Health

Summary

C complained about the care and treatment given to their late sibling (A) by the board. A, who had a history of addiction issues and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties), was admitted to A&E after overdosing on non-prescription drugs. A was treated for the overdose and was discharged to C’s care. A died the following day. C complained that the board inappropriately discharged A and that the treating doctor had failed to communicate adequately with them.

The board did not identify any failings in A’s care, but did apologise that A was discharged with a cannula in place. The board also apologised for communication failures with C. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant in emergency medicine. We found that A was monitored for approximately 12 hours before discharge. This is the minimum period recommended by Toxbase (the primary clinical toxicology database of the National Poisons Information Service). However, we found that A would have required observation over and above this minimum period. This was because of A’s history of acute seizures, intoxication with opiate drugs and their complex medical history. In the circumstances, we found that it would have been reasonable for A to have remained as an in-patient to enable a greater period of medical observation. Therefore, we considered that the decision to discharge A was unreasonable. 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. 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:

• Internal reviews should include a thorough consideration of all of the relevant evidence including clinical records and there should be reflection on these in an open and transparent manner in order that lessons can be learned.
• Overdoses complicated with seizure activity and aspiration lower respiratory tract infection may require observation over and above the advice provided by Toxbase. Patients admitted with overdoses and who present with a history of seizure activity should be admitted for a minimum of 24 hours observation. Concerns raised by relative(s) of patients should be listened to by staff.

Summary

C complained about the obstetrics (specialists in pregnancy and childbirth) care and treatment that they received from the board during and after the delivery of their baby by planned caesarean section. C said that there was a delay in diagnosing retained products of conception (tissue that remains in the uterus after a pregnancy) which led to infection. C also said that they were kept nil by mouth (not allowed to consume food or drink by mouth) for over 30 hours as their surgery for evacuation of the retained products kept being delayed.

We took independent advice from a consultant obstetrician and gynaecologist. We found that some aspects of C’s care and treatment were reasonable. However, a doctor should have attended when C passed a large clot. There was also a misunderstanding between C and a doctor regarding how long they would be kept nil by mouth for before their evacuation procedure. We also found that the board failed to address C’s concerns about the conduct of a sonographer (specialist in the use of ultrasonic imaging devices) in their response to the complaint. Therefore, we upheld C's 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:

• Doctors should attend when advised that patients have passed large clots following c-section delivery and are too tender for fundal palpation.
• In cases such as this, a DATIX should be submitted by the board and the case reviewed by the hospital’s obstetric risk management team.

In relation to complaints handling, we recommended:

• In their stage 2 responses to complainants, the board should address all the issues raised and demonstrate that each element has been fully and fairly investigated, in accordance with NHS Model Complaints Handling Procedure. The board should also answer enquiries from this office in full.

Summary

C complained about the care and treatment provided to their parent (A) in relation to a number of hospital admissions. C complained that A was discharged without clear advice as to whether they had sepsis, and how to manage A’s condition. C also said that the board did not provide a discharge letter. C complained that when A attended hospital four days later, they should have been admitted rather than being sent home with oral antibiotics. Lastly, C said that when A was readmitted to hospital the following month, a day passed before they were seen by a consultant.

We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that, while A received appropriate care during their initial admission, the board's communication around A's sepsis was unreasonable. They also did not provide an interim discharge summary.

In relation to A's second discharge, we found that A's symptoms raised the possibility of a complicated kidney infection. Therefore, we considered that discharging A with oral antibiotics was unreasonable. A should have received treatment with IV antibiotics and consideration should have been given to admission, which may potentially have prevented the need for A to be admitted the following month. We upheld these parts of C's complaint.

Finally, we found that A's condition when they were readmitted did not meet the criteria for an urgent consultant review. Therefore, 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 failings identified in this decision. 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:

• Decisions on admission and treatment with IV antibiotics should be in keeping with European Association of Urology (EAU) guidelines on Urological Infections and The UK Health Security Agency guidance on antimicrobial intravenous-to-oral switch (IVOS) criteria for prompt switch for adults.
• Immediate discharge letters should be issued at the time of discharge and patients and where applicable their families, should receive appropriate advice on discharge which should be documented in the patient’s medical records.
• Patients with sepsis and their family members and carers should be given opportunities to ask questions about a diagnosis, treatment options, prognosis, and complications. There should be a willingness to repeat any information as needed.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C complained about the care and treatment provided to their late parent (A). A had a terminal illness and was discharged from hospital to be cared for at home. A few days later, the family requested a visit from a doctor. They spoke to a doctor on the phone but it was an Advanced Nurse Practitioner that visited them at home. C was also unhappy that A was not provided with emergency medication.

