Health

Summary

Ms C complained that the practice unreasonably referred her to the community mental health team. The practice had been contacted by the social work department and the police about Ms C and, in response, the practice referred Ms  C to the community mental health team without discussing it with her or seeking her consent. Ms C complained about the referral saying that it was unreasonable in the circumstances.

We took independent advice from a medical adviser. We found that the practice did not follow the relevant guidance when they referred Ms C, and that referring her without her knowledge or consent was unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for referring her to the community mental health team withouther knowledge and consent. 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 follow the relevant guidance when they refer patients.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care and treatment she and her baby received during and after the birth at the Royal Alexandra Hospital (RAH) and the Royal Hospital for Children (RHC). Mrs C was concerned that the baby was not admitted to the RHC when they attended A&E with concerns about the baby's eyes. Mrs C also had concerns about her care as she had to be readmitted to RAH for a procedure and later again for treatment of sepsis (blood infection).

We took independent advice from a midwife and consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the in-patient care and treatment Mrs C and the baby received from both midwifery and medical staff was of a reasonable and appropriate standard. We did not uphold the complaint about the baby's care and treatment.

However, we upheld the complaint about Mrs C's care and treatment on the basis that there was a failure in communication with Mrs C about her discharge medication and the record-keeping associated with this. We found that there was no evidence in the medical records to confirm that Mrs C was given information about the safety and dose instructions of the painkillers (paracetamol and ibuprofen) she was prescribed. We considered that this was not appropriate and could have resulted in serious harm in the event of an inadvertent overdose.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failing in communication about discharge medication and record-keeping. 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 recommended/maximum daily dose and frequency of both paracetamol and ibuprofen should be documented in the medication section of the discharge letter. Staff discharging patients should document that the recommended/maximum daily dose and frequency of medication has been clearly explained to the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained about surgery he received at Glasgow Dental Hospital and School, which involved placing Bio-Oss (bovine bone material) around his jaw in order that he would have enough bone to support dental implants. He complained that some of the surgery had been carried out by a trainee without him giving consent for this.

We took independent advice from a consultant oral and maxillofacial surgeon (a  specialist in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck). We found that it had been reasonable for the trainee to carry out the procedure, however, there was not sufficient evidence that Mr C had been informed of this. Therefore, we upheld this aspect of his complaint.

Mr C also complained that the board had not adequately informed him of the risks of the operation. We found that the information given to Mr C had been reasonable and we did not uphold this aspect of his complaint.

Mr C was also concerned that the board had delayed in investigating the complications that he had after the operation and that they had not provided an adequate explanation of what had gone wrong. We found that Mr C had received treatment after the operation without unreasonable delay and that the explanation he had received was reasonable. We did not uphold these aspects of Mr C's complaint.

Finally, Mr C complained that the board had delayed in amending the policy and procedures in the hospital to prevent the problems he experienced from happening again. We found that the action taken by the board to learn from the case had been reasonable and we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of clarity in the consent form about the involvement of a specialist trainee in his surgery. 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 consent form should clearly and correctly reflect the situation if specialist trainees are to be involved in carrying out a procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained about the medical care and treatment and the nursing care provided to her late mother (Mrs A) at Royal Alexandra Hospital. Mrs A was admitted to the hospital with a urinary infection. Mrs A was discharged from the hospital and readmitted within a few hours. Mrs A had a seizure while in hospital and sustained a broken leg.

We took independent advice from a consultant in acute medicine. While the board provided reasonable medical care in a number of areas, we found that the board failed to:

• take steps to increase Mrs A's sodium levels and monitor the effect of this on her delirium prior to discharging her

• ensure that Mrs A received a prompt review from medical staff following her seizure

• administer anti-seizure medication to Mrs A because stocks were not available on the ward

• ensure that Mrs A's records made it clear that she had a fractured leg

We also took independent advice from a nursing adviser. In relation to Ms C's complaint that the board did not provide reasonable nursing care to Mrs A, we found that there were a number of failings. In summary the board failed to:

• ensure the recording regarding Mrs A fluid and nutritional needs followed the appropriate policy and guidance

• record the use of a red silicone mat at mealtimes

• record the date Mrs A's special diet was ordered

• record Mrs A's oral care needs and what oral care was provided

• record Mrs A's episodes of pain

• record Mrs A's specific personal care needs and the frequency that personal care was required in her care plan

• complete a multidisciplinary moving and handling care plan

• involve Mrs A and her family in the assessment and care planning process

• record the physical assessment carried out by nursing staff following Mrs A's seizure

• update Mrs A's care plan to detail what her post-fracture needs were.

