Health

Summary

C, an advocacy worker, complained on behalf of A about the care and treatment they received from the board. A had been referred to the Ear, Nose and Throat (ENT) department when they noticed a growth on their neck. A was diagnosed with a positive squamous cell cancer (type of cancer that starts as a growth of cells on the skin) in their left tonsil which had spread to their neck lymph nodes. C complained about the standard of communication from the ENT department and a failure to provide appropriate treatment which they considered led to A's terminal diagnosis.

The board provided an overview of the care and treatment provided and were satisfied that appropriate care was provided. Due to the metastatic nature (spread) of A's cancer, the only treatment available was palliative. The board also noted there was regular communication with A and they were copied into letters that were sent to A's GP.

We took independent advice from a consultant ENT surgeon. We found that the clinical decision making with regards to treatment for A's cancer was appropriate and clearly set out in the records. While we recognised that A may have been under the impression that their cancer had been successfully treated, we were satisfied that the records documented detailed discussions which took place between clinical staff and A on multiple occasions regarding their diagnosis and treatment plan. We acknowledged it was possible that A may not have understood the complex and technical terminology used, however overall, we did not find that the clinical team failed to communicate with A. As such, we did not uphold C's complaints.

Summary

C complained about the care and treatment provided to their late partner (A) by the board. A had been diagnosed with anorectal cancer which had spread to their liver and was treated over several admissions to hospital. A died while receiving in-patient care. C complained that the board had failed to provide A with reasonable care and treatment while they were an in-patient. C also complained that the board had failed to communicate adequately with them.

The board did not identify any failings in A's care and treatment. However, they apologised for an aspect of their communication with C regarding A's diagnosis. C remained unhappy and asked us to investigate. C complained that clinician's had failed to take adequate action in the face of A's condition and that there had been a failure to provide adequate nursing care for A's stoma. C also complained about aspects of the board's communication regarding A's condition and death certificate.

We took independent advice from a consultant physician in acute internal medicine and a nurse. We found that the clinical and nursing care provided to A was reasonable. We found that the board's communication with A regarding their condition was also reasonable. Due to conflicting evidence we were unable to make findings about other aspects of the board's communication. Therefore, we did not uphold C's complaints but fed back to the board about keeping clear and accurate records of communication.

Summary

C, a support and advocacy worker, complained on behalf of their client (A). A had undergone breast surgery to remove nodes and C complained that the board did not adequately assess and manage A's wound when it showed signs of infection. The wound deteriorated and A became critically unwell with sepsis.

The board carried out a Significant Adverse Event Review (SAER), in which A expected greater involvement. C also complained that the SAER failed to identify that the incident met the Duty of Candour threshold and did not address the key issue, which was the inadequate care provided. The board stated the staff involved used their clinical judgement to assess the wound, which did not show signs of infection. However, it was difficult to investigate the adequacy of the wound assessment due to the omission of notes they made. The board acknowledged communication between health care professionals was impeded by a reliance on a paper-based system and the clinical record keeping was inadequate.

The board further advised the SAER was a formal process, which did not allow for A's inclusion and maintained the incident did not meet the Duty of Candour threshold. They considered the SAER to be adequate, as an investigation had taken place that had identified a number of learning points and recommendations.

We took independent clinical advice from a registered nurse specialising in tissue viability. We found the wound assessment to be inadequate, leading to a missed opportunity for appropriate wound management and that those involved in A's care lacked knowledge of current best practice in terms of wound assessment, wound management and antimicrobial stewardship. We also found the SAER to be inadequate as it failed to address the key issues of wound assessment, wound management and antimicrobial stewardship and failed to identify the incident met the Duty of Candour threshold.

