Health

Summary

C underwent a coronary artery bypass surgery (a surgical procedure that creates a new path for blood to flow around a blocked or partially blocked artery in the heart). C required three further surgical procedures on their chest wound over a period of seven years after their bypass surgery. C’s chest wound developed a sinus (a track that extends from the surface of an organ to an underlying area) and did not heal properly. C also developed osteomyelitis (a bone infection) in their chest wound. C raised concerns about the care and treatment that they received from the hospital.

We took independent advice from a consultant cardiac surgeon. We found that the clinical treatment provided to C was reasonable. However, we found that the hospital failed to provide timely discharge information after C’s bypass surgery and after C’s surgery over a year later. We also found that the hospital failed to reasonably follow up C after discharge from two of their surgical procedures. Therefore, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in providing timely discharge information and failure to reasonably follow up two of their surgical procedures. 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:

• Discharge letters following surgical procedures should be sent out in a timely manner and clear follow-up arrangements should be given in the discharge letters following surgical procedures.

In relation to complaints handling, we recommended:

• When a complaint involves more than one NHS board, the boards should decide who will lead on the complaint and provide a joint 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 submitted a complaint on behalf of their relative (A) who received treatment at hospital. A had previously suffered a stroke (causing left sided weakness) and was admitted after being unwell for a few days. C complained about the nursing care provided to A while they were in hospital.

We took independent advice from a nursing adviser. We found that there were failings in relation to nursing documentation, moving and handling practices, a lack of equipment, and a lack of assessments as to A’s needs. In particular, there was no falls assessment and appropriate action and recording did not take place after A’s fall. In relation to moving and handling, we found that glide sheets should have been utilised and that appropriate equipment should have been available in the ward. The board failed to reasonably record the care that they provided, or carried out appropriate assessments to ensure person-centred care to confirm that A’s needs were met. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings as 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:

• All patients must have a falls risk assessment completed on admission and after a fall a post falls assessment should be completed.
• Every patient should have a person-centred plan of care.
• All patients must have a moving and handling risk assessment undertaken within 24 hours of admission.
• Nursing documentation should be complete and reflect a person's care needs, plan of care, care delivered and evaluation of the care delivered.
• Basic moving and handling equipment should be readily accessible for all patients and staff.
• All patients should have their care needs identified and risk assessments undertaken in order to develop a person-centred plan of care.

In relation to complaints handling, we recommended:

• Complaint investigations should respond to all of the main points raised and identify failings and take learning from what happened.

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 they received from the practice prior to their diagnosis of an abdominal cyst, which was surgically removed some years after C first attended the practice with symptoms. C complained that they did not receive a referral for an ultrasound scan until many months after first attending the practice with symptoms. C also complained that four different doctors were involved in their care and that the practice’s complaint handling was unreasonable.

We took independent GP advice. C’s case was complex and challenging due to the nature of C’s cyst, C’s other diagnoses and the timing of C’s consultations during the COVID-19 pandemic. Nevertheless, we found that there was a missed opportunity for the practice to refer C to the colorectal service based on the positive result of a qFIT test (a test to detect blood in the stool) when C first attended the practice with symptoms, based on the National Institute for Health and Care Excellence (NICE) guidance. We found that there was a further missed opportunity for the practice to consider referring C to secondary care based on C’s subsequent positive qFIT test result, which was taken many months after the first positive qFIT test. We also found that there were delays in the practice contacting C after receiving the result of the subsequent qFIT test and when the practice received the result of C’s ultrasound. We found that, given the state of NHS services at the time C attended the practice, there was not likely a significant delay in C receiving a diagnosis or surgery for their cyst. On balance, we upheld C’s complaint about their care and treatment from the practice.

We found that the practice’s complaints handling was unreasonable, because the first complaint response did not address the issues C raised as a complaint. We upheld C’s complaint about the practice’s complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to action the results of qFIT tests, for the delays and for the unreasonable complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Administrative systems at the practice should support timely actioning of abnormal results.
• Clinical staff should be knowledgeable about the indication and interpretation of qFIT tests, as per NICE guidance.

