Health

Summary

C complained about the care and treatment they received by the board. C was pregnant and called triage as they thought their mucus plug (a protective collection of mucus in the cervical canal) had passed and that they noticed green discharge. C was advised to stay at home and call back if they had further concerns. C went to hospital later that day and underwent an emergency caesarean section to deliver their baby (A). A appeared well following birth, but soon deteriorated. A was initially diagnosed with hypoxic ischaemic encephalopathy (a type of brain damage), and then subsequently diagnosed with quadriplegic cerebral palsy (a lifelong condition that affect movement and co-ordination).

C complained to the board about the advice provided not to attend hospital during the initial call to triage, and about the care and treatment during delivery and immediately afterwards. C believed that clinicians delayed in taking appropriate action in response to A's symptoms and considered this may have impacted their health.

In response to the complaint, the board recognised that C's recollection of the call to triage differed from the notes taken but concluded on the basis of the information available, that the assessment and advice was appropriate. The board gave a detailed account of the care and treatment provided to C and A from C's attendance at hospital, through to delivery and in the period following A's birth. The board explained the decision to proceed to an emergency caesarean section and concluded that this was appropriate and timely. The board also concluded that it was impossible to say if the outcome for A would have been different had C attended hospital earlier, and it was unlikely an earlier birth from the time of admission would have altered the outcomes. C was dissatisfied with the board's response and brought their complaints to our office.

We took independent advice from an obstetrician (specialist in pregnancy and childbirth) and from a consultant neonatologist (specialist in the medical care of newborn infants, especially ill or premature newborns). We found that the call to triage and advice given not to attend hospital was reasonable. With respect to the care and treatment during and following delivery of A, we found that whilst there was some information missing regarding the monitoring of A's heart rate, the decision making regarding the timing of proceeding to a caesarean section and the care immediately following birth was reasonable. A was given appropriate care when their health deteriorated following birth and there was no unreasonable delay in admitting them to neonatal intensive care. Therefore, we did not uphold C's complaints.

Summary

C complained about the care and treatment provided to their parent (A) who had been admitted to hospital with an infection of the gallbladder. A Magnetic Resonance Cholangiopancreatography (MRCP, an MRI scan of the gall bladder) was ordered and gallstones were found to be present. However, A did not hear from the hospital for several months following the scan until they proactively chased up a response. The board later confirmed that the MRCP report had not been provided to the consultant who had ordered the test causing the delay.

A was subsequently admitted for an Endoscopic Retrograde Cholangiopancreatography (ERCP, a procedure combining an endoscopy and X-rays to examine and treat conditions of the bile and pancreatic ducts) and discharged the following day. A was admitted again a few weeks later suffering from a complication of pancreatitis and a drain was inserted. A was discharged to be seen again as an out-patient. However, a few days later A was readmitted as an emergency patient suffering from a significant infection and died shortly after. C complained about the delay between the MRCP and ERCP procedure and questioned whether this had led to A's death. C also complained about the general standard of care provided to A.

We took independent advice from a consultant general surgeon with a specialist interest in upper gastrointestinal problems. We found that there had been a failing in both the board's paper and electronic reporting systems. Despite these failings, we were of the view that the delay did not, on this occasion, lead to a worse outcome for A clinically.

However, we were critical of the care provided to A following the ERCP procedure. We also found that A was discharged too soon, despite having developed pancreatitis, against both local policies and clinical best practice. We considered that A should have been admitted for longer, under the care of the original consultant, and that better initial care for A may have facilitated earlier intervention to possibly allow for their ultimate recovery. Therefore, we upheld C's complaint.

We also commented on complaints handling noting that the complaint had not been handled in line with the board's complaints handling procedure with respect to timescales, and that the initial complaints investigation had not identified issues with post-ERCP care.

