Health

Summary

C complained on behalf of their sibling (A) in relation to the care and treatment that the board provided to A after presenting at an out of hours service with symptoms including epigastric pain, vomiting and shaking. A was sent home with treatment for dyspepsia (indigestion) but died shortly afterwards from acute haemorrhagic pancreatitis.

C complained that the board did not adequately take into account A’s full presentation and relevant background information in considering a treatment plan.

We took independent advice from an experienced emergency medicine adviser. Overall, we found that the care and treatment that A received was unreasonable because A’s physiological observations showed a significant degree of abnormality, and the board did not have appropriate systems in place to identify the deteriorating patient in the acute community setting. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that it was not recognised that the physiological observations documented in A’s notes were abnormal when they were seen in the OOHS. 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 board should ensure that there are systems in place that identify the deteriorating patient in the acute community setting inline with SIGN 167 Care of deteriorating patients.

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) about the care and treatment that A received from the board during their two admissions to hospital for suspected pulmonary embolus (when a blood clot blocks a blood vessel in the lungs). A had a stroke during their second admission.

We took independent advice from a consultant in general medicine. For A’s first admission, we found that the triage nurse who took A’s bloods, clearly documented that a D-Dimer (a test to detect blood clots) had been done and the results were available on the board’s system before A was discharged but it was not noted or considered. We found that A’s D-Dimer result should have been considered and doing so could have led to an earlier diagnosis of A’s pulmonary embolus. We found this aspect of A’s care unreasonable and we upheld this aspect of the complaint.

For A’s second admission, we found that the treatment of A’s blood clots with medication appeared to be in accordance with relevant guidance which was reasonable. We did not uphold this aspect of the complaint.

We noted that the board advised C in their complaint response that they would take A’s case forward to their adverse events review group for further consideration and that 16 months later, there had been no indication that a significant adverse events review had taken place, which appeared unreasonable. In addition, we found that in their complaint response, the board should have provided C with an explanation of what happened when A was readmitted to hospital, and the nature of A’s stroke, as well as more detailed description of when the adverse events review group’s decision would be made and if this would be communicated to C.

Recommendations

What we asked the organisation to do in this case:

• For the board’s staff in the CAU to read notes made by triage staff when patients are passed on to them.
• The board should carry out SAERs in a timely manner.

In relation to complaints handling, we recommended:

• For the board to provide C with a written explanation of what happened when A was readmitted and the nature of A’s stroke. For staff to address all aspects of a complaint in the complaint response. For the board to obtain statements from key staff during their investigations. 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

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 broke their leg and underwent an operation. Following a scan the next day, C was told that the results were fine and that they could be discharged home. However, a few days later, C was contacted and told that a further review of the scan indicated that they would require further surgery, and this was performed by another surgeon a few days later.

C complained to the board about several aspects of their treatment. The board apologised that C was told two different things about their scan results and explained that there was an anomaly in the image that wasn’t seen at first, but was noticed on further review. C remained dissatisfied and raised their complaints with the SPSO.

We took independent advice from an adviser specialising in orthopaedic surgery. We found that a note of a discussion between clinicians in C’s medical record does not accord with another clinician’s later view, and that the board’s position that the discussion was wrongly recorded was the most likely explanation of what occurred. This meant that, from C’s perspective, the board had unreasonably reached different conclusions following the two reviews of the scan. Given these circumstances, the complaint was upheld.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for giving them incorrect information about the scan, for the inaccurate clinical record, and for the incorrect explanation in the 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:

• Medical records should accurately record discussion outcomes.

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 during an admission to hospital. C attended A&E and the Acute Medical Unit for symptoms that were later diagnosed as an acute ischaemic stroke.

We took independent advice from a consultant physician. We found that some aspects of C’s care were reasonable, particularly the communication between the board and C and their partner.However, we found that C’s assessment in A&E was unreasonably delayed in relation to their triage category. In addition, no structured stroke assessment was carried out.

We also found that there was a delay in senior medical review and a lack of specialist stroke input. Furthermore, a prescription for aspirin was not made timeously after a CT scan excluded bleeding. Therefore, 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 report. 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 to hospital with symptoms potentially indicative of stroke should receive timeous assessment, investigation and treatment.

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 practice unreasonably failed to take the appropriate action in response to C's elevated prostate-specific antigen (PSA, a protein in the blood) test result. C requested a PSA test due to having a family history of prostate cancer. C complained about the failure to refer them to urology (specialists in the male and female urinary tract, and the male reproductive organs) based on the test result. The practice had said it was appropriate to advise C to repeat the test in one month’s time. This did not happen and C was diagnosed with prostate cancer 13 months later.

We took independent advice from a GP. We found that the practice failed to follow Scottish Referral Guidelines for Suspected Cancer. According to the guidelines, due to C’s age, their family history and the test result, the GP should have referred C to urology for further investigation. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow the Scottish Referral Guidelines for Suspected Cancer and to refer C to urology in light of their PSA test result. 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:

• Practice staff should be familiar with Significant Event Analysis (SEA) guidelines: https://learn.nes.nhs.scot/984.
• The GP involved should be informed of the findings of this case.

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 sibling (A) about the cancer care and treatment that A received and the handling of C’s subsequent complaint about this.

We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs) and a consultant oncologist (specialist in cancer).

We found that there was a delay in arranging an MRI scan and a ureteroscopy (a procedure that uses a thin telescope with a camera on the end to look inside the ureters and kidneys) for A. We also found that it was unreasonable that A had to involve their GP to prompt urology treatment and that there was no evidence that A’s scan results were revealed or discussed with them.

