Health

Summary

C complained about the care and treatment they received from the board. C suffered a subarachnoid haemorrhage (a form of stroke caused by bleeding on the surface of the brain). Following a period of admission to different hospitals, C was discharged home. C complained that the board failed to communicate appropriately with them after their admission, that they were not fit for discharge and that inadequate rehabilitation plans were made in the community. C chose to stay at a relative’s property and was eventually admitted to a rehabilitation unit but believed this had affected their prognosis. C also complained that the board failed to respond reasonably to their concerns about the COVID-19 vaccine they had received.

We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system) and an occupational therapist. We found that communication with C was unclear and confusing and did not always address the main points C was raising. Therefore, we upheld this part of C’s complaint.

In relation to C’s discharge, we noted that more consideration could have been given to supporting C prior to their discharge, given C’s concerns at the time. However, we found the decision making to be appropriate and did not uphold this part of C’s complaint.

In relation to plans for C’s rehabilitation, we found that the board made reasonable plans and attempted to commence the initial assessment that would have established what support C required. However, we found that there was a failure to provide C with written information about the plans for their rehabilitation. C was unable to retain this information when given verbally which meant they were unaware of the plan and could not access the support available to them when they were unable to return to their property as quickly as anticipated. Therefore, we upheld this part of C’s complaint.

We also found that the board failed to follow up on a commitment given to C to explore any potential link between the COVID-19 vaccine and C’s brain injury. They also failed to support C’s attempts to gather information to assess the risk of further vaccine doses. Therefore, we upheld this part of the complaint.

C also complained about the board’s handling of their complaint. We found that although there were some failings, in the circumstances the board were operating under at the time these were apologised for and reasonably addressed. We did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues identified in this decision. 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:

• That the board confirm what action they have taken to ensure patients with brain injuries are provided with discharge information in a format they can understand and refer back to after leaving hospital. The Board should share this decision with the clinical team involved in C’s care with a view to identifying points of learning.

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 arterial surgery. The board accepted that there were issues related to the surgery and communication with C before the procedure.

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, overall, the clinical treatment provided to C was reasonable. We did not uphold the complaint.

Summary

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted to hospital but was discharged later that month. Two days after discharge, A was readmitted and died a short time later.

We took independent advice from a consultant in geriatric and general medicine. We found that some aspects of A’s care were reasonable particularly in relation to COVID-19, A’s diabetes, and detailed assessments from physiotherapists and occupational therapists prior to discharge. However, we found that while A’s last blood tests were normal, A was then unwell for several days which could have developed into kidney impairment if levels of hydration in the body became low. A’s blood tests were not repeated prior to discharge. Had A received blood tests prior to discharge, taking into account A’s blood tests on readmission, it is likely that the test would have been abnormal which would have resulted in A remaining in hospital. We considered that the board failed to provide A with reasonable care and treatment. Therefore, we upheld this part of C’s complaint.

C also complained that the board unreasonably failed to consider their concerns in sufficient detail when responding to their complaint. We found that the board’s complaint response did not reasonably address C’s specific concern in relation to the comments of a nurse. We also found that when investigating the complaint there was a lack of attention given to the reasons for readmission and a lack of reflection by the medical team to ensure lessons were learned. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment to A and to appropriately consider and respond to C’s 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 should be appropriately assessed prior to discharge and any tests required e.g. blood tests carried out in accordance with their symptoms.
• The board should ensure that their complaint investigations and responses appropriately consider and respond to the points raised by the complainant and that, where appropriate, there is reflection on the issues raised by the staff involved, for example discussion at a team meeting/huddle.

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 had a history of Parkinson’s Disease (a condition in which parts of the brain become progressively damaged over many years), dementia and cerebrovascular disease (a range of conditions that affect the flow of blood through the brain). A was admitted to hospital with a suspected urinary tract infection but their condition deteriorated and they died a few months later.

C complained that the board failed to provide A with appropriate nutrition and hydration in the first few weeks following admission, that staff had not treated A with dignity and ascribed A’s symptoms to their pre-existing conditions rather than treating individual needs. C also complained about the personal care provided to A, particularly with respect to management of their skin during admission.

The board considered that they provided A with reasonable care and treatment but acknowledged and apologised for a delay in inserting an nasogastric tube (NG tube, a tube that carries food and medicine to the stomach through the nose).

We took independent advice from a consultant geriatrician (specialists in care of the elderly) and a registered nurse with experience in tissue viability care.