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:

• Patients receiving scans should have their scans reported to the relevant and appropriate clinicians; reviewed, and followed up without delay.
• Patients should be under the care of the appropriate medical team during their admission. Any decision in relation to discharge should be taken by the appropriate medical team with appropriate account taken of local protocols and management pathways.
• There should be appropriate learning from serious events that ensure failings are identified and addressed and appropriate learning and practice improvements are made.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures. They should fully investigate and address the issues raised and identify and action 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 on behalf of their parent (A) who had been admitted to hospital with pneumonia. C complained that they found medication on the floor and in A's bedside cabinet. C complained that A's personal care needs had not been met, as they had not been washed and they had sore gums and an ulcer in their mouth. C also complained that A had red, sore skin in the groin area.

The board apologised for the fallen medication and advised that they were undertaking a project to reduce medication errors. They advised that A had not wanted to shower and that both personal and oral care had been undertaken regularly. They also said that the skin in the groin area had been checked and had only become red on the day that C visited.

We took independent advice from a nurse. We found that there appeared to be a design fault with the lockers, such that medication could fall out of the medication pod. We also found that A should have had a personal care plan and had not been offered sufficient personal care or oral care. We found that red skin had been noted 11 days prior to C's visit but had been recorded as healthy in the interim period. This would suggest that the skin was not properly checked. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for providing unreasonable personal care and unreasonable skin care. 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:

• Person centred care plan to be put in place for patients within 24 hours, as per board policy and skin care guidance to be followed correctly.

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 attitude of a doctor during an inpatient admission. C stated that the doctor had treated them in a dismissive, derogatory and unprofessional manner. C further complained that the doctor removed their diagnosis, stopped their medication and made no arrangements for them to receive support following their discharge. C told us that the actions of the doctor had resulted in them not receiving a reasonable standard of care.

We found that the inpatient doctor's communication and documentation did not meet the required professional standards and impacted on the board's overall communication of C's care and treatment needs. The clinical records evidenced a dismissive and disrespectful attitude towards C. The doctor's documentation lacked a clear clinical rationale for the decisions that they made about C's diagnosis and medication. Therefore, we upheld this part of C's complaint.

In relation to the standard of care C received, we found that board staff had ensured that C's care and treatment needs were met. The decision to discharge C from inpatient care was reasonable and the community-based care that was provided was appropriate to C's identified needs at the time. When it was clinically indicated, the board arranged a further inpatient admission and reviewed C's diagnosis and treatment plan. There was evidence that the doctor did not stop C's medication. 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 unprofessional language used by the doctor, the doctor's communication regarding diagnosis and medication, the impact the doctor's communication had on C and not adequately reflecting that the board recognised that the doctor's communication was unreasonable in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should review the support being provided to C to assess whether the current level of support is appropriate and sufficient; and ensure that C is able to access medical assessment and review from a doctor other than the doctor at the subject of the complaint, if required.

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

• Communication with patients is professional and respectful. Documentation evidences that clinicians work in partnership with patients. Concerns and disagreements are documented using professional, non-judgmental language.
• There should not be a pattern of poor practice.

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 their spouse (A) received from the practice. A had contacted the practice on several occasions with worsening symptoms including headaches, and problems with vision and mobility. C complained that the practice unreasonably failed to undertake tests or act on results, such as when a discrepancy was found in the power of A's legs. C considered the practice unreasonably treated A for anxiety and failed to recognise there was a serious underlying reason for A's symptoms. A was ultimately found to have a brain tumour and died within a few days of receiving this diagnosis.

In responding to C's complaint, the practice provided a letter each from two of the GPs involved in A's care which explained their decision making in respect of the presenting symptoms at the time. The practice also explained they had undertaken a Significant Adverse Event Review (SAER) of A's case for learning and improvement.

We took independent advice on the complaint from a GP. We found that A had initially been treated for labyrinthitis (an inner ear infection) and urinary tract infection which was reasonable and in keeping with the symptoms reported by A at the time. We also found that after A was given a new prescription for glasses, it was appropriate to trial the glasses for improvement of the symptoms of headache and light headedness on standing. In relation to A's upper leg weakness, we found that this can occur for many reasons and, in isolation, would not suggest a more serious underlying cause. Referring to the working diagnosis of anxiety, we considered that this was not unreasonable in the circumstances.