In view of these failings we upheld Ms C's complaints that the board did not provide reasonable medical care and treatment and nursing care to Mrs A. We also found that the board did not identify these failings during their own investigation of Ms C's complaints and made recommendations in light of this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mrs A with reasonable medical and nursing care. 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:

• Patients with low sodium levels should not be discharged without attempts to increase them.
• Patients who have a seizure should be reviewed promptly by medical staff.
• Where prescribed medication is not available on the ward, this should be obtained from another ward or the pharmacy and administered accordingly.
• Fractures should be recorded clearly in patient medical records.
• Patients should receive adequate nutritional, hydration and oral care assessment and care planning in accordance with the relevant standards.
• Patient food and fluid recording charts should be completed in line with policy and guidance.
• Nursing assessments and care plans should clearly document the care needs of patients and what care has been provided.
• Where appropriate, assessments, care plans and reviews of care should be completed in collaboration with patients and their family members.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified and enable learning from complaints to inform service development and improvement.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained about the care and treatment that her mother (Mrs A) received when she attended the emergency department at Queen Elizabeth University Hospital. Mrs A attended the hospital with severe headaches and pain radiating down her face and mouth. Ms C said the consultant who dealt with Mrs A failed to consider her reported symptoms properly, failed to carry out a thorough physical examination of Mrs A and instead referred Mrs A to her GP.

We took independent medical advice from a consultant in emergency medicine. We found that as Mrs A did not present with features of an immediate life threatening condition, it was safe and reasonable to redirect her to her GP. However, we found that the triage process (the process for sorting patients in an emergency department according to urgency) for patients presenting with headache was not followed in Mrs A's case, and information which should have been obtained and recorded was not. The board should also have provided Mrs  A with a redirection leaflet which explained the redirection process. On balance, we considered that the board did not provide Mrs A with appropriate care and treatment and we upheld this part of the complaint.

Ms C also complained that the board unreasonably failed to send a report to Mrs  A's GP following her attendance at the hospital. We found that the board should have sent a letter to Mrs A's GP, but failed to do so. Therefore, we upheld this part of the complaint.

Ms C also complained that the board unreasonably delayed in responding to her complaint. The evidence showed that while there were delays in obtaining formal consent from Mrs A for Ms C to make a complaint on her behalf, there were also unreasonable delays by the board in their handling of Ms C's complaint. Therefore, we upheld this part of the complaint.

At the beginning of our investigation into this complaint, the board failed to provide us with the correct version of their redirection policy which resulted in a delay in our decision making. Therefore, we made a recommendation to the board in light of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C, her family and Mrs A for failing to follow their triage process in Mrs A's case and obtain and record information on Mrs A; failing to give Mrs A a redirection leaflet; not sending a report to Mrs A's GP following her attendance at the emergency department; and unreasonably delaying in responding to Ms C's complaint. 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 triaged within the emergency department should have their observations appropriately documented in line with the board's triage guidelines.
• Patients who are being redirected under the board's Redirection Policy should be provided with a redirection leaflet and this should be documented in the clinical records.
• In a similar situation, the patient's GP should be appropriately contacted on discharge from the emergency department.

In relation to complaints handling, we recommended:

• Complaints should be responded to in accordance with the board's complaints handling policy/procedure.
• The board should ensure that the correct documentation is provided at the appropriate point in an SPSO investigation.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Miss C complained about the care and treatment her late father (Mr A) had received in Glasgow Royal Infirmary before his death. Mr A had previously been diagnosed with lung cancer, which had been treated with radiotherapy (a  treatment using high-energy radiation). He also had moderate chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed), peripheral vascular disease (a common condition, in which a build-up of fatty deposits in the arteries restricts blood supply to the leg muscles) and severe heart disease. After his admission to the hospital, Mr A's condition deteriorated over the next week and staff decided that he was not fit enough to undergo further radiotherapy. Mr A died just over a week after being admitted to hospital.

We took independent advice from a consultant in acute medicine. We found that there had not been any failings in Mr A's care and treatment. His oxygen levels had been monitored appropriately and the action taken to diagnose and treat his chest infection were reasonable. It had also been reasonable to give Mr A morphine (pain relief) and to discuss end of life care with him. We did not, therefore, uphold Miss C's complaint.

Summary

Ms C complained to us about the care and treatment that her late partner (Mr A) received at Aberdeen Royal Infirmary when he attended on two separate occasions with severe chest pain. Mr A died during his second attendance at the hospital.

