Health

Summary

C complained about the care and treatment provided to their parent (A) during an admission to hospital. At the time of admission, A was taking medication for atrial fibrillation (a heart condition affecting the rhythm and rate of the heart). The medication included a blood-thinner to reduce the risk of blood clots. While A’s condition was being assessed, a decision was made to withhold this medication. A developed pain and discolouration in their leg and was unable to weight bear. C complained that there was a delay of 12 hours before medical staff acted upon this. A required a transfer to another hospital by ambulance, where they underwent emergency surgery for clots in the leg. A has been left with deep incisions in the lower leg and their mobility has been significantly reduced.

The board discussed the case at a Morbidity and Mortality meeting, and following review of the circumstances did not think that there was anything from a system perspective that should be changed.

We took independent advice from a consultant physician and geriatrician (specialist in medicine of the elderly). We found failings in record keeping and examination. We found that the board ought to have been alert to the risk of A developing blood clots after the blood-thinning medication was withheld, and should have acted more promptly when A started to deteriorate. We considered that A suffered pain for a longer period because their deterioration was not recognised in a timely manner. Their situation might not have been so serious had their condition been recognised sooner. We also found that the board did not carry out a suitably rigorous analysis of what happened, including review by staff who were not involved in A’s care. The board’s review failed to identify appropriate learning. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings our investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Before reaching a decision to stop anticoagulant medication in patients with atrial fibrillation, full consideration should be given to the risks and benefits of doing so. Clear records of patient care should be maintained, with all patient examinations documented. Deterioration in patients should be escalated appropriately including clinical examination where merited. Staff are confident in identifying adverse events and conducting appropriate reviews.

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

C complained about delays in ambulance response time after their elderly parent (A) had a fall at their care home. Care home staff called 999 and, following triage, the call generated an emergency but non-life-threatening response. A clinical triage call took place shortly after followed by another 999 call by care home staff. A paramedic response unit arrived at A’s location, followed by an ambulance. A arrived at hospital around 5 and a half hours after the first 999 call.

Scottish Ambulance Service (SAS) acknowledged that the wait for an ambulance was unreasonable and apologised to C for this. They explained that the delay was due to limited resource and very high demand at that time. C was unhappy with this response and brought their complaint to us. C felt that A was not prioritised fairly following the 999 and clinical triage calls. C considered this to be partly due to A’s age. Although SAS had already acknowledged that there was an unreasonable delay, we carried out an investigation to determine whether the assessment and prioritisation of the calls also contributed to that delay.

We took independent advice from a paramedic. We found that the non-clinical call handling was appropriate. We also considered that there was no indication that A was treated differently or unreasonably as a result of their age. Therefore, we did not uphold C’s complaint. However, we did provide feedback to SAS regarding an aspect of the clinical triage call which did not cause or contribute to the delay in an ambulance being provided, but was not in line with relevant national guidance.

Summary

C complained about the ear, nose and throat surgery (ENT) that they received from the board. C was referred for surgery for biopsy of a nasal ulcer that would not heal, and for treatment of a nasal drip. C complained that the biopsy had not been taken as expected, which they were not aware of until making a complaint. C also complained that they had been left worse off due to a perforation being caused during the procedure. This has caused them to have an audible whistling sound when they breathe. C said that, while the risk of perforation had been mentioned at the outpatient appointment, they were led to believe it was not something they had to worry about. Furthermore, they were not told that if it happened, it wouldn’t heal naturally, and surgery to fix it often fails.

The board explained that the biopsy had not been taken as the ulcer had healed by the time C attended for surgery. The board apologised for the perforation. They noted that the surgeon was not aware of one occurring before in their career but had since changed their practice to ensure it was discussed when obtaining consent.

We took independent advice from an ENT adviser. We found that C had not been reasonably consented for surgery at the outpatient clinic or on the day of surgery. We noted that the documentation did not support the reported discussions which took place about the surgery or the associated risks, or the implications should C have decided not to proceed with the procedure. We also found that the written information provided to C was unreasonable. The patient information leaflet did not provide information about the short and/or long-term implications of a perforation or that it may occur after the surgery has taken place. It did not note that it was unlikely to heal on its own, that surgery to correct it may not be an option or, if attempted, successful.