However, the complaint presents a significant learning opportunity, highlighting the need for recognition that symptoms can deteriorate within a short time, and consideration that confused or difficult reporting of symptoms by the patient could in itself be an indicator of an underlying cause. We considered that the practice had provided a reasonable standard of care to A. Therefore, we did not uphold C's complaint but provided the practice with feedback on guidance on conducting adverse event reviews.

Summary

C complained about their care and treatment following a hysterectomy (a surgical procedure to remove all or a part of the uterus). C complained that they were not provided with adequate pain relief following the surgery, and that they were not fitted with an abdominal drain (a thin plastic tube which is inserted into an abnormal collection of fluid to help remove it from the body). C was discharged a few days later but disputes whether they were fit to be discharged home at this point. C was later readmitted suffering from a blood clot and an infection. C was discharged with oral antibiotics and again disputes whether they were fit to be discharged at this point.

A few days later, C began to bleed heavily. An ambulance was called but the wait was likely to be significant and C was taken to hospital by their partner. C was triaged but asked to sit on a chair in a corridor, despite suffering from obvious heavy vaginal bleeding. C was reviewed by a consultant and sent up to the gynaecology ward where they were then taken for emergency surgery.

We took independent advice from a consultant obstetrician (specialists in pregnancy and childbirth) and a consultant in emergency medicine. We found that C received a reasonable standard of care following their surgery and was appropriately discharged on both occasions. Therefore, we did not uphold these parts of C's complaint.

In relation to C's attendance at A&E, we found that they were not triaged sufficiently quickly and the way C was asked to wait was not appropriate given their condition. C was medically assessed within an appropriate timescale within A&E and appropriately transferred. The board had accepted there were failings in C's care, but they had not set out clearly how they planned to address these issues. Therefore, we upheld this part of C's complaint.

C also complained that the board failed to handle their complaint reasonably. We found that the board handled C's complaint appropriately and did not uphold this part of their complaint.

Recommendations

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

• Complete an assessment of the delay in triaging C.
• The board should consider what it can do to improve the experience of patients who require privacy when awaiting medical assessment.

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 partner (A). A had a history of Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties). A was suffering from constipation which was treated by the district nursing team at home. When this did not resolve, A was admitted to hospital for review and treatment of their constipation. C said they asked that A be treated and discharged home as quickly as possible. A fell whilst in hospital and fractured their shoulder. A developed a chest infection and subsequently died in hospital.

C believed A's condition could have been treated in the community. C felt A's vulnerability had not been recognised by nursing or clinical staff in hospital. C said that A had been designated as an adult with incapacity (AWI) and do not attempt cardiopulmonary resuscitation (DNACPR) without discussion with them as A's power of attorney (POA). C felt A's fall was avoidable had staff listened to the family's requests for 1-to-1 nursing.

We took advice from a registered nurse and a consultant respiratory physician. We found that A was not provided with a reasonable standard of nursing care in the community, as more could have been done to treat their constipation at home. Therefore, we upheld this part of C's complaint.

In relation to A's care while in hospital, we found both the standard of nursing and medical care to be reasonable. Therefore, we did not uphold these part's of C's complaint.

In relation to communication with C as A's next of kin and POA, we found there was a lack of communication regarding A's care and in particular decisions around designating A as AWI and DNACPR. Therefore, we upheld this part of C's complaint.

Finally, we found that A's death certificate should have included the fall as a secondary factor in their death. Initially it was believed that C would need to request this amendment, but the responsibility in fact lay with the board, who have been asked to ensure that the death certificate is amended. We upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted 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 develop a bowel management guideline to ensure appropriate prescribing and escalation if no response to treatment. This should include clear escalation pathways for patients with deteriorating health.
• That the board remind the clinical team of the importance of discussing and recording discussions about DNACPR and AWI decisions with patients and their next of in/powers of attorney, including ensuring that all parties understand how and why the decision has been reached.
• The responsible consultant should contact the Death Certificate Advisory Service and have the full amendment made as soon as possible.

