Health

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client (Ms  B) about the care and treatment her elderly mother (Mrs A) received at Wishaw General Hospital and Kello Hospital. Mrs A had been in hospital after being diagnosed with lung cancer. Due to her frail condition, Mrs A was unsuitable for further care and could only be made comfortable. She was discharged home. Mrs A's condition deteriorated further and she was admitted to hospital for pain relief and palliative care. Mrs C complained that Mrs A was not fit for discharge and there was insufficient discussion with the family about this or about the medication Mrs A required to take at home. Mrs C also complained that the support provided by a nurse was unreasonable and on admission to Kello Hospital, staff failed to communicate reasonably with Mrs A family and delayed in providing appropriate pain relief.

We took independent advice from a doctor and from a specialist registered nurse. We found that discharge planning for someone with a terminal illness was complicated and difficult. While it was acknowledged that Mrs A wanted to go home, the arrangements made for her discharge had been hasty with insufficient discussion with the family who were unprepared for the demands of looking after her; they had no clear understanding of the medication prescribed and needed by her. Therefore, we upheld these aspects of Mrs C's complaints.

In relation to the nursing care, we found the support to be reasonable. We also considered the communication from staff at Kello Hospital to be appropriate and found no concerns with the pain relief given to Mrs A. Therefore, we did not uphold these aspects of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for failing to fully discuss with her the advanced nature of Mrs A's illness and discharge medication. 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 and their family/carers should receive appropriate information on discharge arrangements and, where appropriate, have an adequate understanding of the nature and seriousness of the condition. Conversations about this should be recorded.
• Patients should receive the medication prescribed and this should be documented.

Summary

Mr C complained on behalf of his wife (Mrs A) about the care Mrs A received at the practice. Mrs A had previously been diagnosed and treated for breast cancer. Six months after her treatment concluded she began attending the practice complaining of recurrent urinary tract infections and back pain. Six months following that it was found that the cancer had returned and spread to her bones.

We took independent advice from a GP. We found that the practice had carried out reasonable investigations when Mrs A first reported her symptoms. They had appropriately sought to investigate and exclude other possible causes of the symptoms Mrs A was presenting with. However, when Mrs A's symptoms did not resolve and investigations did not reveal a definite cause, the practice should have been alert to the possibility of a more serious underlying condition. We noted that referral guidelines for patients who have previously suffered from breast cancer note that unresolved back pain is a 'red flag' sign, indicating further serious investigation is required. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failure to provide a reasonable standard of care and treatment. 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 practice should familiarise themselves with red flag signs and should ensure trainees are aware of this also.
• Ensure that the findings of this investigation are shared with the doctors involved in Mrs A's care and discussed at their next appraisal for shared learning and improvement in clinical practice.

Summary

Mrs C complained about the care and treatment given to her elderly mother (Mrs  A) by both the out-of-hours (OOH) service and the Emergency Department (ED) of the Queen Elizabeth University Hospital. She said that Mrs A called the OOH service early in the morning as she feared she had sepsis (a blood infection). A GP attended and decided that she could remain at home. Mrs C believed that Mrs A should have been admitted to hospital. Later the same day, Mrs C took Mrs A to the ED as she said that she was experiencing rigours (episodes of shaking). She was later discharged. Mrs C said that Mrs A had to return to hospital within the week, when she was diagnosed as having sepsis.

We took independent advice from a GP and from a consultant in emergency medicine. We found that both at home and in hospital, Mrs A had been treated reasonably. The GP initially examining her had found her temperature, pulse rate, oxygen saturation and blood pressure all to be in the normal range. She had no 'red flags' in terms of the guidance and she was given clear advice about what to do if her condition worsened. When Mrs A attended the ED, all the tests undertaken were normal and did not indicate further screening. As Mrs C was unhappy with this, further examination was made, but again this did not indicate admission or screening for sepsis. While Mrs C said that Mrs A went on to develop sepsis within a few days, we found that this was not unusual. We did not uphold the complaints.

Summary

Mr C complained about the treatment which he received at Aberdeen Royal Infirmary. He had attended for a regional anaesthetic (nerve block) procedure. During the procedure he suffered a reaction and became unwell with severe breathing difficulties and had to undergo Cardiopulmonary Respiration (CPR) (medical procedure for a patient in cardiac arrest). Mr C wondered if the nerve block procedure had been carried out correctly.

We took independent advice from a consultant anaesthetist and found that the nerve block procedure was performed to an appropriate standard but unfortunately Mr C had an adverse reaction, possibly due to a combination of factors. When it became evident that Mr C was experiencing problems, staff appropriately carried out CPR as a precaution. We did not uphold the complaint.

Summary

Mr C has a complex medical history and made a number of complaints to the board. Mr C complained that the board failed to adequately address repeated errors in the provisions of prescription drugs, failed to inform the prison service of the requirements of his care plan and allowed his medical records to be altered retrospectively. Mr C also complained about the board's handling of his complaint.

We took independent advice from an adviser specialising in general medicine. We found that, on occasion, there had been delays in the provision of prescription drugs. However, these delays did not have a significant impact and it was not unreasonable for the dispensation of medicine to be subject to prison procedures, which limited the hours when medication could be issued. We did not uphold this aspect of Mr C's complaint.