We took independent advice on the complaint from a GP. We found that A should have had a named and experienced clinical lead coordinating and planning their care. We found that it would have been preferable that a GP had visited A following their discharge from hospital. However, it was not unreasonable that A was visited by an ANP. We found that A should have been provided with emergency medicine. We upheld C's complaint.

We noted that the practice had recognised potential failings and had demonstrated that they had taken reasonable learning and improvement action. Therefore, we made no further recommendations.

Summary

C complained on behalf of their client (B) about the care and treatment given to B's late parent (A). A was admitted to hospital and discharged a few days later. A was readmitted the next day and died the following week. B had concerns around A's diagnosis and said that they should have been consulted given that they held Welfare Power of Attorney (Welfare POA). C also complained that the board's communication with B was unreasonable.

The board said that A was treated for infection with broad spectrum antibiotics. A was discharged after their first admission as it was deemed appropriate and clinically safe to do. The board said that during A’s second admission a lumbar puncture procedure was indicated. They acknowledged that an Adults with Incapacity (AWI) certificate was in place and that during that time, Welfare POA rights were in effect. However, the board said that when the AWI certificate was revoked, the Welfare POA did not maintain the ability to make decisions on the patient’s behalf.

In relation to communication, the board apologised that B found the manner of staff to be abrupt and explained that the situation was urgent.

We took independent advice from a consultant physician in medicine for the elderly. We found that A received appropriate care and treatment. Appropriate investigations were carried out and various diagnoses were considered during A’s treatment. However, the board did not seek appropriate informed consent from B for a medical procedure when the AWI certificate was in place which was unreasonable.

We found that the content of the communication recorded in the medical notes was reasonable. However, the tone of communication lacked sensitivity and respect of B and their role as the Welfare POA. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for failing to appropriately discuss treatment plans and seek their consent as the power of attorney for an incapacitated patient, communicating with B in an inappropriate way, failing to address all of the concerns raised in their complaint response, and failing to provide full and detailed responses and explanations in their response to the complaint.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:

• Detailing planned treatments on patients with an AWI certificate in place should be done with the full involvement of the power of attorney holder (or equivalent). When an AWI certificate is in place, consent for procedures should be sought from the power of attorney holder (or equivalent) before procedures are carried out.
• When communicating with patients, their families, and/or their power of attorney holders, the board should ensure that the content of the communication is accurate, whilst also paying mind to the manner in which they are communicating. Care should be taken to communicate in a way that is sensitive to the circumstances, compassionate, and respectful.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in line with the NHS Model Complaints Handling Procedure. When specific issues have been raised, these should be fully investigated and a meaningful response provided including, where appropriate, an explanation of the board’s position and the reasons why action was taken, rather than simply stating the facts of the situation. When a complaint investigation indicates that an apology is appropriate these should, insofar as possible, be sincere and acknowledge the impact on the complainant whilst meeting the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C complained that the practice failed to adequately investigate and/or diagnose the cause of their persistent cough. C was subsequently hospitalised and diagnosed with pneumonia while on holiday.

The practice did not uphold C’s complaint. They said that they had taken reasonable action in light of C’s presenting symptoms and that C’s cough had been reasonably treated. They said that C’s final examination was normal and not in keeping with a diagnosis of pneumonia and that, therefore, there was no missed diagnosis.

C remained unhappy and asked us to investigate. We took independent advice from a GP. We found that there had been a failure to adequately investigate the cause of C’s cough. In light of C’s presenting symptoms, a persistent cough and infection, we found that an in person appointment and an urgent referral for a chest x-ray should have been considered after their initial telephone presentation. We also considered that C should have been referred for an urgent chest x-ray following a second presentation, in accordance with the Scottish Referral Guidelines for Suspected Cancer. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately investigate the cause of their persistent cough. 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 treatment should be considered in line with relevant guidance.

Summary

C had a bilateral total knee replacement surgery, which was carried out by another organisation. Approximately three weeks after their surgery, C was admitted to a hospital within Forth Valley NHS Board following a fall. Approximately three weeks after C’s discharge, C had surgery to repair a tendon in their right quadriceps (thigh muscle), which was carried out by another organisation.

C complained about the care and treatment that they received in hospital during their admission and the care and treatment that they received from the outpatient physiotherapy service over the next six months.

The board said that the presentation of C during their hospital admission was a common presentation following knee replacement surgery and very similar to the presentation for an injury to the quadriceps. The board said that the outpatient physiotherapy guidance was followed when treating C.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a physiotherapist.

