Health

Summary

Mrs C complained that the board failed to prevent her baby (Baby A) developing hypothermia (the condition of having an abnormally and typically dangerously low body temperature) in the hours after their birth at the Royal Infirmary of Edinburgh.

We took independent advice from a midwife. We found that Mrs C and hospital staff had different recollections of what was said about the reason why Baby A developed hypothermia. The medical records noted the likely reasons, such as possible infection or due to medication given to Mrs C during labour, but did not reach a definitive conclusion. We noted that staff gave Baby A antibiotics in line with relevant clinical guidance to ensure they recovered. We did not find evidence that the board acted unreasonably. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board's response to her complaint was unreasonable. Mrs C was particularly concerned that Baby A's hypothermia could have developed because the birthing centre was too cold. We found that the board failed to investigate this specific part of Mrs C's complaint, and did not respond to her about it, despite having noted it in their acknowledgement letter. 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 failing to investigate and respond to her specific complaint about the birthing centre temperature. 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:

• Responses to complaints should address the points raised, or explain why information cannot be provided.

Summary

Ms C complained about the way her son (Mr A)'s psychiatrist dealt with communication from Mr A's father (Mr B). Mr A is estranged from Mr B, and the psychiatrist had been in contact with Mr B regarding some communication from Mr A to Mr B's work. Ms C and Mr A subsequently met the psychiatrist whose' contact with Mr B was discussed. Ms C said that the psychiatrist failed to deal with the matter in a reasonable way.

We took independent advice from a medical adviser. We found that the quality of record-keeping in relation to clinical decisions made and the rationale for these in relation to the communication was poor. We also found that the relevant guidelines in relation to consent was not followed. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for how communication with Mr B was handled. 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:

• Relevant staff should follow the General Medical Council guidance in relation to consent.
• Clinical records should be audited regularly.

Summary

Mr C complained that there was an unreasonable delay in being offered an ophthalmology (the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) appointment at Hairmyres Hospital following a referral by his optician with possible glaucoma (a common eye condition where the optic nerve becomes damaged).

We took independent advice from a consultant ophthalmologist. We found that it had been an unreasonable for Mr C to wait for seven months for the appointment. We noted that the board had apologised to Mr C for the unacceptable length of time he had had to wait for the appointment. We also found that there was a lack of documentation of the triaging process (a process in which things are ranked in terms of importance or priority) used by the board for referral to secondary ophthalmic care which made the auditing of the triage decisions impossible. We upheld Mr C's complaint.

Recommendations

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

• Cases of possible glaucoma who have optic disc and visual field changes typical of glaucoma should be seen within four to six weeks.
• Triage systems for referral to secondary ophthalmic care should be transparent and auditable and should specify the desired appointment time in weeks.

Summary

Mr C complained about the care and treatment he received at Monklands Hospital. Following an accident, Mr C presented to the emergency department on three occasions over a two day period. He raised concern that doctors did not listen to his concerns about his injury and that an x-ray was not performed until his third presentation. At the first presentation, Mr C was examined for a head injury and was discharged without an x-ray being performed. Mr C returned to the department the next day and was assessed by a different doctor who also discharged Mr C. A short time later, the doctor revised their decision to discharge Mr C and he returned to the department a short time later. An x-ray identified that he had suffered a spinal fracture.

In response to Mr C's complaint, the board acknowledged that a scan should have been performed at the first presentation and an apology was offered to Mr  C. The board detailed a number of steps that would be taken to learn from the issues identified. We took independent advice from an emergency medicine consultant. We found that the board had appropriately identified all the failings in relation to this matter. We upheld this aspect of Mr C's complaint and asked the board to provide evidence of actions taken to prevent these failings reoccurring.

Following the diagnosis of a spinal fracture, Mr C experienced an episode of urinary retention (inability to empty the bladder completely) during the admission. A number of attempts at urethral catheterisation (insertion of a thin tube into the urethra to drain and collect urine from the bladder) were made, yet these were unsuccessful. Urology doctors (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) offered to perform suprapubic catheterisation (surgical insertion of a thin tube through the skin to drain and collect urine from the bladder), yet Mr C did not consent to this procedure. Mr C felt that doctors did not listen to him when attempting catheterisation and was unhappy that a camera was not used to assist catheterisation. We took independent advice from a consultant urologist. We found that the attempts at catheterisation were not sufficiently documented and that the documentation regarding consent was inadequate. Therefore, we upheld this aspect of Mr C's complaint.

Finally, Mr C was unhappy that, during a previous admission to hospital a number of years before, he was not informed that he had experienced complications related to urological treatment. We did not find evidence that Mr C had experienced complications related to earlier treatment and so we were unable to conclude that there had been a failure to inform Mr C. Therefore, we did not uphold this aspect of his complaint. However, we gave feedback to the board regarding communication as it seemed that a communication breakdown had contributed to Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the inadequate documentation of the urethral catheterisation attempts and the inadequate documentation of the consenting process for catheterisation. 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:

• Where catheterisation has been attempted, this should be documented along with any complications (such as bleeding). Where the attempt fails, the size of the catheter used, the level of obstruction within the urethra and number of attempts should be clearly documented.
• The risks and benefits of catheterisation should be explained to the patient and this should be documented. If a patient has objections or queries about catheterisation, these should be listened to, documented and resolved before proceeding with catheterisation.

Summary

Ms C, an advocacy and support worker, complained on behalf of her client (Mr  A) about the care and treatment for knee pain Mr A received at Raigmore Hospital. Mr A had been assessed by a physiotherapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) but they did not arrange an x-ray or CT scan. Mr A's GP continued to prescribe pain relief, but as there was no improvement he sought a private opinion. The private opinion included a CT scan of the knee which identified that Mr A would require surgery for a torn cartilage. Mr A complained that there had been a delay in his treatment by the failure of the physiotherapist to arrange a CT scan of his knee.

We took independent advice from a physiotherapist. We found that the physiotherapist had taken an appropriate medical history from Mr A and an appropriate examination which resulted in a reasonable diagnosis of degenerative damage to the knee cartilage with a treatment plan of rehabilitation. There was no clinical requirement to arrange a CT scan at that time. Although it was subsequently established that Mr A had suffered an acute cartilage injury rather than by normal wear and tear, the treatment by rehabilitation can be used for either. Therefore, did not uphold Ms C's complaint.

Summary

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.

Summary

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.

Summary

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.

Summary

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.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mrs A with reasonable nursing care during her admission to hospital. 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:

• Daily checks on Peripheral Vascular Catheters should be carried out and recorded in accordance with relevant standards.
• The appropriate care plan should be in place in accordance with relevant guidance.
• Patient Feed/Fluid Balance Charts should be completed in line with policy and guidance.
• There should be appropriate assessment, monitoring, recording and communication regarding patients at risk of developing pressure ulcers in accordance with relevant policies and guidance.
• A “Getting to Know Me” document should be used to support person centred care for older people in hospital, especially if they are frail.
• Active Care or Care Rounding Charts should be used to evidence that patients have been asked about their care and comfort needs.

Summary

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.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to discuss Mr A's prognosis, to provide appropiate follow-up and for the lack of knowledge about the complaints 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:

• In patients with conditions that are likely to impact upon their prognosis, early discussion should be had with the patient and their family that is clear, unambiguous and documented.
• Cardiology patients should be appropriately followed-up/reviewed.
• All staff should be aware of the complaints process and able to advise accordingly.