We considered that C had received reasonable post-operative care and follow-up from the board. It was reasonable to plan to see them back at 3 – 6 months, and for this to be expedited at the point of C reporting their concerns about the whistling noise that had developed. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in relation to the consent process for surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be reasonably consented for surgery and this should be documented in the patient’s medical record and on the consent form for the planned procedure.
• Patients undergoing septoplasty surgery should be given appropriate verbal and written information about the procedure. Risks and complications should be fully explained to allow patients to make an informed decision.

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

C complained about the care and treatment provided to their parent (A) on two separate admissions to hospital. A was detained on both occasions under the Mental Health (Care and treatment) (Scotland) Act 2003. C had concerns about A being sedated and that staff had restrained A in an inappropriate manner.

In their response to the complaint, the board explained the care provided to A, the reasons for the administration of medication, how this was overseen and adjusted to address A’s levels of sedation, and the process and performance of restraints when they were required. C was dissatisfied with the board’s response and brought their complaint to us.

We took independent advice from a consultant psychiatrist and a mental health nurse. We found that on both admissions, there was appropriate oversight of A’s medication and care was taken to consider sedative effects and find a balanced approach. We found that medications were administered appropriately to manage A’s distress and aggression. Therefore, we did not uphold this part of C’s complaint.

In relation to the use of restraints, we found that these had been performed reasonably and that A’s concerns about pain to their ribs was appropriately assessed. Therefore, we did not uphold this part of C’s complaint. However, we did provide the board with some feedback on the requirements for accurate record keeping.

Summary

C complained about the care and treatment that their late parent (A) received whilst in hospital following a stroke. C said that the board failed to provide appropriate nutrition for A when they lost the ability to swallow. A required a percutaneous endoscopic gastrostomy (PEG) feeding tube to be fitted (a tube passed into the stomach through the abdomen to provide a means of feeding). However, there were delays with this and A died shortly after the procedure was carried out. C was concerned that other types of feeding were not considered by the board and that staff were not appropriately qualified to deliver alternative feeding.

The board said as soon as it became apparent that a PEG feeding tube would be appropriate, a referral was made to have this done. A dietician identified another method of feeding called TPN (a type of nutritional fluid administered to a patient intravenously) however, ward staff were concerned that they were not trained on how to deliver this method of feeding. As such, a decision was taken to expedite the referral to have the PEG tube fitted instead.

Before surgery could take place, A had to be tested for COVID-19. The results of the test were not back in time for surgery to be carried out on the day it was initially scheduled. The board apologised for the delay that this caused.

We took independent clinical advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the clinical decisions made in the management of A’s nutrition were reasonable. TPN feeding is not typically used in cases like this one. The standard of care was in keeping with guidance and was of reasonable quality. However, the delay in receiving the results of the COVID-19 test, and the failure to expedite this, was unreasonable. This led to the delay in treatment. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in receiving the results of the COVID-19 test that led to a delay in A having a PEG tube fitted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Obtaining the results of tests required before surgery should not be delayed. In cases where surgery is urgent, tests should be expedited where required to ensure that they are received timeously in order to avoid delays in the patient receiving surgery. When delays are experienced, the reasons for this should be noted in the medical records.

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

C complained about the care and treatment provided to their adult child (A) in relation to A’s pregnancy. A attended hospital on two occasions over a weekend with no fetal movement. The baby (B)’s heartbeat was considered normal on both occasions and A left the hospital with a plan to return on the Monday. On A’s return to hospital, an intrauterine death (when a child dies in the womb) was diagnosed. A requested to have their waters broken to relieve the pressure that they were experiencing. A ‘s labour was very quick and they delivered B in the toilet of the labour suite at the hospital. They called for a midwife to attend and assist them.

C complained that the hospital did not listen to their concerns for B to be delivered as an emergency. C and A believed that there was too much focus on B’s heartrate and that further investigations, including ultrasound, should have been undertaken. C also complained about the difficult circumstances of B being born in the toilet, and the care provided in the run up to, and following, labour.