We found that the board failed to consider a right-sided quadriceps tendon injury when C was seen by a consultant in hospital, failed to reassess C during their admission and failed to escalate C when C did not progress when in hospital. On this basis, we upheld this part of C’s complaint.

In relation to the physiotherapy service, we found that the exercises C received were in line with post-operative guidance and that physiotherapists followed protocols for treating C. 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 failings identified by this investigation. 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:

• The Morbidity and Mortality meeting scheduled should include input from physiotherapy; discuss appropriate escalation procedures, including who to contact if a consultant is unavailable; and how patients are reviewed as inpatients, with a view to reviewing patients daily.

Summary

C complained about the medical care provided to their late parent (A) by the board when they were admitted to hospital. We took independent advice from a consultant in emergency medicine. We found that there should have been better communication between the medical, nursing, and other allied health professional staff in relation to bruising found on A. We found that medical staff failed to take note of the physiotherapy findings of bruising and to document the presence of any significant injury.

We also found that medical staff should have prescribed a second antibiotic at the time of A’s admission, that an assessment using arterial blood gas analysis should have been carried out before A’s transfer to the critical care unit and that the mental health team failed to assess A’s delirium, or prompt medical staff to consider this. Finally, we noted that the cause(s) of A’s death should have been recorded in more detail on the death certificate. Therefore, we upheld this part of C's complaint.

C also complained about the nursing care that the board provided to A. We took independent advice from a nurse. We found that nursing records, in particular, risk assessment and care planning documents, were not always completed to the required standard or frequency. We also found that A did not receive a reasonable standard of person centred care in relation to their fluid intake and nutritional support and there was poor and inadequate support provided to assist A with their personal hygiene. Nursing staff should also have identified earlier the bruising on A’s body and ensure A had timely access to their medications.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 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:

• A patient’s cause of death should be accurately recorded.
• All relevant staff should be aware of the board’s responsibilities under the Adults with Incapacity (Scotland) Act 2000.
• All relevant medical staff should have read and understood the contents of the board's doctors handbook.
• Arterial blood gas analysis should be considered for 'any patient with a new oxygen requirement' and 'all critically ill patients'.
• Patients should receive their prescribed medication at the appropriate time.
• Patients should be appropriately examined and assessed and findings from the examination / assessment should be appropriately recorded and communicated.
• Patients should be appropriately examined and assessed. Relevant documentation should meet the standard required by the NMC The Code. All nursing staff involved in this case should be aware of their requirements to document to the standard required by the board and the NMC to ensure patient safety, person centred care and essential communication.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the relevant model complaint handling procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died.

We took independent advice from a nursing adviser and consultant geriatrician (specialist in medicine of the elderly). In relation to nursing care, we found failings with A's nutrition, pressure care, person centred care planning, and documentation. We upheld this part of C's complaint.

In relation to medical care and treatment, we generally found this to have been reasonable and did not uphold this part of C’s complaint. However, we provided feedback to the board regarding starting oral nutrition supplements in line with Scottish Hip Fracture Guidance.

Finally, we found that there were delays in the handling of C's complaint and the board failed to fully address of all C's concerns. The board had acknowledged these failings and taken action to address them. Therefore, we upheld this part of C's complaint but made no further recommendations in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in nursing care provided to A, and the failings in complaint handling. 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:

• Appropriate assessments should be accurately completed in a timely manner to identify patients at risk of or with existing pressure sore damage. Those patients should receive appropriate and timely pressure sore care in accordance with relevant local and national guidance.
• Malnutrition Screening should be completed in a timely manner and repeated as appropriate. Food charts should be completed accurately.
• Person-centred care planning should be completed for every patient, and documentation should support this.

Summary

C complained about the care and treatment they received from the board when they attended the hospital with pain and a tight feeling in their leg. C raised concerns that the board failed to: reasonably assess them on admission to hospital, and undertake the correct scans; provide them with timely information about their test results; reasonably identify an arterial clot and diagnose their condition; and provide them with reasonable treatment following admission to hospital.

We took independent advice from a consultant in acute medicine. We found that a detailed clinical assessment of C’s right leg and foot was carried out on their admission to hospital, and that it was reasonable that the clinicians did not identify an arterial clot at that time. We found that the possible diagnoses that were considered at the time were correct, and the diagnosis of plantar fasciitis was a reasonable conclusion to have reached. We also found that the correct scan had been carried out to exclude deep vein thrombosis (DVT, a blood clot in a vein) as a cause of C’s symptoms, and that the care and attention C received from medical staff was reasonable.

Therefore, we did not uphold C’s complaint.