hospice could have been better. In particular, the hospice referral letter did not detail all the drugs that Mr A was receiving and it did not explain the reasons for the unusual combinations he was prescribed. Therefore, we upheld Mrs C's complaint about the palliative care and treatment that Mr A received.

In relation to communication from the board with the family, we did not find evidence that this was unreasonable. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the nursing care that Mr A received. We took independent advice from a nursing adviser. We found that the majority of the nursing care was reasonable. However, we also found that the Nutrition Profile and Malnutrition Universal Screening Tool were not completed within 24 hours of Mr A's admission to hospital. On balance, we upheld Mrs C's complaint about nursing care.

Finally, Mrs C complained about the way the board handled her complaint. We found that:

• there was a delay in responding to Mrs A's complaint.

• the board did not agree a timescale with Mrs A about when she could expect to receive the minutes of a meeting about her complaint.

• the board's complaint response used generic terms and did not clearly explain what medication Mr A received, why the medication was changed, what the possible side-effects were and how these were monitored.

Therefore, we upheld Mrs C's complaint that the board failed to handle her complaint reasonably.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to clearly document the handover of Mr  A's drug regimen to the hospice, the failure to complete the Nutrition Profile and Malnutrition Universal Screening Tool within 24 hours of Mr A's admission, the delay in responding to Mrs C's complaint, that no timescale was agreed with her about when she could expect to receive the meeting minutes and that the complaint response did not clearly explain what medication Mr A received. 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 handover of patient drug regimens to other care providers should be clearly documented.
• Patients should receive adequate nutritional assessment and care planning in accordance with the relevant standards.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.
• There should be an appropriate level of detail in complaint responses that can be clearly understood.

Summary

Mrs C complained that, despite attending the dentist over the years with tooth pain, the cause of her pain was not identified or treated appropriately. She was ultimately referred to a periodontal (gum) specialist. Mrs C complained that she had not been informed of the presence of gum disease, and that she had to wait several months for this specialist assessment and treatment. Mrs C felt that the lack of earlier treatment had placed her dental bridgework at increased risk.

We took independent advice from a dentist. We found that Mrs C's dental records confirmed discussions having taken place with Mrs C regarding her gum disease. We noted that Mrs C's gum health had deteriorated rapidly at the time she was referred to the periodontal specialist, and we considered this referral was appropriate. We considered that the actions of the dentist were appropriate and did not contribute to the increased risk of Mrs C losing her dental bridge. Therefore, we did not uphold Mrs C's complaint.

Summary

Miss C complained about the care and treatment she received from a podiatrist (a physician who specialises in the study and medical treatment of disorders of the foot, ankle and lower extremity) at Glasgow Royal Infirmary for pain in her foot. Miss C said that the way the podiatrist handled her foot caused damage to it. Miss C also said that she was told she would be referred for an ultrasound guided steroid injection and that the podiatrist would follow up on this and ensure something was in place by her next podiatry appointment, but this did not happen.

We took independent advice from a podiatrist. Although it was not possible to determine exactly how the podiatrist handled Miss C's foot, we found that the evidence suggested that the initial manipulation/mobilisation treatment by the podiatrist did cause a flare up of Miss C's symptoms. This was accepted by the board and the podiatrist involved. The board said that the podiatrist apologised, however, there was no record of this. We noted that it would be reasonable to expect that mobilisation/manipulation might create an increase in symptoms, however, there did not appear to be any evidence that Miss C was informed of this or a record of her consent to the treatment. We also found that there were no treatment notes for any of Miss C's appointments.

In terms of the ultrasound guided steroid injection, it appeared that the podiatrist's referral letter for this was not received by the rheumatology department (the  branch of medicine specialising in rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) due to a system failure and this might have resulted in a delay in Miss C's treatment. Therefore, we upheld Miss C's complaint. However, we noted that the podiatrist apologised to Miss C for the length of time it took for review by some of the departments involved in her treatment. We found no evidence that Miss C was advised that the podiatrist would follow up on the steroid injection prior to her next appointment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to advise her that mobilisation and manipulation treatment could have the potential to exacerbate her symptoms, to obtain her consent for such treatment and adequately document this and for the failure in the referral 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:

• Patients who are to receive mobilisation and manipulation treatment should be advised that the treatment can have the potential to exacerbate symptoms, where appropriate, their consent obtained and the information should be documented. There should be appropriate treatment notes for patients' appointments with podiatrists.
• The board should have a robust process in place for such referrals from podiatry to rheumatology.