In relation to Mr C's care plan, we found that it had been reviewed and he had been able to participate in those meetings along with prison service staff. We considered that the board communicated reasonably and appropriately with the prison service. We did not uphold this aspect of Mr C's complaint.

In relation to Mr C's medical records, we found that the board said it was impossible to amend records retrospectively. The adviser noted that this statement was inaccurate and we provided feedback to the board in light of this. However, we found no evidence that Mr C's medical records had been altered retrospectively and did not uphold this aspect of Mr C's complaint.

Finally, we found that Mr C had received an explanation from the board for the way his complaint was handled and an apology for any confusion caused. We considered this approach to be reasonable and did not uphold this aspect of Mr  C's complaint.

Summary

Mrs C complained about the care and treatment she received on the labour ward at Victoria Hospital when she was admitted with a history of reduced fetal movement for 24 hours and no movement felt during the daytime. Mrs C complained that the decision to perform a caesarean section was unreasonably delayed and that once in theatre there was further delay in the delivery of her baby (Baby A) due to the difficulty in achieving an effective spinal anaesthetic. The board carried out a significant adverse event review (SAER, a structured approach to learning from an adverse event) which identified a number of failings in relation to the care and treatment given to Mrs C. Prior to our investigation, the board accepted that there had been a number of failings and detailed the action taken.

We took independent advice from a consultant obstetrician and gynaecologist (a  doctor who specialises in the female reproductive system, pregnancy and childbirth) and a midwife. We found that there were failings in relation to the clinical care given to Mrs C which led to the delay in the delivery of Baby A. We were also concerned that there had been a breakdown in communication regarding a post birth anaesthetic review and that there was no evidence that a proposed review meeting between Mrs C and the obstetric consultant had been offered, and either taken up or declined. We also noted that the SAER had failed to identify the anaesthetic involvement in the delay in the delivery of Baby A. In relation to midwifery care, we found that Mrs C's paper records had not accompanied her when she was transferred to another hospital. We considered that the care and treatment Mrs C received was unreasonable and upheld this aspect of her complaint.

Mrs C also raised concerns about the handling of her complaint. We found that the board had failed to comply with the NHS model complaints handling procedure. 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 failings in care, communication and complaints handling. 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:

• All relevant medical staff, including locum medical staff, should be mindful of current clinical guidelines.
• Processes should be put in place to ensure transfers of care receive a post- operative anaesthetic review.
• Accurate and full clinical records should be maintained.
• All staff directly involved in care delivery should be included in the SAER process.
• All relevant paper records should accompany a mother on transfer to another hospital.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints procedure.

Summary

Mrs C complained about the care provided to her late husband (Mr A) by the practice. Mr A who suffered from chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) attended the practice on a number of occasions reporting breathing problems but felt that the doctors did not listen to him. Mr A was later admitted to hospital with pneumonia (an infection of the lungs) where he suffered a heart attack and died. Mrs C complained that the practice failed to provide Mr A with appropriate treatment in view of his symptoms.

We took independent medical advice from a GP. We found that the practice had carried out thorough investigations into the symptoms reported by Mr A and that his COPD did result in him having breathing issues. We also found that the practice prescribed appropriate antibiotics but that Mr A's condition and symptoms were drastically different between his final two consultations and it was only at that time that a hospital admission was required. Therefore, we did not uphold the complaint.

Summary

Mr C complained about the clinical treatment which he received when he attended Borders General Hospital for treatment for a shoulder injury. He felt he had been seen by staff who were not qualified to treat his injury and that there had been a delay in seeking a surgical option for the injury. He also complained that the x-rays taken were of poor quality and that this had contributed to his delayed recovery.

We took independent advice from a consultant in orthopaedics (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that Mr C had sustained a type of shoulder fracture and that these fractures are treated conservatively, without the need for surgery. Mr C's shoulder injury was initially treated by placing in a collar and cuff sling, and he was seen for follow-ups at clinics. Mr C then developed a mal union (where the bones do not heal up straight) and a stiff shoulder, which are recognised complications of the injury which Mr C had sustained. We also found that Mr C had been seen by appropriately qualified clinicians and allied health professionals and that the x- rays which were taken were of a sufficient quality. We did not uphold Mr C's complaint.

Summary

Mr C complained about the advice he received from NHS 24 staff when he called for assistance for a dental problem. He spoke to a dental nurse initially who advised that he should take painkillers and contact his dentist when the practice opened later that morning and ask for an urgent appointment. Mr C was unhappy with this advice and asked to speak to another dental nurse and again remained dissatisfied with the advice given. The telephone calls to NHS 24 became challenging and staff terminated a call as Mr C was deemed to have been offensive.

We took independent advice from a dentist. We found that the advice that Mr C should attend his own dentist later that morning was appropriate. It was also appropriate that he was given advice to take painkillers and that there was no medical need for an emergency appointment. We also found that Mr C's behaviour during the calls was challenging for all concerned and that it was not unreasonable for the staff to have terminated the call when it was clear that nothing further would be achieved. We did not uphold the complaint.