On Mr A's first attendance at the hospital he was seen in the Acute Medical Initial Assessment Unit and the Ambulatory Emergency Care Unit. Ms C complained about the assessment and examination that Mr A received and that he was diagnosed with musculoskeletal chest pain. We took independent advice from consultant in acute medicine. We found that assessments and examinations were reasonable and in accordance with the relevant guidance for chest pain. In particular, Mr A's chest pain was viewed as cardiac until it was positively excluded by the results of a troponin blood test and an electrocardiogram (ECG - a test which measures the electrical activity of the heart to show whether or not it is working normally). We did not uphold this aspect of Ms C's complaint.

Around two months later, Mr A attended the emergency department at the hospital. Ms C complained that Mr A's condition was too serious for him to be asked to sit and wait for an initial assessment. Mr A collapsed in the emergency department waiting area. He then went into cardiac arrest (where the heart suddenly and unexpectedly stops beating) and died. We took advice from a consultant in emergency medicine. We found that it was unreasonable that Mr A was asked to sit and wait for an initial assessment when he presented to the emergency department with chest pain and shortness of breath. 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 assess Mr A promptly when he presented to the emergency department with chest pain, clammy skin and shortness of breath. 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:

• Patients in a similar situation and/or with certain conditions and symptoms should be brought to the attention of nursing staff immediately, so that self-presenting patients can be fast-tracked for clinical assessment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client (Mr  A) who is in the process of gender transition. Mr A heard that a consultant in the Gender Identity Clinic (GIC) was going on extended leave, with no cover being provided, and therefore requested an out of area referral. He had been advised by his psychiatrist to seek the extra-contractual referral for medical reasons. Mrs C complained that the board failed to address Mr A's request in their response to his complaint and failed to provide an adequate service.

After Mrs C brought the complaint to us, the board wrote to Mr A and apologised for not having addressed his query about extra-contractual referral when they originally responded to the complaint. They explained that they would not support a referral to another board because they were continuing to offer the same level of service as previously. Given that the board had not addressed this referral request at the time it was made, we upheld this aspect of Mrs C's complaint.

In relation to the complaint about service provision, we took independent advice from a psychiatric adviser (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the level of service at the GIC had not changed and that there were plans in place and enacted to cover the period of leave taken by the existing consultant. We also noted that given there were no additional risk factors identified such as major mental or physical illness, there would be no indication to go outwith the normal process followed by the board. We considered that the board had gone to significant effort to ensure their service was not adversely affected by the period of leave and provided Mr A with a reasonable service. We did not uphold this aspect of Mrs C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• When responding to complaints, staff should be confident that they have addressed all relevant matters.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care and treatment her late husband (Mr A) received from the board's out-of-hours emergency care centre and during his time as an in-patient at Aberdeen Royal Infirmary. In particular, Mrs C was dissatisfied that the out-of-hours service did not admit Mr A to hospital at the time and that after he was admitted around a week later, he died following a head scan.

We took independent advice from a general practitioner in relation to the out-of-hours care and treatment. We found that an appropriate medical history was taken and an appropriate examination performed. We considered that it was not necessary to repeat blood tests that had been done at Mr A's GP practice which were found to be abnormal. We found that the out-of-hours service's decision not to admit Mr A to hospital was in keeping with national guidelines on the treatment of community acquired pneumonia (an infection of the lungs) and that appropriate antibiotic treatment was prescribed with follow-up review advised. Therefore, we considered that the out-of-hours care was reasonable and we did not uphold this aspect of Mrs C's complaint.

In terms of the hospital care and treatment, we took independent advice from a consultant in general medicine. We considered overall that there was evidence to show that the severity of Mr A's illness was recognised and responded to appropriately. We found that it was reasonable to perform a head scan given Mr  A's increasing confusion and there was evidence to show that his clinical observations (temperature, pulse, blood pressure and breathing rate) were stable before it was carried out. We found that there was evidence to support that communication took place with Mrs C and the family regarding Mr A's deteriorating condition and the possibility that he might not survive. We did not uphold this aspect of Mrs C's complaint but provided feedback to the board about checking a families understanding of information given to them.

Summary

Miss C, an advice worker, complained on behalf of her client (Mr B) regarding the care and treatment of his late wife (Mrs A). Mrs A had been admitted to Forth Valley Royal Hospital for treatment for influenza and was discharged back to her care home with medication. Mrs A had to be readmitted after five days where she was treated for pneumonia (a lung infection). Mrs A did not respond to further treatment and died in the hospital. Mr B felt that Mrs A should not have been discharged from the hospital initially and that staff had reached a wrong diagnosis.

We took independent advice from a consultant in medicine and found that Mrs A had received appropriate treatment during the hospital admissions. In the first admission, her symptoms were appropriately diagnosed as being influenza related and she received appropriate investigations and treatment and was discharged when her symptoms improved. Mrs A was then readmitted with different symptoms suggestive of further or a new chest infection. We did not uphold Miss C's complaint.