In response to the complaint, and following the completion of a Significant Adverse Event Review (SAER), the board found no specific failings of care which led to B’s death. Monitoring of A and B was appropriate, and ultrasound scanning was not available over the weekend. The board noted that A had chosen to return home, rather than be admitted over the weekend which was against medical advice. The board explained that early delivery by caesarean section was not indicated given the clinical picture was reassuring. C and A met with representatives from the board following the complaints response where issues relating to the delivery of B were discussed. The board acknowledged that a midwife should have responded to A’s calls that they were delivering B in the toilet, and acknowledged that A should not have been in a labour ward where they could hear other mothers and healthy babies.

C was dissatisfied with this response and brought their complaint to us. They disputed the accounts of doctors that A was advised about the risks of going home during the weekend and remained of the view that more should have been done for A and B over the weekend.

We took independent advice from a GP who worked as an obstetric and gynaecology registrar (a specialist in pregnancy, childbirth and the female reproductive system) and a registered midwife. We found that appropriate advice was offered to A about the risks of returning home over the weekend, that the level of monitoring and assessment was reasonable and that the assessments were reassuring with respect to the health of A and B. Therefore, we did not uphold this part of C’s complaint.

In relation to the treatment provided to A during labour, we found that care in preparation for delivery of B was reasonable, with appropriate monitoring and pain relief provided. When A rushed to the toilet, given the recent examinations checking the progress of A’s labour, it was reasonable for midwifery staff not to consider A was about to give birth. However, there was a lack of documentation and records at the time of delivery and the immediate period before and after this which prevented our office from drawing conclusions about the level of care provided. Given the board’s acknowledgements that a midwife should have attended immediately to A when they called for help, together with the lack of appropriate record keeping during labour, and the accommodation in the labour suite being inadequately soundproofed, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Clinical and midwifery staff should keep clear and accurate records, relevant to their practice, in line with the Nursing and Midwifery Council code.

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

C complained about the care and treatment provided to their late spouse (A). A was admitted to hospital with a suspected small bowel incarcerated in the hernia (a part of the intestine that becomes trapped in the sac of a hernia). Following a CT scan and assessment by a surgeon, it was decided to treat A’s condition conservatively and transfer them to a larger hospital in the area. However, there was a delay in the transfer taking place due to a lack of ambulance resource and A’s condition deteriorated further during their admission. A died shortly after admission. C complained about the delay in transferring A to another hospital or operating on them sooner. In C’s view, A did not receive a reasonable standard of treatment or end of life care following their admission to hospital. In addition to this, C complained about the board’s communication with the family during A’s time in hospital.

We took independent advice from an emergency medicine consultant and a general and colorectal surgeon (specialist in conditions of the colon, rectum or anus). We found that the treatment provided by the board was reasonable. In light of A’s presentation, and without the benefit of hindsight, it was reasonable to treat A conservatively and arrange for a transfer to a better resourced centre. We also found that the end-of-life care provided to A was reasonable, given A’s rapid deterioration and the circumstances within the hospital at that time. Therefore, we did not uphold this part of C’s complaint.

In relation to the standard of communication with the family, taking into account A’s rapid deterioration and the circumstances within the hospital at the time, we concluded that communication was reasonable. Therefore, we did not uphold this part of C’s complaint.

Summary

C suffers from chronic pain and had been receiving pain management and musculoskeletal physiotherapy treatment from the board for many years. Changes were made in the board’s approach to pain management which coincided with some experienced consultants retiring. C’s care and treatment was reassessed and a number of treatments previously provided to C were said to no longer be available and an emphasis was placed on self-management. C complained that withdrawing treatments harmed their health and wellbeing, the local pain management service was now limited requiring patients to travel for certain treatments, effective interventions were removed, the board prioritised cost over patient needs, and the transition to self-management relied too heavily on online resources.

The board stated that the changes were evidence based and in line with clinical guidelines.

