Health

Summary

C complained that the board had unreasonably failed to follow the care plan put in place to support them with their mental health. In particular, C complained that the board had failed to arrange their admission to hospital during an episode of crisis.

The board’s response to C’s complaint advised that they had been appropriately assessed at the time, with it being the view of the mental health service that further support in the community would help to reduce the need for an inpatient admission. The board also advised that, in keeping with the care plan, C’s request for admission had been discussed with a consultant psychiatrist, with the decision not to arrange admission on this occasion being based on clinical opinion.

We took independent advice from a consultant psychiatrist. We found that C’s care plan included provision for a five day admission to hospital when required, however, the need for this would be discussed with a consultant at the time. When C reported feeling low in mood to the mental health service during their episode of crisis, they had responded reasonably, noting that C had been supported by increased phone and face to face contacts. On receiving C’s requests to be admitted to hospital, this had been assessed by the consultant psychiatrist in keeping with the care plan. Overall, we considered that the board had reasonably followed C’s care plan. We did not uphold this complaint.

Summary

C complained on behalf of their spouse (A) about the care and treatment provided by the board before they died. A was an end of life patient having been diagnosed with incurable lung cancer. A developed symptoms likely caused by an obstruction of one of the major blood vessels attached to the heart and was scheduled to have a stent inserted through the blockage. C complained about their experience on the ward on the day of the procedure which, they said, caused great pain and distress.

We took independent advice from a registered senior nurse. We found that A lacked person centred information to prepare them for admission which caused distress, that there was a failure to provide a clear pathway for a patient diagnosed with end stage lung cancer the Peripheral Vascular Cannula (PVC)(insertion of a plastic conduit across the skin into a vein) process was not followed. We found that a pressure ulcer risk assessment was not undertaken and a plan of care not developed or implemented to prevent pressure damage. We also found that there was a failure to provide A with their prescribed steroids, despite requesting this. We noted record keeping failures during A’s admission and found failings in the board’s handling of the complaint, with the complaint not addressing all the issues raised by C and failings to fully investigate and respond to C about the PVC process. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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:

• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant nursing and midwifery standards.
• Patients should be appropriately assessed to prevent pressure ulcer damage, in accordance with the current pressure ulcer prevention and management standards.
• Patients should receive appropriate information to prepare them for a procedure, and to manage expectations about the admission. The board has said a draft patient information leaflet relating to the Superior Vena Cava Stent Insertion procedure has been developed and awaits final approval. The board should consider updating this leaflet to address person centred concerns.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to investigating and addressing all the elements of a complaint.

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 that their late adult child (A) received from the board about symptoms of productive cough, breathlessness and occasional wheeze. A was referred by their GP to the board and received two outpatient chest x-rays. Separately, A also self-presented at the A&E owing to their symptoms, where they were discharged with a trial of steroids and inhaler. A’s first of the two outpatient chest x-rays was reported as normal and their GP routinely referred them to the respiratory department for further investigation of their symptoms. The second of the two outpatient chest x-rays was considered to show changes suggestive of pulmonary oedema (a condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally). At this point, A’s GP upgraded the respiratory referral to urgent. On vetting by a respiratory consultant, A’s GP was contacted with advice to commence a diuretic (drugs that enable the body to get rid of excess fluids) straight away and urgently refer A to cardiology, on suspicion of heart failure.

A was seen at the cardiac function clinic, with the plan being made to see them at the heart failure clinic. A’s condition deteriorated before being seen at the heart failure clinic and the GP arranged for their immediate admission to the coronary care unit (CCU). A suffered a cardiac arrest shortly after admission requiring resuscitation, and they were subsequently transferred to another health board for surgery where they died.

C complained about the delays by the board to assess, diagnose and treat A’s condition, especially as A had presented to the A&E, and after the follow-up x-ray showed significant deterioration within a 4 week period. Having been referred to cardiology, C complained that the board failed to treat A’s condition with the urgency it required. C also complained that A had been transferred to another health board for surgery when it was known A’s condition was such that this intervention would have been futile.

The board’s response to C’s complaint advised that the treatment A received at the A&E was appropriate to their presenting condition at the time. The board did not comment on the timings of the cardiology appointments or assessments, however they explained the immediacy of A’s condition was understood at the time of the admission to CCU, with appropriate treatment being provided at the time, including in relation to A’s transfer to another health board for surgery.

We took independent advice from three clinical advisers, a consultant radiologist, a respiratory and general medical consultant and a consultant cardiologist (specialist dealing with disorders of the heart). We found that the treatment provided to A at the A&E was reasonable, based on what was known at the time.

We found that the first of the outpatient chest x-rays which had been reported as normal was in fact abnormal and required clinical correlation in respect of A’s presenting symptoms. Had this happened, a cardiac cause for A’s symptoms could potentially have been made sooner. With regards to the second chest x-ray, we found that the board failed to use the radiology alert system in place to flag urgent and/or unexpected findings.