Summary

Mr C complained about the care and treatment his late father (Mr A) received at Queen Elizabeth University Hospital. Mr A was taken to A&E by ambulance as he had a severe headache, light sensitivity and was vomiting. Mr A was taken for a CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) and was found to have suffered a brain haemorrhage (a type of stroke caused by a blood vessel rupturing, which causes bleeding in or around the brain). Mr A's treatment options were discussed with neurosurgeons (specialists in surgery on the nervous system, especially the brain and spinal cord). They considered that treatment would not be appropriate for him and that his outlook was poor. Mr A died in the hospital several hours later. Mr C complained that there was a delay in assessing Mr A and in carrying out a CT scan. Mr C considered that an earlier diagnosis and treatment could have saved Mr A's life.

We took independent advice from a consultant in emergency medicine. We found that there was an unreasonable delay of almost an hour in a nurse initially assessing Mr A at A&E. We found that although there was a high number of patients that day, Mr A's assessment should not have been delayed, as he had a time sensitive condition. We also found that there was an unreasonable delay in carrying out Mr A's CT scan, which was partly due to the delay in initially assessing Mr A and partly due to the lack of availability of a CT scanner. Therefore, we upheld Mr C's complaint.

We also took independent advice from a consultant neurosurgeon on the impact the delay had on Mr A's treatment options and outlook. We found that the nature of Mr A's condition was so serious that it would have been terminal even with an earlier diagnosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in assessing and triaging Mr A and in carrying out his CT scan. 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 time critical conditions should be triaged and treated timeously.
• Patients should receive CT scans within a timescale appropriate to their need.

Summary

Ms C complained on behalf of her constituent (Mr A) who suffered from severe incontinence following surgery for prostate cancer. He was referred to a urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) and had an appointment seven months later, where further surgery was agreed to address this. Mr A was given a Treatment Time Guarantee date (12 weeks from the initial appointment), but he was not offered a date for surgery within this timeframe. He then arranged the treatment privately and the board removed him from the waiting list. Ms C complained about the delays in treatment, including the seven month wait for the initial appointment (which was only offered after she complained about the timeframes) and the further failure to meet the Treatment Time Guarantee.

The board said that they were not able to meet the Treatment Time Guarantee due to a staffing issue. They also said that their letter to Mr A explained that some specialities were not meeting the Treatment Time Guarantee.

We took independent urology advice and found that there was an unreasonable delay in arranging Mr A's surgery following the initial referral to the urologist. We also found that the board did not adequately communicate about the failure to meet the Treatment Time Guarantee. The letter Mr A received explained that some specialities would not meet the guarantee, however, there was no clear statement about urology not meeting the guarantee or that it would not be met in Mr A's case. There was also no evidence that they considered arranging treatment by another provider, which they are required to consider. Therefore, we upheld Ms  C's complaint.

While we acknowledged that Mr A was partly responsible for his decision to seek private treatment, we considered that the board's poor communication contributed to this and therefore we recommended that they partially reimburse Mr A for his treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for not meeting the Treatment Time Guarantee and not communicating more clearly with him about this. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Reimburse Mr A the amount that the operation would have cost the board. The payment should be made by the date indicated: if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

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

• The board should take all reasonably practicable steps to ensure that it complies with the Treatment Time Guarantee.
• Where the board is not able to meet the Treatment Time Guarantee, they should consider arranging treatment by an alternative provider (as required by the Patient Rights Act and Regulations and their own Access Policy).
• Where the board is not able to meet the Treatment Time Guarantee, they should write to the patient with an explanation and the information specified in the Patient Rights Regulations.