As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A 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 person centred approach should be adopted.
• For all patients with a wound to have an adequate wound assessment undertaken and documented in a formal wound assessment chart. This should be in line with the following guidance Vale of Leven Inquiry Scottish Government Recommendations 2015NMC: The Code 201Scottish Ropper Ladder for Infected Wounds 2020 and HIS Scottish Wound Assessment and Action Guide 2021.
• A Duty of Candour Investigation to be undertaken, unless there is definitive evidence that the UTI caused the sepsis as wound deterioration is still a strong possibility.
• All staff involved in wound management are competent in appropriate management and familiar with the relevant guidance.
• Pathway to be developed to ensure timely referral to tissue viability specialist for deteriorating or non-healing wounds.
• Recommendations added to the SAER to address learning and improvement around wound assessment, management and antimicrobial stewardship.
• Staff to be reminded of Stage 3 of the Scottish Ropper Ladder for Infected Wounds, and consideration of antibiotics.

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 by the practice. C was diagnosed with polycystic ovary syndrome (PCOS, a condition that affects the function of the ovaries) a number of years ago and had previously had an ovarian cyst removed. Over the following years, C experienced a number of symptoms, including abdominal pain which the practice attributed to irritable bowel syndrome (IBS, a common condition that affects the digestive system). C complained that the practice did not explore a potential link to their PCOS. C attended A&E with severe pain. It was identified that C had a large ovarian cyst which required surgery. C complained that the practice's failure to diagnose the cyst exacerbated their symptoms and led to prolonged pain and discomfort. C also complained about poor postoperative care by the practice.

The practice confirmed they were satisfied that their treatment of C's symptoms was appropriate in the circumstances and explained that the NHS does not offer routine surveillance scans for patients with PCOS or to patients who have a history of cysts.

We took independent advice from a GP. We found that prior to C's attendance at A&E, there was no significant evidence of a cyst and in the absence of any other clinical indication it was reasonable to attribute C's symptoms to IBS. With regard to C's concern about the postoperative care provided, we noted that the practice diagnosed an incisional hernia and referred C to the Surgical Admissions Unit where an ultrasound was carried out but failed to show anything. A subsequent CT scan identified three hernias. We concluded that the GP's presumed diagnosis of a hernia was reasonable and therefore C was appropriately referred to the Surgical Admissions Unit. Overall, we were satisfied that the care and treatment provided to C was reasonable and we did not uphold C's complaints.

Summary

C complained about the care and treatment provided to their spouse (A) by the out-of-hours (OOH) service. A had a headache, temperature and dizziness and collapsed twice. The OOH GP spoke with A and A's family and prescribed painkillers for their headache. A later started hallucinating and the OOH service sent an advanced nurse practitioner who diagnosed A with a urine infection. A was later taken to hospital where they died from organ failure a few weeks later.

We took independent advice from a GP. We found that it was reasonable for the GP have carried out a telephone consultation instead of a home visit and that the telephone assessment conducted appears to have been reasonable. We also considered that it was reasonable for the OOH GP to have obtained a medical history from A and A's family and that given the symptoms described and the results of the urine test, the diagnosis of a urine infection was reasonable, as was treatment with antibiotics rather than admission to hospital. We also found it reasonable that a Significant Adverse Event Review was not considered given that there were no direct issues raised with the OOH service at the time of events.

We did not uphold C's complaint but provided feedback to the board that the notes of the telephone consultation were inadequate given that reasonable record keeping is an integral part of patient care.

Summary

C complained that their late sibling (A) should have been given a telephone or face-to-face consultation with a GP following increasing contact with the practice and an escalation of symptoms relating to chest pain that resulted in A's death from acute myocardial infarction (heart attack). C also complained that the practice's handling of the resulting Significant Adverse Event Review (SAER) was unreasonable.

The practice considered the care and treatment of A to be reasonable. The GP was shielding at home during the COVID-19 pandemic and could not see patients face-to-face. The practice stated it was subject to restrictions imposed by the Scottish Government at the time. The practice also said that A was appropriately triaged and their care managed by a range of healthcare professionals.

We took independent clinical advice from a GP. We found that A should have been offered a telephone consultation with the GP and a face-to-face appointment with the locum GP. We found that A's care was delegated to nursing staff when GP input was required and there was a lack of review between the GP and nursing team when A's symptoms failed to resolve.