We also found that the vetting process by the respiratory consultant had been reasonable, as was the advice to urgently redirect to cardiology and immediately commence A on a diuretic. On the matter of the timing of A’s cardiology review, we found that this was unreasonable in light of them having significant indicators of heart failure, known to date back. We found that A received reasonable care and treatment on being admitted to CCU and ICU. On balance of the above, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in assessing and treating A’s condition. 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 presenting with signs of heart failure should be appropriately assessed including in relation to deciding to manage patients in an inpatient or outpatient setting.
• Abnormal findings on x-rays should be appropriately identified and reported.
• X-rays which are considered critical, urgent and/or where unexpected significant findings are identified should be flagged to the referrer using the significant finding alert system.

In relation to complaints handling, we recommended:

• The board should ensure SPSO requests for documentation and evidence are responded to in line with the time frames requested and that they are fully compliant with their complaints handling guidance when responding to SPSO enquiries.

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.

When this report was first published on 21 February 2024, it referred to A as 'late child' of C.  However the summary was amended to read 'late adult child' on 26 March 2024 for clarification.  We apologise for any confusion caused.

Summary

C complained about a mis-diagnosis of their parent (A) at hospital. C noted that A was diagnosed with pancreatitis (inflammation of the pancreas) during their first admission. A CT scan was taken to confirm this diagnosis. During a later second admission, blood tests and an ultrasound were taken but no CT scan was taken and pancreatitis was again confirmed. A then attended a different hospital while away. A CT scan was taken and A was diagnosed with late stage pancreatic cancer and died shortly after. C complained that the pancreatic cancer had not been diagnosed at the original hospital. The board explained that the original scans confirmed pancreatitis and showed an abnormality which increased the risk of it recurring. During A's second admission, blood tests confirmed acute pancreatitis and there were no clinical signs to indicate that a further CT scan should be arranged.

We took independent advice from a gastroenterology (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) adviser. We found that the care and treatment was appropriate throughout the period and that there was no reason to suspect pancreatic cancer. In their second admission, A’s presentation was consistent with an attack of mild acute pancreatitis and immediate further CT scanning was not indicated at this time. As such the complaint was not upheld.

Summary

C complained about the care and treatment provided to their adult child (A). C complained that actions taken shortly before and after A’s discharges were unreasonable as was the board’s response to the complaint.

We took independent advice from a consultant in general medicine and a registered general nurse. We found that appropriate assessments were carried out prior to discharge and that the board reasonably discharged A. As such, we did not uphold these parts of C’s complaint.

We considered C’s complaint regarding the level of support offered after A’s falls. We found that the board’s response to these falls were reasonable. Action taken after the fall in the car park were in line with policy and the level of staffing available on the day, and in relation to the fall while being admitted, the care as documented was considered to be reasonable. As such, we did not uphold these parts of C’s complaint.

In relation to the complaints handling, we found that there were failings in the response to C’s verbal and written complaints, with no response issued to the verbal complaint, and not providing a full response to the written complaint. While there were some aspects of the board’s response which were reasonable, overall we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably respond to the complaints regarding A’s discharges and the response to A’s fall in the car park. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• All staff must be aware of the complaints handling procedure and how to handle and record complaints at the early resolution stage.
• Complainants should be advised prior to the deadline if the board will not meet the 20 working day target for responding to a complaint, and be advised of the reasons for the delay.
• Responses to complaints should be clear and answer the points of concern raised.

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 surgery performed to remove material from their leg was not carried out to a reasonable standard. C broke their leg and underwent an operation to insert pins, plates, and a device known as a ‘TightRope’ (a device where string is passed through a channel in the bone and secured with ‘buttons’ at each side) to stabilise their leg. C developed an infection in their leg and subsequently underwent a further procedure to remove the ‘TightRope’. The procedure was not successful, some material was retained in C’s leg and the infection persisted. C then underwent further procedures to have the material removed completely, however, the infection proved to be too advanced and C had a below knee amputation. C complained that the board did not appropriately remove the ‘TightRope’ material during the initial procedure when they should have done.

The board said that although there was an intention to remove all of the ‘TightRope’, the material is not always visible. Cutting through the ‘TightRope’ in order to pull it through, staff expected all of the material to come out. Staff assumed that they had removed all of the suture, however, some of the material had stayed behind. The only way to have fully confirmed this would have been to make a larger hole through the bone, which could have allowed further spread of the infection.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the surgeon who carried out the initial procedure to remove the ‘TightRope’ should have been familiar with the device, including the volume of material, and should therefore have been able to assess whether removal was complete. The surgeon should have curetted (cleaned/scraped) the channel in the bone to ensure that all material was removed. We noted that an experienced surgeon would likely have undertaken a more complete removal of the material and suggested that the board could consider reviewing their arrangements for supervision of surgeons who are not experienced in a specific procedure. We considered that the initial surgery performed to remove the ‘TightRope’ material was not carried out to a reasonable standard. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out the procedure to an acceptable standard resulting in some material being retained in the TightRope channel and for the impact this had on C. 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 high standard.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Complaints Handling Procedure. Particular notice should be given to the responsibility to ensure that staff learn from complaints, especially when mistakes have been identified. Good practice should be followed when compiling the complaint response.

