Health

Summary

Mr C complained on behalf of his mother-in-law (Mrs B) about the care and treatment provided to her husband (Mr A) at Raigmore Hospital. Mr C complained that the board failed to manage Mr A's falls risk appropriately and failed to provide a reasonable standard of oral and nutritional care to Mr A.

We took independent advice from a nursing adviser. We found that Mr A sustained seven falls during his admission, with the last fall resulting in him suffering a serious injury. The board had apologised for this and the lack of communication by their nursing team on some occasions, and we acknowledged the action that the board said they had taken to address this. However, we found that there were additional failings and an unreasonable level of care provided to Mr A not identified by the board. We noted that there appeared to have been a lack of action and a failure in record-keeping in relation to the management of Mr  A's falls risk. We considered that the supervision provided was unreasonable and highlighted that there was no person-centred care plan provided to record the management of Mr A's falls risk and interventions in place to reduce the risk of falls, or the level of observation he required. In addition, communication with Mr A's family was unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

In relation to Mr A's oral and nutritional care, the board accepted that this was not of an acceptable standard and apologised. We found that there were shortcomings in the assessment and management of Mr A's nutritional needs and in record-keeping. Although staff made urgent referrals to the dietician, Mr A did not appear to have been treated as a priority. We also found no evidence that Mr A's oral care needs were met. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B and her family for the unreasonable level of care provided to Mr A in relation to falls sustained by Mr A, his nutritional and oral care, record-keeping and communication with Mrs B and her family. 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 at high risk of falls should have their falls risk appropriately managed.
• Nursing records should be maintained in accordance with the nursing and midwifery code of practice.
• Patients should have their nutritional and oral care appropriately assessed and managed.
• There should be adequate communication with a patient's family and this should be appropriately documented.

Summary

Mr C complained that the practice failed to contact him to arrange a blood test. Mr C's GP had referred him to the plastic surgery department who wrote back to the practice to request blood tests. The practice failed to contact Mr C to arrange the blood tests and he complained that this caused a delay in him receiving further treatment. Mr C also complained that the practice's handling of his complaint was unreasonable.

We took independent advice from a GP. We found that the practice failed to contact Mr C to arrange the blood tests and upheld this aspect of his complaint. However, we noted that this failing was likely an administrative oversight and was not due to a lack of clinical skill. The practice acknowledged this failing and apologised.

In relation to complaint handling, we found that the practice referred Mr C to our office appropriately and responded within the required timescales. Therefore, we did not uphold this aspect of Mr C's complaint.

Summary

Mr C complained about the treatment he received at Glasgow Royal Infirmary. He had attended as a day case for an Endoscopic Ultrasound Scan (EUS, a minimally invasive procedure to assess digestive and lung diseases) where a biopsy was taken. On the way home after the procedure Mr C became unwell and was taken to another hospital where he was diagnosed with acute pancreatitis (inflammation of the pancreas). He was admitted for treatment and further deteriorated, and it was found he had ruptured his spleen which then had to be removed. Mr C felt that the EUS had not been carried out appropriately and that it had caused his health problems.

We took independent medical advice from a consultant surgeon. We found that the EUS had been performed appropriately but unfortunately Mr C had developed pancreatitis which is a rare but recognised complication of the procedure and there was no evidence of any failings during the procedure. Similarly, Mr C then developed a further rare complication of pancreatitis where his spleen ruptured which is usually as a result of infection or severe inflammation. We did not uphold the complaint.

Summary

Ms C complained about the care and treatment she received from the practice regarding a flu vaccination and that the practice did not provide her with an appointment when she called them. Ms C was subsequently diagnosed with Idiopathic Thrombocytopenic Purpura (ITP, a disorder that can lead to easy or excessive bruising and bleeding. The bleeding results from unusually low levels of platelets (the cells that help blood clot)) which she considered was linked to the flu vaccination she received.

We took independent advice from a GP. We found that the care and treatment Ms C received was reasonable and that she was not informed about the risk of ITP because it is not a recognised side effect of the flu vaccination.

We also found that there was no record of Ms C's call to the practice to book an appointment. We considered that it was reasonable that there was no record of this call in Ms C's medical record. In the circumstances we did not have sufficient evidence to determine whether Ms C should have been offered an appointment or that the care provided by the GP Practice was unreasonable.

We did not uphold Ms C's complaints.

Summary

Ms C complained about the care and treatment she received at the GP out-of-hours service at Gartnavel General Hospital when she attended with a rash and bruising on her legs. We took independent advice from a GP. We found that the examination carried out within the out-of-hours service was reasonable and it was reasonable that Ms C was referred to the Immediate Assessment Unit (IAU) rather than A&E. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the care and treatment she received within the IAU at Queen Elizabeth University Hospital. We took independent advice from a consultant in acute medicine. While most of the care and treatment that Ms C received was appropriate, we found that it was unreasonable that Ms C was not assessed for signs of bleeding when an initial low platelet (cells that help blood clot) result became available. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to carry out an assessment for signs of bleeding when the initial low platelet result became available. 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 a low platelet count should be assessed for signs of bleeding.

Summary

Mrs C complained that the practice failed to provide her late aunt (Ms A) with appropriate care and treatment. Ms A visited the practice on three occasions and was later admitted to hospital where she was diagnosed with septicaemia (blood poisoning), multi-organ failure and metastatic gastric (stomach) cancer. Mrs C complained that the practice failed to reasonably investigate Ms A's symptoms. Mrs C also complained that the practice failed to respond to her complaint in a reasonable way.

The practice acknowledged that there were shortcomings in record-keeping and checking observations. The practice apologised and took action to address these issues.