We also found that the SAER failed to identify learning points, failings and reflection and did not include the health care professionals involved in A's care.

Therefore, we upheld C's complaints.

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 should receive appropriate treatment in relation to their presenting symptoms and potential causes considered as appropriate.
• Significant Adverse Event Reviews should be a reflective and learning process that appropriately considers events in sufficient detail, to ensure failings are identified and any appropriate learning and practice improvements.
• When appropriate, patients should be reviewed by a GP either by phone or in person dependant on their symptoms.
• When necessary and required, patients receiving treatment from the nursing team should have their care appropriately reviewed and discussed with a GP.

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 they received from the practice. A was prescribed an anti-inflammatory drug by a rheumatology consultant (specialists in diagnosing and managing chronic inflammatory conditions). The medication was issued on repeat prescription by the practice. C told us that the medication had risks and the practice failed to carry out appropriate medication reviews or update A about the risks. C said A was not aware of the risks of the medication and trusted that it was safe to use long-term. They felt it was unreasonable for the practice to assume A would have read the leaflet with the medication to identify any changes or to know to ask for a medication review.

The practice said that the medication was prescribed by the rheumatology service and would have been monitored by them. The practice highlighted that at the time the medication was prescribed, it was not considered high risk, and that the risks only became known after A had been prescribed the medication for a number of years. The practice noted that A did not proactively contact the practice to review their medication periodically but acknowledged that they did not contact A either.

We took independent advice from a GP. We found that national guidance states that patients should have annual checks when taking medication of this sort. The responsibility for carrying out these checks lies with whoever is issuing the prescription. When discharged from the rheumatology service, the practice should have invited A for a review and arranged appropriate follow-up. The practice should have carried out medication reviews and informed A about the change of risks associated with the medication.

We found that it was unreasonable for the practice not to have carried out medication reviews or informed A about the change in risks. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failingto alert them to the changes in risks associated with the medication, having a discussion about the risks, and allowing them to make an informed choice on whether or not to continue with the medication; failing to carry out medication reviews annually as they should have done; and failing to invite A to a review of their health when the practice became aware they were discharged from the rheumatology service. 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:

• GPs should recognise that as the prescriber of the medication it is their responsibility to carry out medication reviews on medications provided via repeat prescription. When a GP is alerted to the fact a patient is discharged from a secondary care service due to non-attendance, they should contact the patient to arrange a review and consider appropriate follow-up. Medication reviews should be carried out annually.
• When medication alerts are issued nationally, the practice should identify and review any of their patients to whom such an alert might apply.

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 infant (A). C's concerns related to A's urinary function. C had concerns about the monitoring they had received whilst pregnant with A, the care provided to them and A immediately post- birth as well as during A's early years. C raised issues about the assessment of A's bladder function, A's renal health and the pain and discomfort A was suffering. C also felt that the family had not been listened to and their concerns dismissed or minimised. C had sought a second opinion at a hospital in England and believed board medical staff criticised the family for taking this step. They also said that the board failed to liaise with the hospital in England, resulting in A not receiving treatment or care for an extended period.

The board had accepted that communication with the family could have been better but considered the standard of care and treatment provided to A was reasonable.

We took independent advice from a consultant paediatrician. We found that A's symptoms were reasonably investigated initially and that they were referred to urology timeously. We also found no clear evidence that A's bladder had been damaged by failings on the part of the board. Therefore, we did not uphold these parts of C's complaint.

We found that the impact on A and their family of their condition was not adequately acknowledged and that the board had failed to communicate appropriately with C and their family. We also found that the board did not act when it became apparent that A was no longer being cared for by a hospital in England, resulting in avoidable delays in their care. Finally, we considered that the board failed to handle C's complaint reasonably. We upheld these parts of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's parents for the failures 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:

• The board should share this decision with the staff involved in A's care with a view to identifying any aspects of the care and treatment that could have been improved. This should include consideration of whether there are any immediate actions which need to be taken to address A's ongoing issues.
• Patients' families should receive clear explanations and be provided with appropriate information which addresses their concerns.
• The board should reflect on the experience of A's family with a view to identifying any ways that communication and care planning for A could have been better managed.