Summary

Mr C, an advocacy and support worker, complained on behalf of Mrs B about the care and treatment provided to her late husband (Mr A) at Inverclyde Royal Hospital. Mr A was referred to the hospital for a scan of his urinary tract. A  blockage was found and subsequent investigations identified an inoperable bladder tumour. Palliative treatment was planned for Mr A and he had a number of scans carried out over the following months. Mr C complained about the reporting of Mr A's scans, palliative care support and communication between staff and with Mr A and Mrs B.

We took independent advice from a consultant 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), a palliative care nurse and a consultant urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that there had been errors in reporting the extent/spread of Mr A's cancer and also in relation to a possible bowel perforation. We upheld this aspect of Mr C's complaint, however, the errors were unlikely to have affected the clinical treatment that Mr A received.

In relation to the palliative care support provided to Mr A, we found that there had been reasonable palliative care whilst Mr A was in hospital. However, there were issues with the referral process and access to community palliative care support. The board had already identified failings in palliative care support and apologised following their own consideration of the case. We upheld this aspect of Mr C's complaint.

Finally, we found that the board had acknowledged there were failings in relation to communication when Mr A was referred to another treatment centre and that they had offered apologies. We were also concerned that it was unclear from the case notes that the situation regarding prognosis and palliative care had been communicated and understood by Mr A and Mrs B. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

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

• Consideration should be given to issuing a report addendum when additional significant features are identified after review of medical imaging by the multidisciplinary team.
• Consideration should be given to issuing a report addendum if the interpretation of a medical image alters significantly from the previously issued report, following discussion with the referring clinician.
• Reporting errors should be discussed at imaging discrepancy meetings.
• There should be clearly defined referral criteria and process in place for discharge home from hospital for palliative care patients. Consideration should be given to using a discharge/transfer of care checklist.

Summary

Mrs C complained about the care and treatment she received from the board following spinal surgery. We took independent advice from a consultant neurosurgeon (a doctor who specialises in conditions of the nervous system, including the brain, the spine, the spinal cord and nerves) and from a nurse.

Firstly, Mrs C complained that the board failed to reasonably prevent and treat her infection following the surgery. We found no evidence that the board had failed to prevent the infection. However, we found that Mrs C was not assessed and treated as soon as the results showing the infection were reported. There had also been a delay in carrying out a wound washout which was unreasonable. We, therefore, upheld this complaint.

Mrs C also complained that the board failed to provide her with appropriate pain relief immediately after surgery. We noted that the board had acknowledged their failing in relation to providing post-operative pain relief and had apologised for this. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to provide a reasonable standard of nursing care following her operation. We found that overall the nursing care was reasonable and did not uphold this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board unreasonably delayed in responding to her complaint. We found inaccuracies in the board's response, and that there were delays in acknowledging and responding to the complaint. Further to that, the board did not keep Mrs C updated about the delay. We also noted that the board did not appear to have kept a full record of their internal investigation. 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 delays in treating her wound infection and the inaccuracy in their complaint response. 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:

• Lab results showing infection following spinal surgery should result in prompt assessment and treatment.
• Emergency wound washouts should be carried out promptly.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and supported by relevant evidence in the medical records. Any failings should be openly acknowledged and used to improve services and prevent a recurrence of the issues found.
• Stage 2 complaints should be acknowledged within three working days and responded to within 20 working days where possible.
• Where complaints cannot be responded to within 20 working days, the board should give a revised timeframe and keep the complainant updated regularly (for example, every four weeks).
• Complaint files should include records of all the information gathered during an investigation (and copies of internal correspondence about this).

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received when she was a patient in the geriatric long stay facility at Mearnskirk House. Mrs A became unwell and was treated for a presumed urinary tract infection. Her condition deteriorated and she developed sepsis (blood infection) and jaundice (a condition with yellowing of the skin or whites of the eyes), and later died.

Mrs C suspected that Mrs A's urinary tract infection was from a liver source and raised concerns about the board's response to Mrs A's jaundice. However, the board considered that a urine source was more likely and that the treatment Mrs  A received had been reasonable.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the source of infection often remains uncertain in particular situations, and that treating the sepsis would be the correct priority. We considered that more vigorous medical investigations or interventions would have been disproportionate. We did not uphold Mrs C's complaint.