We found that the management of A’s hydration was reasonable. However, there was a period of up to two weeks where A was Nil by Mouth without any other arrangements in place to ensure their nutritional needs were being met. We also found that staff were aware of A’s Parkinson’s Disease and it remained a priority during their admission. However, whilst specialist advice was sought, there was only limited input from relevant specialists and we found it unreasonable that there was not more direct involvement from relevant specialities. We also found that there was a failure to document the reasons for the provision of different medication and changes in delivery method. In relation to wound management, we considered that there were gaps between wound assessments and that the documentation was not completed appropriately, resulting in no structured or measurable approach to assessing A’s pressure sore. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision notice. 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:

• Decisions in relation to medication changes should be appropriately documented and, where appropriate, the risks and benefits of a particular medication regime and its delivery fully considered and documented.
• Patients at risk of or with existing pressure sore damage should receive appropriate and timely pressure sore care in accordance with relevant local and national guidance.
• Patients that have complex care needs should receive appropriate input and care from all the relevant clinical specialities when requested.

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 partner (A) that their initial CT scan was misread and their symptoms misdiagnosed as ischaemic colitis (injury to the colon as a result of reduced blood flow), leading to a delay in treatment and diagnosis of a bowel obstruction. C felt as A’s condition deteriorated, further investigation should have taken place to identify the cause of A’s symptoms.

The board maintained that there was no misdiagnosis as the first CT scan showed the appearance of ischaemic colitis, with no obstruction reported. A was treated appropriately with antibiotics and there was no evidence of deterioration during the period of observation. When A developed symptoms after the reintroduction of food, a second CT scan was ordered and the bowel obstruction identified. The board considered that A had an incomplete or evolving obstruction on admission, which was not picked up by the CT scan.

We took independent advice from an experienced general and colorectal surgeon. We found that while the reading of the scan was reasonable, the failure to consider clinical presentation alongside the scan was unreasonable. We found that this led to a focus on treating ischaemic colitis and no consideration was given to identifying the underlying cause. There was minimal investigation carried out to identify the cause and consideration should have been given to endoscopic investigation, a contrast enema, a colonoscopy and listening to bowel sounds. All would have identified a bowel obstruction, resulting in the correct diagnosis and earlier treatment for A. We also found that as the delay led to A’s deterioration and an increase in treatment, the incident met the Duty of Candour threshold, which the board failed to identify. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and 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:

• For the board to undertake the Duty of Candour Process. It is important to note that should C or A not wish to meet with the Board in person an alternative way of including them in the process should be explored.
• Staff to be reminded that NEWS and blood tests can appear normal in patients with a bowel obstruction and can deteriorate later.
• Staff to be reminded that scans should not be read in isolation and a patient’s clinical presentation must be considered along with the reason for requesting the scan.
• That staff recognise ischaemic colitis is the consequence of an underlying problem and investigations should continue until a cause is 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 to the board about the midwifery care and treatment that they received during and following the birth of their baby. In particular, C complained that they had been unsupported during the birth, that their birth plan had not been followed, that the umbilical cord had snapped during delivery and that no meeting had been arranged to discuss the incident despite requesting one. C also complained that there had been a failure to recognise that this had been a traumatic incident for them, and that the board’s response to the complaint had lacked empathy.

The board’s response advised that C had been assisted during the birth, however they apologised that C's expectations had not been met at the time. The board also apologised that it had not been understood that C had intended to use the water pool for pain relief only, and that they did not want to give birth in the pool. In relation to the cord snapping, the board explained that this had been recognised as an emergency incident straight away, but on reflection, the emergency buzzer could have been activated sooner. In terms of communication, the board explained that the circumstances of the birth had been discussed with C by the delivery midwife during a post-natal visit to C's home. When a further meeting was requested, the board said a meeting date had initially been offered by text message which C declined. In hindsight, the board recognised it would have been better to arrange this with C by phone. It was further explained that C had been given contact details to arrange discussion with a consultant in keeping with their request, however C had not gone on to take up that offer.

We took independent advice from a consultant of obstetrics and gynaecology. We found that a minimum standard of care had not been met on this occasion. We noted that key aspects of the medical notes and birth plan had not been read, as C’s preference not to birth in the pool was clearly documented but had not been known by the midwife. In reference to the cord snapping, we found that it can snap spontaneously after either an attended or unattended birth, and in the pool or out. It was difficult to say what this was attributable to the birth, nevertheless bringing the baby above the surface of the water was likely to have been more important than care of the cord. We highlighted that the board’s complaint response had said it was recognised by the midwife that the cord snapping was an emergency incident, however we could see no evidence from the notes of an acute crisis.

In reference to communication, we found that the board had recognised that it would have been better to phone C rather than text them to arrange a time to discuss their concerns. We found that it would have been better for the board to arrange the debrief meeting with the consultant, rather than to expect C to arrange this themselves. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision notice. 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:

• Midwifery care should be informed by the patient’s records.
• Midwifery care should be clearly and accurately recorded and include reference to any incidents and the actions taken in response.

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.
• The board should offer C a debrief meeting at a mutually convenient time to discuss the events which occurred and to answer C’s questions regarding the circumstances of the birth.