In relation to complaints handling, we recommended:

• The board's complaint monitoring should ensure that failings, as well as good practice are identified and that learning and information gathered from complaints is used to drive service improvement.

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 practice about the care and treatment provided to their relative (A). A began to experience abdominal pain and was reviewed by doctors at the practice a number of times before being admitted to hospital as an emergency. Following discharge, A was seen at the practice again with continuing symptoms and unintended weight loss. They were referred to hospital and again discharged. A colonoscopy performed suggested acute diverticulitis (where small pouches from the wall of the gut become inflamed or infected). A attended the practice again with worsening symptoms and was admitted to the hospital after an urgent request was submitted. A died in hospital a few weeks after.

C was concerned about the standard of care provided to A by the practice. The practice met with A's family. The practice carried out a Significant Event Analysis (SEA). The practice responded to C's complaint and noted their frustration that A had been discharged from the hospital without progress in the management of their condition. However, they did not find that they should or could have done anything differently in A's care.

C submitted a further complaint to the practice after they received a response from the health board regarding the care provided at the hospital. The practice responded confirming that an SEA had been carried out. The doctor who had seen A had discussed the case with colleagues in the practice and with their Educational Supervisor. These discussions had been informal and had not been documented in A's notes.

C was dissatisfied with the complaint responses and brought the complaint to our office. We took independent advice from a GP. We found that most of A's care was of a reasonable standard. However, there was a delay in acting on concerns about A's condition following their second discharge from hospital. Given the significance of the failures identified, we considered that A's care fell below a reasonable standard and upheld this part of C's complaint.

C also complained that the practice failed to reasonably respond to C's concerns. We found that the identified failure should have been communicated to the family, by the practice, during their investigation of the family's complaints. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the failure to act with sufficient urgency following A's discharge. The apology should meet the standards set out in the SPSO guidelines on apology. available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for the complaint investigation's failure to identify a failing in A's 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:

• Patients requiring urgent care should be referred to specialists within a reasonable timeframe.
• The practice should ensure relevant staff are aware of the need to document discussions about patient care appropriately, in this case discussions between a trainee doctor and their Educational Supervisor, concerning a patient's care.
• Complaint investigations by the practice should address all relevant issues and should clearly identify and address any failings.

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) during their admission to hospital for a knee replacement. A said that they woke up during their surgery.

The board responded to the complaint noting that there was no evidence A woke up during surgery. C and A were unhappy with this response and brought their complaint to our office.

We took independent advice from a consultant anaesthetist (specialist doctors responsible for providing anaesthesia and pain management to patients before, during and after operations and surgical procedures) and asked the board to comment on issues we had identified.

The board explained that A had been under a deep sedation during the procedure and provided further details about the management of A's sedation. They confirmed that A had to receive a 'top up' in medication during the procedure and had reflected on the manner of their complaint response and the detail they had originally provided and offered to make an apology to A.

We found that the procedure was undertaken with a spinal anaesthesia and sedation rather than under general anaesthetic. We noted that the board's explanation with respect to managing A during the procedure was reasonable but confirmed that A did wake up. A did not appear to be aware this could be a possibility given they were not under general anaesthetic.

We considered that while A did wake up, this was not due to inappropriate or unreasonable levels of care. Indeed, it was possible it could happen and it was handled appropriately. Therefore, we did not uphold C's complaint.

However, we concluded that the board should have acknowledged that A woke up during the procedure and provided C and A with an explanation as to why this happened and how this was managed. Therefore, we found that the hospital failed to appropriately investigate and respond to C's complaint and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the lack of detail contained in the complaints response and for providing misleading information regarding the circumstances of A becoming aware during the surgery. It would be appropriate to acknowledge the significant impact the lack of a clear response from the outset has had on both C and A. 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.