However, we noted that there was insufficient documentation to demonstrate adequate discussions with Mrs C regarding Mrs A's management plan, particularly surrounding the uncertainty of her recovery. We also highlighted that adequate internal communication was not demonstrated and that communication failings were contrary to Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the care of deteriorating patients. We made recommendations relating to these observations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure of clinical staff to communicate adequately, both with her and with each other. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• As per SIGN 139, patients identified as deteriorating with limited reversibility should have a written management plan which considers and includes discussion with the patient and family (which may include discussion of uncertain recovery and medical plan, preferred place of care and concerns or wishes); and standardised and agreed ceilings of care.
• As per SIGN 139, all communication about patients identified as deteriorating should be formalised and should include a structured handover process which includes all relevant clinical information.

Summary

Mrs C was admitted to Queen Elizabeth University Hospital with severe abdominal pain. She was pregnant at that time and had been referred to the hospital with suspected appendicitis (a serious medical condition in which the appendix becomes inflamed and painful). The hospital carried out an ultrasound scan and considered it was likely that Mrs C had gastroenteritis (inflammation of the stomach and intestines). Her condition deteriorated over the next few days and it was found that her unborn baby had died. Mrs C was taken to theatre where it was identified she had appendicitis and her appendix was removed. She was then admitted to the intensive care unit at the hospital with sepsis (blood infection) and organ failure. Mrs C recovered but later had two further admissions with infections in her abdominal muscles. Mrs C complained that there was an unreasonable failure to diagnose appendicitis and sepsis.

We took independent advice from a consultant general and colorectal surgeon (a  surgeon who specialises in conditions in the colon, rectum or anus). We found that there had been a number of failings in Mrs C's care and treatment, including:

• a failure to adequately consider an alternative diagnosis to gastroenteritis in view of rising CRP (C-reactive protein - a blood test marker for inflammation in the body),

• a failure to give adequate consideration to carrying out a CT scan or diagnostic laparoscopy (a surgical procedure in which a fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or permit small-scale surgery),

• the national early warning scoring (NEWS - an aggregate of a patient's 'vital  signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration) that was carried out was not done appropriately,

• a failure to interpret and actively pursue signs of sepsis on the NEWS scores,

• staff should have used maternity early warning score (MEWS) observation charts,

• there was no review by an experienced obstetrician (a doctor who specialises in pregnancy and childbirth),

• the lack of physical examination by experienced doctors,

• there was a delay in carrying out a repeat ultrasound scan and

• the delay in considering a diagnostic laparoscopy or surgery was unreasonable.

We considered that there was an unreasonable failure to diagnose Mrs C with both appendicitis and sepsis and, therefore, upheld Mrs C's complaints. A number of failings had been identified by the board, but we made some additional recommendations for learning and improvement.

Mrs C also complained that the board's investigation into her care and treatment was inadequate. We found that there had been a delay in starting a critical incident review and that there were some failings in the report. We also 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 starting the significant clinical incident investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsandguidance.

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

• In relevant cases, NEWS scoring should be carried out appropriately.
• Deteriorating patients should be escalated to a senior clinician especially in the presence of sepsis. Where appropriate in these cases, a senior doctor should carry out a physical examination.
• Significant clinical incident investigations should be started promptly in appropriate cases.

Summary

Mrs C attended the dentist for restorative crowning treatment of one of her teeth, having recently completed a course of private orthodontic treatment. Following completion of the crown preparatory work, Mrs C complained that her retainer felt slack and that there was subsequent movement in one of her teeth between then and her re-attending for the crown fitting a week later. The dentist considered that the movement was an orthodontic relapse issue and did not accept liability for the cost of the remedial orthodontic work required. Mrs C complained that there had been no movement prior to the crown preparatory work and that the movement could, therefore, only be attributed to this work.

We took independent dental advice from a general dental practitioner. We found that the treatment provided by the dentist was carried out appropriately and that this could not reasonably be responsible for the movement of Mrs C's tooth. We noted that any movement was likely to have occurred over a period of months, due to orthodontic relapse, rather than the short period of time between the crown preparation and crown fit appointments. We observed that the dentist's notes from an earlier appointment suggested that the tooth in question was not in a stable position and that relapse had already occurred. Therefore, we did not uphold Mrs C's complaint.