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 their cancer diagnosis was unreasonably delayed. They had previously suffered from cancer which had been successfully treated. C believed there was an inappropriate focus on the wrong part of their throat as a consequence, and that this combined with inadequate review of the CT imaging of their oesophagus had resulted in a delayed diagnosis, much more significant surgery and had allowed the cancer to spread to other parts of their body. C believed the extent of the cancer when diagnosed, meant it must have been visible earlier in the diagnostic process.

We took advice from a consultant ear, nose and throat surgeon. We found that C was correctly examined and there was no evidence of failings in their care. It was not possible to determine whether earlier diagnosis would have resulted in a different outcome for C. We did not uphold the complaint.

Summary

C complained on behalf of a family member (A) who was diagnosed with breast cancer and died less than two years later. C complained that during a consultation the consultant oncologist (specialist in the treatment of cancer) treating A had given the impression that despite having a condition that was treatable but not curable, A was likely to live for many more years. C noted that they had been present when this had been explained, and that it was evident that A had made important life decisions based on what C considered, in light of subsequent events, to be have been highly misleading communication. C also noted a lack of documentation relating to the initial consultation.

In response, the board stated that the oncologist treating A was clear that it had been explained that they had metastatic, stage four cancer. The consultant was also certain that they had not stated that the treatment would definitely work in an on-going sense and life-expectancy would be unchanged. The board apologised if this has been the impression formed by A.

We took independent advice from an oncologist. We found that the board’s position that it was not the oncologist’s custom to discuss life expectancy at the first meeting in order not to overwhelm a patient, and that such predictions can be very difficult to make was reasonable. Additionally, we noted that a letter had been sent to A’s GP following the initial consultation. We found it was not unreasonable for a letter to be in lieu of additional notes in a paperless system, and that it is not a requirement for a copy to also be sent to the patient. We also noted that this was one of a number of records and communications with A’s GP that were somewhat generic in nature, noting that while a further letter referenced discussions of palliative options, which implied a discussion about the seriousness of A’s condition, this letter could have been more specific in relation to what exactly was discussed.

Overall, we found that while communication and documentation could have been better and more detailed, it was reasonable. For this reason, we did not uphold C’s complaint. However, we did provide feedback for the board outlining the adviser’s criticisms of the documentation in relation to communication.

Summary

C complained about arterial surgery. The board accepted that there were issues related to the systems in place at the time for the sharing of information between board sites and communication, and apologised for this.

We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, the issues related to the sharing of information between board sites and communication meant that aspects of the care and treatment C received fell below the standard C could reasonably expect. We upheld C’s complaint.

Recommendations

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

• That the board review their policies and practice regarding inter-hospital transfers, specifically around documentation accompanying patients and verbal ward-to-ward handovers and that the board feedback the findings of this investigation to the medical team involved with C to highlight the poor communication with C and their family whilst they were in hospital.

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, an MSP, complained on behalf of their constituent (B) about the standard of care B’s late spouse (A) received from their GP practice. A attended an appointment with a GP and received antibiotics and steroids for a possible chest infection. A’s health deteriorated a short time later and they suffered a cardiac arrest at their home. B complained that the practice failed to recognise that A was suffering from a serious cardiac condition.

The practice said that a full examination and history had been taken from A. The GP concluded that the symptoms were from the chest wall rather than originating from the heart, with a suggestion of chest infection and narrowing of the airways. A received steroids and an antibiotic in treatment of a chest infection, and given advice on what to do if their condition worsened. On learning of A’s death, a Significant Event Analysis was carried out by the GP, which identified learning points in relation to arranging ECGs (a test that records the electrical activity of the heart, including the rate and rhythm), and strengthening the advice given to a patient about phoning again should their condition worsen.

We took independent advice from a GP. We found that it was reasonable for the GP to treat A on suspicion of a respiratory infection having taken a history and clinical examination. While A’s oxygen saturation levels were low, this can also be found in cases of acute or chronic lung disease, such as infection. A also displayed symptoms that were not typical of classic heart attack pain. We found that A’s blood pressure and heart rate were both normal which did not suggest a heart attack. We considered that the GP made a careful assessment and reached a reasonable working diagnosis at the time based on the information available and their clinical judgement. Therefore, we did not uphold C’s complaint.