Mr C complained about the practice's management of his son (Mr A)'s medication.
We took independent advice from a GP. We found that Mr A's medication was managed in a reasonable manner and did not uphold Mr C's complaint.
Mr C complained on behalf of his son (Mr A) about the mental health care and treatment provided by the board. Mr C complained that there had been a failure to provide support from a community psychiatric nurse, a delay in referral, and a failure to provide the necessary crisis support.
We took independent advice from a psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the mental health care and treatment provided to Mr A had been timely, supportive, and in line with Mr A's needs and wishes. We did not uphold this aspect of Mr C's complaint.
Mr C also complained about the board's complaint response. We found that whilst the board gave limited information in response to one of Mr C's questions, this was in relation to care provided by another organisation. Therefore, we did not consider this unreasonable and we did not uphold this aspect of Mr C's complaint.
Mrs C complained that the board unreasonably communicated with her about the care of her mother (Mrs A). Mrs C was named as Mrs A's next of kin and had been listed as Power of Attorney, although this was not invoked for the majority of the period complained about.
We took independent advice from a social worker. We found that the records indicated Mrs C was involved regularly and kept up to date by the care home, which would be normal practice given the care home was responsible for the day- to-day care of Mrs A. We considered that the communication with Mrs C was reasonable and did not uphold the complaint.
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.
What we asked the organisation to do in this case:
What we said should change to put things right in future:
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.
What we asked the organisation to do in this case:
What we said should change to put things right in future:
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.
What we asked the organisation to do in this case:
In relation to complaints handling, we recommended:
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.
What we asked the organisation to do in this case:
What we said should change to put things right in future:
In relation to complaints handling, we recommended:
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.
What we asked the organisation to do in this case:
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.
What we asked the organisation to do in this case:
What we said should change to put things right in future:
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.