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 was diagnosed with pancreatic cancer. C was unhappy with the delays with A's treatment and said that these prevented A from receiving any treatment before their death.

The board said that their intention was to treat the cancer and that A was required to meet with a consultant to assess their fitness for surgery. The board said that the delay in meeting with a consultant was to allow the health board to carry out two multidisciplinary meetings, for some of A's symptoms (such as jaundice) to improve, and for other investigations and procedures to be carried out (such as, imaging scans and the fitting of stents). The board acknowledged that there was a delay in a PET-CT scan (where a drug is injected before the scan to help clinicians identify how certain body functions are working) being carried out due to failures in the drug production. The board said that when this fails, there is no back-up facility in Scotland to provide a replacement batch.

We took independent clinical advice from a consultant colorectal and general surgeon. We found that the timeframe for A's treatment could have been improved even with the allowable delays from the PET-CT scan. We considered that the investigations carried out were reasonable and the early scan and procedure to fit a stent were good points in the treatment pathway. However, the length of the pathway could have been improved and A's lengthy pathway to the offer of chemotherapy was unreasonable. The timing of the clinic appointment and PET-CT could also have been improved. Whilst we recognise some of the delays experienced could not be predicted or avoided, on balance, the timescale for A's pathway was unreasonable. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in assessing A's fitness for surgery and the impact this had on other investigations i.e. arranging a PET-CT scan, the delay in the PET-CT scan being carried out and A being identified as unsuitable for 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:

• Patients who are considered suitable for surgery should have early assessment to establish fitness for surgery.

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 they received from the board in relation to knee replacement surgery. C said that a surgeon failed to adequately advise them of the potential risks of a total knee replacement and therefore failed to obtain their informed consent for the operation. C also complained that the surgeon failed to adequately examine their leg either pre or post operatively. C said that they had experienced a mal-alignment of their leg as a result of the operation leading to significant pain and loss of mobility.

The board was unable to identify the cause of the mal-alignment of C's leg, but did not identify any failings in their care and treatment.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that, despite some failings, the consent process in C's case was reasonable. We also found no evidence that the board's surgeon failed to adequately examine C's leg either pre or post operatively. Therefore, we did not uphold these parts of C's complaint.

C also complained that the board failed to adequately investigate or respond to their complaint. We found that the board's complaint response was unreasonable and 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-leaflet.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. The investigation should be thorough, and the complaint response should be accurate in their findings and conclusions and supported by relevant evidence such as medical records. Where there have been failings in surgery, the case should be presented and discussed within a departmental surgical morbidity and mortality meeting.

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 B about the care and treatment provided to B's spouse (A) by the practice. A attended the practice on a number of occasions over a few years with ongoing and worsening abdominal and lower back pain. C complained that the practice assumed A was suffering from a musculoskeletal problem and failed to consider other diagnoses sooner. A was later diagnosed with lymphoma and died at the time of diagnosis.

In responding to C's complaint, the practice undertook a Significant Adverse Event Review (SAER) and noted it was not clear when the lymphoma started. The practice also found that A had several normal or reassuring examinations and tests, and that several of A's presentations and tests pointed towards other diagnoses including liver disease and prostate disease. The SAER ultimately concluded that it seemed very unlikely that A had lymphoma for a long period of time given the very aggressive nature of their disease.

We took independent advice from a GP. We found that a number of tests and investigations were reported as normal and therefore there was no cause to refer A to specialists on suspicion of cancer. However, when concerns were raised about a possible missed renal cause for A's pain, we found that further investigations should have been undertaken at this time. These did not occur until almost a month later. A was suffering from an aggressive and difficult to diagnose cancer and, while the care and treatment provided by the practice was generally considered to be reasonable, the review should have triggered further tests at the time. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B 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 practice share this decision notice with their GPs with a view to identifying any 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.