We found that the board’s investigation of the failings were inadequate. The board should have carried out a local significant adverse event review and there appeared to have been no process changes to prevent similar failings in future. The board also failed to keep C updated on the reason for the delay in issuing their complaint response. We upheld C's complaints. However, we considered that it is unlikely that earlier treatment would have changed A's prognosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to advise C that a named member of staff was available to clarify any aspect of the 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:

• Staff should discuss scan results with patients and record this in the patient’s records.
• The board should ensure that where events meet the definition of a Category 1 adverse event (events that may have contributed to or resulted in permanent harm), as set out by Healthcare Improvement Scotland, they carry out a local SAER.
• The board should have systems in place which adhere to the Royal College of Radiologists recommendations on cancer imaging alerts and a robust system for booking procedures in theatre that does not rely on email.

In relation to complaints handling, we recommended:

• The board should keep complainants updated on the reason for any delay in issuing their complaint response and when the response is issued, advise complainants that a named member of staff is available to clarify any aspect of the complaint response. [In response to a draft copy of this decision notice that was issued to both parties, the board indicated that since this complaint, they had implemented a new complaint system that provided a facility to monitor when holding letters were due.]

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their parent (A). A suffered a heart attack and was treated with increased levels of digoxin (heart medication) in hospital. Over a two-week period A became increasingly paranoid and agitated and needed to be medicated. A was then transferred to a nursing home.

A’s digoxin levels were found to be very high and this medication was reduced. C believed that A was suffering from digoxin toxicity. C felt that A’s digoxin levels were not properly monitored or controlled and that A's outcome might have been different with better monitoring.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s digoxin was not appropriately monitored. However, it is difficult to assess whether A was suffering from digoxin toxicity. The board acknowledged this failing and provided information on the action taken by individual staff members as well as the board as an organisation to reflect on A’s experience and improve the delivery of care and treatment in the future. We upheld C's complaint and made recommendations to ensure these changes were taken forward.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• Complaints should be investigated fairly and fully and in line with the requirements of the NHS Scotland Complaints Handling Procedure. Complaint responses should be accurate, complete and address all the points raised in line with the NHS Scotland 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.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their parent (A). A was admitted to hospital with a suspected stroke, confusion and poor mobility. A CT scan was performed but the results were not reviewed until a few days later. The result was discussed with other specialists and a further scan was requested. A’s warfarin treatment (blood thinning) was reversed because A’s condition had deteriorated. C was concerned that A’s condition was not properly recognised as a stroke and that imaging of A’s head was not reviewed. Consequently A’s blood thinning medication was not stopped promptly.

The board carried out a Significant Adverse Event Review (SAER) which identified delays in reviewing A’s scan, and a lack of clarity between medical staff over who was responsible for organising tests for A, as well as poor communication. C felt the SAER lacked rigour and failed to address all the issues in A’s care.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the SAER lacked detail and did not contain sufficiently clear recommendations to ensure the failures in A’s care did not reoccur. It also did not adequately address the decision making around A’s scan or the level of awareness amongst clinicians of the scan being performed.

During our investigation the board provided further evidence of the feedback provided to staff, and the actions taken in response to the incident involving A. We found that these were reasonable and proportionate. The board accepted that the SAER had not adequately explored all the issues in the case. Therefore, we upheld C's complaint but did not make any further recommendations.

Summary

C complained about the care and treatment of their late spouse (A). A had a history of multiple myeloma (a type of blood cancer). C raised concerns about the board’s response to A’s symptoms, including a delay in carrying out a CT scan (a type of medical imaging) and a potential misdiagnosis of pancreatic cancer. The board said that A received prompt and appropriate management.

We took independent advice from a consultant haematologist (specialist in blood disorders). We found that the board’s use of CT scanning to explore A’s symptoms was reasonable, and the investigation of a mass near A’s pancreas was reasonable and consistent with National Institute for Health and Care Excellence (NICE) guidelines. Therefore, we did not uphold this aspect of the complaint.

We also investigated the board’s communication regarding A. We found no significant failings in communications in this case, and we did not uphold this aspect of the complaint.

Additionally, C complained about the handling of their complaint. We found that the board reasonably investigated A’s complaint. Therefore, we did not uphold this aspect of the complaint.

Summary

C complained about the care and treatment provided to their adult child (A). A has hereditary haemorrhagic telangiectasia (HHT, a rare genetic disorder characterised by abnormal blood vessel formation, leading to frequent bleeding, with potentially severe complications). A attended A&E as they had previously been bleeding from the left eye. A was triaged within 30 minutes and seen by a senior nurse within 90 minutes. The senior nurse discussed A’s presentation with a senior doctor. A was advised that they could await clinical review by a doctor, with a likely wait of up to two hours. A decided to leave and see an optician the next day. A was subsequently referred to the ophthalmology department (eye specialists) for further review and then to the oculoplastic clinic (specialists in surgical procedures around the eye) to consider cauterisation of a lesion inside the left, lower lid.

C complained that triage and initial review were unreasonable, as no-one examined A’s eyes or nose, staff had little understanding of the condition, on-call ophthalmology were not consulted and A felt pressured to leave. Overall, C was concerned that A could have lost their sight without timeous, specialist intervention.

The board considered that A had been appropriately managed in A&E. They noted that the discharge letter advised A had no active bleeding and no visual disturbance. A was offered to wait for medical review but decided to make their own optician appointment.

We took independent advice from a consultant in emergency medicine. We found that triage and staff understanding of A's condition was reasonable. We found that it was reasonable to give A the opportunity to await clinical review and not to have ophthalmology input prior to clinical review. No harm came to A and no adverse event review was required. We did not uphold C's complaint.