In relation to complaints handling, we recommended:

• Complaints should be appropriately acknowledged in line with the Model Complaints Handling Procedure for NHS Scotland, and the complaint response should fully address the substantive issues raised in 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 they received from the practice prior to receiving a diagnosis of a cancerous brain tumour, for which C underwent surgery, radiotherapy and chemotherapy. C had eight consultations at the practice over the course of ten months prior to receiving a referral to the neurology department.

We took independent advice from a GP. We found that there was a missed opportunity for the practice to review C in person and consider an earlier neurological referral on the basis of C’s worsening symptoms. We upheld the complaint. During the course of the investigation, the practice acknowledged these failings and took action to address them.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to offer a face-to-face appointment and neurology referrals, and for the practice’s shortcomings in their complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• The practice’s complaints handling procedure should ensure that complaints are properly investigated and responded to, are accurate and that failings are identified.

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 parent (A) received from the board. A was admitted to hospital after a fall at home. A’s condition declined whilst in hospital. C complained that during A’s admission there were clinical errors, inappropriate treatment and insufficient diagnosis work. In C’s view, this contributed to and hastened A’s death. C stated that clinicians had fixated on alcohol as the primary cause of A’s condition. A post-mortem later confirmed this not to be the case and that A had Lewy Body dementia (a brain disorder that can lead to problems with thinking, movement, behaviour, and mood) or similar when they died. C also asserted that A’s two brain bleeds sustained in the fall were not adequately monitored or treated. C highlighted concerns that there was no intervention and no repeat computed tomography (CT) scan carried out to check the condition/size of the two brain bleeds. This was despite a decline in A’s neurological condition.

In addition to this, C complained that the board’s communication with A’s family fell below a reasonable standard. C stated that, in their view, A’s two brain bleeds were more significant than clinicians had led the family to believe at the time of admission. They also highlighted an unwitnessed fall on the ward that was not reported to the family.

We took independent advice from a neurologist adviser. We found that the treatment provided by the board was reasonable. Given A’s circumstances and presentation, we did not consider the focus on alcohol-related cognitive failure to be unreasonable or that it materially affected the treatment provided. We also found that the decision not to carry out an additional CT scan to be reasonable. However, we highlighted concerns about some of the board’s justification for not carrying out an additional CT scan. We also received a limited amount of advice from an independent nursing adviser about some additional concerns raised by C. We found that in the context of the difficult circumstances of A’s condition, the nursing care provided was reasonable. Overall, we concluded that the board provided a reasonable standard of treatment during A’s admission. Therefore, we did not uphold this aspect of the complaint.

Summary

C complained about the standard of care and treatment provided to their parent (A) whilst A was in hospital. C's concerns covered A’s medical care, nursing care and physiotherapy care.

C said that A’s myeloma (blood cancer) treatment was delayed by a failure to provide the specialists treating A with blood samples for analysis. Additionally, A was not given an infusion correctly, as nursing staff failed to give A intravenous fluids first to ensure A was hydrated. C felt A’s pain relief was inappropriately managed, with A’s medication being unnecessarily reduced, resulting in A suffering significant and avoidable pain. C also believed that A was injured during a physiotherapy session and that this contributed to A’s decline.

We took independent advice from a registered nurse, a consultant haematologist (specialist in the the diagnosis and treatment of patients who have disorders of the blood and bone marrow) and a chartered physiotherapist. We found that nursing staff had not followed written instructions for the administration of A’s treatment, and A’s records showed that they had consumed only around 15% of the food and water that they should have in the period leading up to the infusion treatment. Nursing staff could not therefore have ascertained that A was properly hydrated. Nursing staff did not appear to have taken all the requested blood samples from A, and they had not taken steps to address A’s pain management. Therefore, we upheld this part of C's complaint.