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 board prior to and during the birth of their child (A). C complained that the midwives were dismissive of their pain levels during labour, failed to properly assess their condition, was wrongly sent home to allow labour to progress, and that staff denied their requests for an epidural. C also complained about the poor communication from the clinical team when they were in theatre for a caesarean section.

The board said that they considered the decision to send C home was made in line with current guidelines but apologised if the reasons for the decision were not communicated at the time. The board explained that C’s request for an epidural was not actioned as labour was progressing rapidly and consideration was being given as to whether an emergency caesarean section was required.

We took independent advice from a midwifery specialist. We found that the midwifery care provided to C was reasonable. We noted that the board apologised for some shortcomings in the care provided and that this was a reasonable response. Overall, we were satisfied that the decisions taken by the midwives were based on a reasonable assessment of C’s presenting condition. In respect of the medical care provided during the birth, we acknowledged that there may have been a lack of clarity around the consent process, however, overall, we did not find any significant shortcomings in the clinical care and treatment provided to C. We did not uphold C’s complaints.

Summary

C complained about the care and treatment that they received in respect of their cancer. C was diagnosed with colorectal cancer which had spread to their liver and required surgery. The surgery was to be performed in two stages. C complained that the second surgery was not performed within a reasonable timescale and about poor pain relief following the second surgery.

The board apologised to C for the poor communication about the arrangements for the second surgery and explained that repeating imaging was required before arranging the surgery and that they did not consider the delay to be significant. The board provided an overview of the pain relief provided and noted that any issues identified were addressed at the time.

We took independent advice from a colorectal and surgical consultant. We found that communication with C about when they could reasonably expect to have their second surgery was poor and there was an unexplained delay in their case being reviewed by the multi-disciplinary team. This resulted in a delay of around one month, however we did not consider this would have caused further spread of C’s cancer. We upheld this complaint.

We noted that there were some issues with the equipment used to deliver pain relief post surgery, however these were rectified and appropriate additional pain relief was provided promptly. We found the post surgical care and treatment provided to be reasonable and we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues 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:

• That the board review their approach to communication with patients to ensure that cancer patients are proactively kept informed of progress in their treatment plan.
• That the board review their processes for prioritising the review of important cases by the MDT to ensure that such cases are progressed without delay.

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 advocate, complained on behalf of A about treatment that they received after sustaining a knee injury. A ruptured the anterior cruciate ligament (ligament connecting the thigh bone to the shin bone) and underwent an arthroscopy of the knee (a type of keyhole surgery). This was followed up with a second surgery at a later date to complete the reconstruction of the ligament.

During the surgery, the surgeon’s scalpel snapped and to remove the tip of the blade, the surgeon had to create a larger incision. C raised concerns about the actions taken following the incident. The board acknowledged the incident and explained that damage to instruments is a rare but known complication of surgery.

We took independent advice from a consultant orthopaedic surgeon. We found that when the blade snapped, appropriate care was provided to A. It was appropriate to create a larger incision and the incident was appropriately communicated to A. However, we found that whilst a datix incident report was completed, a more in-depth investigation could have been carried out. There was no evidence that the board considered either the possibility of improper use of the instrument or that there was a defect in the instrument. We also considered that the board should have discussed the incident at a departmental level. In conclusion, we upheld C’s complaint about care and treatment in relation to the initial surgery. We did not uphold the complaint about the post operative care provided to A as we were satisfied it was reasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to thoroughly investigate the adverse event where by the scalpel broke during A’s 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:

• Operation notes should be sufficiently detailed, particularly when an adverse event has occurred.
• The board should ensure that adverse events are thoroughly investigated and that appropriate reflection and learning is 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 on behalf of their spouse (A) who was admitted to hospital with pain, spams and weakness in their right leg which was later diagnosed as being caused by an infection in the iliopsoas muscles (a group of muscles running from the lower spine to the thigh). A is a dialysis patient and had also previously suffered a stroke, leaving them with weakness on the right side and wheelchair bound. C therefore usually supports A with dialysis and medication.

The complaint centres around an incident in the first week of A’s admission when both C and a nurse separately administered A’s evening medication. C stated that they had previously been given the medication by ward staff to support A. C had administered the evening medication and gone out for a few hours. On return, they had found A to be unresponsive. A nurse said that they had also administered evening medication. C complained that this overdose of medication had occurred and that record keeping and incident management had been unreasonable.

We took independent advice from a nursing adviser. We considered that this incident should not have happened, and that it indicated a lack of clarity, process, recording and communication within the ward.

We found that record keeping before and after the incident had been lacking, as there had been no clear record in a person centred care plan to state that the medication was being held and administered by C, that there had been a 24 hour gap in nursing records over the period of the incident and that no extra observations or conversations with a doctor had been recorded following the incident. We found that categorisation and management of the incident had been unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for poor record keeping. 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 and A that an extra dose of medication was administered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.