We took independent advice from an experienced pain management consultant. We found that the board were correct in stating that the current guidance for the management of chronic pain does not support the long-term use of massage, acupuncture or trigger point injections. We noted that the transition away from this approach towards self-management can be very challenging for patients. We considered that C had been offered a person-centred management plan. We also found that it was reasonable for the board to have explained to C that previous therapies offered in an ongoing sense were likely provided because of discretion and goodwill on the part of a now retired physiotherapist. We noted that this is not uncommon for practitioners, however, approaches to treatment change over time. We did not uphold C’s complaint. However we provided feedback about the need to reflect on cases such as this to inform how best to manage similar situations in the future.

Summary

C, a support and advocacy worker, complained on behalf of their client (A) about the care and treatment that A received from the board in relation to a planned gynaecology (relating to the female reproductive system) surgical procedure. Following a discussion with the operating consultant on the day of the surgery, A said that the planned procedure was changed from a keyhole subtotal hysterectomy (removing the main body of the womb and leaving the cervix in place) to a keyhole total hysterectomy (removing the womb and the cervix). A said that they felt they had been put under pressure to accept the operation, and did not understand the consequences of losing their ovaries.

A’s surgery was carried out at a private sector hospital by the board’s surgical team due to the board experiencing issues with theatre capacity at that time. During the operation, a complication occurred which caused A to bleed and the procedure was converted to an open procedure to manage the bleeding. Having complained about the matter, the board explained to A that an issue with equipment during the surgery meant that the correct equipment had not been available during the procedure. A complained to the board on two further occasions in order to gain more understanding about the complication and the issue with the equipment which had occurred during the operation. A felt that the board’s responses were contradictory and asked C to complain to this office on their behalf.

We took independent advice from a consultant gynaecologist. We found that there were failings in relation to the process of consent at both the pre-operative clinic and on the day of surgery. We also found failings in relation to the documentation of the operation, including the complication and the way this had been managed during the procedure, and in the equipment log of the surgical instruments used during the procedure. To manage the bleeding, we found that the choice of equipment used had been unreasonable, noting it was likely this would have caused further tearing and bleeding, as appeared to have happened in this case. We found that the post-operative communication with A had been unreasonable in relation to the explanation given regarding the complication, and in relation to the change of procedure and the implications of this on A’s future health. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Operations should be carried out to a reasonable standard. Operation notes should provide a clear record of the procedure carried out and include relevant information about technique, and of significant findings and incidents and on the management of same.
• Patients should be given complete and accurate information during the consent process for surgery to enable them to make informed decisions about the planned procedure. Discussions with patients should be fully documented in the medical record and include key areas of discussion in relation to the pros/cons of the procedure; the risks associated with the procedure generally; and with reference to any specific risks for the individual patient.
• Post-operative communication with patients should be informative and transparent. The discussion should be documented in the medical record.
• When significant failings become apparent via the complaint process, the board should commence an internal risk management review process, appropriate to the circumstances of the case.

In relation to complaints handling, we recommended:

• Complaint responses should be clear and fully respond to the issues raised. This should include a full explanation of what occurred and a description of what happened and/or what should have happened at the time.

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

C complained that the board failed to provide their spouse (A) with reasonable care and treatment during an in-patient admission to hospital for a fractured hip. C who is A’s Power of Attorney also complained that the board failed to communicate adequately with them and A’s family.

We took independent advice from an orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found that the board had failed to provide A with adequate care and treatment, particularly in relation to pressure care management. We found that the board had failed to maintain a reasonable standard of care records. We also found that the board failed to communicate adequately with C and A’s family. Therefore, we upheld C’s complaints. Additionally we found that the board failed to adequately investigate C’s complaint and made a recommendation to address this.

In response to our enquiries during our investigation, the board sent us a detailed list of actions that they have taken to address and learn from the failings we identified. We considered that these were reasonable, but that further learning could be identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failings in communication identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failings in the board’s complaint handling identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide C with a copy of the action plan (redacted to remove any personally identifying or otherwise sensitive details) and an update on the progress of implementation.

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

• All relevant documentation including the nursing notes should be completed in accordance with the relevant policies and guidance.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling 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.