In relation to A's medical care and treatment, we noted that their condition was progressing rapidly and that they had already had a number of treatments. The decision that A was not suitable for further treatment was not impacted by the missing blood sample and overall, we found that the medical care A received was reasonable. Therefore, we did not uphold this part of C's complaint.

In relation to A's physiotherapy care, we found that there was no evidence within the physiotherapy records that A had sustained an injury. Although there were some unexplained gaps in A’s physiotherapy records, it was clear that the decision to cease physiotherapy treatment was driven by the decision to designate A for palliative care only, rather than active treatment. Therefore, we did not uphold this part of C's complaint.

C also complained about the way that their complaint was handled. We found that the board’s complaint investigation had fallen below a reasonable standard. The evidence showing the failings in A’s nursing care should have been identified by the board’s own investigation. Therefore, 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 provide A with a reasonable standard of nursing care and for failing to provide C with a reasonable response to their complaint. 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 fluid and nutrition needs should be appropriately monitored. Where there is evidence that fluid and hydration needs are not being met, appropriate action should be taken.
• Patients’ level of pain should be reviewed and where the patient is unable to comply with the administration of pain relief orally, action should be taken to explore alternative means of medication delivery.
• Staff should ensure that written instructions by medical staff and, where appropriate, manufacturer’s guidance is followed when administering infusions and that, where appropriate, the patient is adequately hydrated.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that responses are accurate and reflect the information available in the clinical record.

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 on behalf of their adult child (A) about the standard of care and treatment that they had received in relation to their mental health from their GP practice. In particular, C complained that the surgery did not provide the support recommended for A following an Adult Autism Disorder (ASD) assessment. C also complained that the surgery had prescribed medication for A without any follow-up despite knowing that they had expressed thoughts of suicide. Additionally, C complained that the surgery had failed to explain the nature and process of a mental health telephone review A had been referred for and that the surgery had failed to let them know when this had been cancelled by the receiving service.

The surgery explained that referrals had been made to mental health services on behalf of A, however, the decision to accept or decline them was made by the receiving service and not the GP surgery. Regarding the cancelled appointment, the surgery said that they had not received advanced notice and were, therefore, unable to let C know that it would not go ahead.

We took independent advice from a GP adviser. We found that the ASD assessment report did not contain any recommendations or actions for the surgery to arrange on behalf of A, that A had been regularly reviewed during the period of the complaint and referrals had been appropriately made to other services. We also found that the surgery could not influence whether a referral was accepted or declined. In relation to the cancelled telephone assessment, we found that there was no evidence to suggest the surgery received advance notice of it being cancelled. Therefore, we did not uphold the complaint.

Summary

C complained about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died.

C complained to the board about their parent contracting COVID-19, which they felt must have been hospital acquired as A was shielding prior to admission. C complained that A was unnecessarily transferred between wards which increased the risk of exposure to the virus. C reported concerns that there were known COVID-19 cases in a neighbouring ward and possibly within A’s ward. C was concerned that A wasn’t offered the opportunity of home rehabilitation.

The board’s response stated that national infection prevention and control guidance for COVID-19 was followed at all times. They advised that it wasn’t always possible to accommodate all shielding patients in a single room. They advised that A was transferred between wards according to their care needs. They said that they could not meet A’s rehabilitation needs at home due to capacity issues with their community stroke team.

We took independent clinical advice from a nursing adviser specialising in infection control. We found that A required inpatient care to ensure that they received appropriate investigations and treatment for their suspected stroke. We found that the care provided to A in treatment for their stroke was reasonable and in keeping with their diagnosis.

We found that the board did not comply with relevant guidance on COVID-19 by failing to document the assessment of A’s COVID-19 risk pathway during their admission. We found that there was an unreasonable delay in isolating A from the other patients once A’s diagnosis of COVID-19 was suspected. Given these failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to triage A’s level of risk, for failure to document A’s shielding status and failure to isolate and follow airborne precautions from the point at which COVID-19 was suspected. 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:

• Feedback the findings of this investigation to relevant staff for reflection and learning, and to inform future practice.
• Medical records should contain all relevant information including the outcomes of assessments and the information required to clarify the decision making regarding the delivery of care.