We took independent advice from an adviser in general practice medicine. We found that the investigation and treatment decisions provided to Ms A at each of the three consultations were of a reasonable standard and that an emergency admission to hospital by ambulance was not required given the circumstances. We considered that the standard of medical care and treatment provided to Ms A was reasonable. We also found that the practice responded to Mrs C's complaint in a reasonable way. Therefore, we did not uphold Mrs C's complaints.

Summary

Ms C complained about the care and treatment provided to her late husband (Mr  A) by the board in relation to treatment of his cancer. Ms C raised concerns that after a scan which showed progression of Mr A's cancer, neither the 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) nor oncologist (a doctor who specialises in the treatment and management of cancer) involved in his care contacted him to discuss this with him. Ms C said that Mr A did not discover that his cancer had progressed until he contacted his GP several month later. Ms C also complained that when Mr A was having palliative chemotherapy (a treatment for terminal cancer to prolong survival and minimise suffering, but which cannot cure the disease) the oncologist failed to identify or investigate his low haemoglobin (a protein in the blood that carries oxygen).

We took independent advice from a consultant oncologist. We found that it was reasonable that Mr A's low haemoglobin was not identified as he had not been reporting unusual symptoms. However, we found that the failure to contact Mr A to discuss his scan results was unreasonable. We determined that this was due to a miscommunication between the oncologist and radiologist and that the radiologist had changed their practices as a result of this complaint. However, we upheld Ms C's complaint and made a further recommendation to the board regarding this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the breakdown in communication which resulted in neither the oncologist nor radiologist contacting Mr A to discuss the scan results. 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:

• When two or more specialists are involved in a patient's care, it should be clear who is going to contact them to discuss their ongoing treatment, and this contact should be made in a timely manner.

Summary

Ms C, a support and advocacy worker, complained on behalf of her client (Ms A) about the care and treatment Ms A received at Queen Elizabeth University Hospital following an operation. Ms A also considered that she had not received a transparent account of events of her post-operative care.

We took independent advice from a nurse. We found that Ms A had issues with urine retention after surgery. Ms A reported not feeling well and this was responded to by nursing staff; however, no attempt was made to catheterise (a  process that involves inserting a tube to the patient's urethra to allow urine to drain freely from the bladder for collection) Ms A, prompt her to self-catheterise or to take a bladder scan. We also noted there were inadequate records of Ms A's fluid balance.

Ms A also had issues with the surgical stockings she was required to wear after her operation, as she found these to be too tight. We noted that according to the Scottish Intercollegiate Guidelines Network (SIGN) guideline 122 a lack of mobility after surgery put a patient at risk of venous thromboembolism (a blood clot that starts in a vein) and devices such as surgical stockings should be worn unless there are specific reasons why these should not be used. We noted that there was no record of an assessment being carried out and we considered this should have been documented. However, as there was no evidence in the notes to raise concerns about the fit of the stockings, it was reasonable that these were worn.

In relation to the board's response to Ms A's complaint, we found that the board did not provide a full, objective and proportionate response.

We upheld both of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to perform a bladder scan and/or prompt Ms A to self-catheterise, failing to keep adequate records and for failing to provide Ms A with a full and objective response to her complaint. The apology should meet the standards set out in theSPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Nurses should have clear guidelines to ensure a consistent approach to the indicators patients should achieve during an assessment period or a trial of voiding post catheter removal.
• Assessment of the suitability of surgical socks recorded prior to application and regular review of these should be documented as part of ongoing care planning.

In relation to complaints handling, we recommended:

• The board should follow their complaints handling procedure and issue appropriate responses.

Summary

Mr C attended the Western Infirmary Hospital a number of years ago when he was experiencing dizziness and migraines. Mr C was referred for an MRI scan to investigate his condition further. Several years later, Mr C was diagnosed with a schwannoma (a tumour on the nerve tissue). His original MRI scan images were reviewed and he was told that the tumour had been visible at that time.

Mr C complained that there was a failure to investigate the tumour when he first attended hospital as it had been visible in his MRI scan. We took independent advice from a consultant neuroradiologist (a radiologist who specialises in the use of radioactive substances, x-rays and scanning devices for the diagnosis and treatment of diseases of the nervous system). We found that in retrospect, the tumour was visible in the original MRI scan. However, as it was small and not clearly defined, we found it was reasonable that it was not identified at that time. We found that even if the tumour had been identified then, it was reasonable for it not to have been reported as it was only borderline abnormal. We also found that Mr C did not yet have any sign of a neck tumour or any symptoms relating to it. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to provide an appropriate response to his complaint. We found that their response did not accurately identify all of his concerns or provide a reasonable response to them. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not accurately identifying and providing an appropriate response to all aspects of his complaint. 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:

• Complaints responses should accurately identify and provide a reasonable response to all the issues of concern.

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs  A) at Vale of Leven hospital. Mrs A had been admitted with a fractured hip after a fall and remained in hospital for four months before her death. Ms C complained about a number of medical issues, including the timing of the diagnosis of the hip fracture, hydration and nutrition, diagnosis of dementia and end of life care.

We took independent advice from a consultant physician. We found that whilst the documentation of the initial assessment of Mrs A should have been more detailed, her care and treatment was reasonable. We found that Mrs A's hydration and nutrition was managed appropriately and in line with national guidelines, that the diagnosis of dementia was appropriately handled and that her care was holistic and reasonable given her declining health. We did not uphold Ms C's complaint; however, we made a recommendation to the board regarding the documentation of the initial assessment.

Recommendations

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

• Patients with an unwitnessed fall should have a full neurological (nervous system) and musculoskeletal (muscles and bones) system examination documented on admission.