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 reasonable care and treatment to their sibling (A) after they were admitted to hospital. A had a cardiorespiratory arrest (the cessation of effective ventilation and circulation) in the hospital and suffered a brain injury as a result of this.

We took independent advice from a consultant in critical care. We found that the board had provided reasonable care and treatment to A and we did not uphold this aspect of the complaint.

C also complained that the adverse event review that the board subsequently carried out was unreasonable. In relation to this complaint, we found that the board had carried out a level 2 review when a level 1 review should have been carried out. The level 2 review had also been allocated to an inexperienced review team, it reviewed only part of A’s care journey, and it was short and poorly detailed. We also found that the record-keeping on the ward immediately before and after A’s cardiorespiratory arrest was limited and not of the standard expected. Detailed retrospective entries should have been completed shortly after these events occurred, by both medical and nursing staff. We therefore upheld this aspect of the complaint.

We also found that the board’s complaint handling of C’s complaint was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for causing confusion in their responses which related to the new structure that had been put in place. Apologise that part of the complaint handling process was uncoordinated and delayed and that they added to the stress and anxiety the family were feeling at that time. Finally, apologise that they failed to deal with C’s complaints in a timely or satisfactory manner. 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 that a level 1 review should have been performed in place of the level 2 review and that the level 2 review that was performed was allocated to an inexperienced review team, it reviewed only part of A’s care journey and it was short and poorly detailed. 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:

• For a level 1 review to be carried out.
• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant medical and nursing standards.
• Before an adverse event review is carried out, the board should appropriately identify the review level, identify the terms of reference (part of the patient’s care journey to be reviewed) and allocate a suitable staff review team.

In relation to complaints handling, we recommended:

• The board should ensure all complaints are handled in line with the guidance set out in the NHS Model Complaint Handling Procedures, in particular, respond in writing and in a timely manner and address all issues raised that the board is responsible for.

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 nursing care that their parent (A) received. A had dementia and was admitted following a fall in their care home, remaining in hospital until their death some weeks later. C complained that during A’s admission, A was not treated with dignity, that they were left without food or water, and that they were allowed to aspirate on pureed food because they were not safely positioned in bed.

The board maintained that overall the nursing care was of a reasonable standard, but they accepted that documentation had been poor. They provided us with a detailed action plan which they were implementing in response to the failings that they had identified.

We took independent nursing advice. We found gaps in record-keeping in relation to food and fluid intake. We found that the board had failed to evidence that A was cared for in a dignified and respectful manner. Comfort rounding was not provided as frequently as it should have been, taking into account A’s frailty and general condition. A had pressure ulcers and we found that the board had failed to demonstrate sufficiently frequent skin checks and repositioning. The board also failed to maintain wound charts, recording wound sizes and grade. There was no evidence of oral care having been provided.

We did not find evidence to support the account that A was left to choke on pureed food on the day before they died. The records indicated that A was being checked on regularly that morning, and that A was asleep much of the time and noted to be ‘too drowsy for oral intake’. A was being treated for secretions, which we considered may have accounted for the gurgling sound reported. Although it was not possible to establish precisely what had happened on this date, it was regrettable that this incident caused so much distress to the family, and we noted that the board had apologised for the distress caused.

Taking all of the above into account, we upheld the complaint. We found that the board’s action plan did not adequately address the failings in this case and we therefore made our own recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for the failings our investigation has found. 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 receive appropriate pressure ulcer care, prevention and grading in line with relevant guidance.
• Records should document what is required to capture that person-centred care has been assessed, planned and the outcome of the plan evaluated.
• Patients should have wound charts completed as appropriate and in line with relevant guidance.
• There should be a discussion with family/carers as appropriate when a patient moves onto a palliative care treatment plan to facilitate understanding and an awareness of what to expect particularly in relation to fluid and nutrition in line with relevant guidance.

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.