Health

Summary

C complained about the care and treatment provided by the board to their partner (A). A had a seizure and was admitted to hospital for further assessment. C reported their concern to staff that A had dislocated their jaw during the seizure, and advised that this had happened to A before.

A underwent x-rays and was referred to oral and maxillofacial surgery (OMFS, specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) for review. OMFS concluded that no further treatment was required for A. C continued to report their concern about A's jaw and an urgent referral was made to ear nose and throat (ENT) for further assessment. This was later re-directed on vetting to OMFS, however no follow-up review by OMFS took place by the time of A's discharge some weeks later.

On discharge, C contacted A's GP who arranged for A to be seen by another health board. A was diagnosed as having a dislocated jaw and underwent emergency surgery.

The board said that there had been evidence of dislocation in the right jaw joint. They said that due to A's dementia and reduced mobility, they were unable to fully cooperate during their assessment and would not have been able to manage further x-ray procedures. They noted that A did not appear to be experiencing any pain and appeared to have a good range of movement of their jaw.

We took independent advice from an oral and maxillofacial surgeon. We found that A's initial assessment on arrival at the hospital and the decision to wait until the x-rays had been reported before referring A to OMFS for further assessment was reasonable. However, we found that the assessment of A's jaw by OMFS failed to elicit the clinical features of the dislocation and failed to consider other types of scan after concluding the diagnosis was unclear.

On the matter of the urgent referral to ENT which was later redirected to OMFS, we were critical that no follow-up review by OMFS took place prior to A's discharge. We considered that the board failed to provide A with reasonable care and treatment and upheld C's complaints.

We also noted that, at the point of C complaining to the board, it was known that A had in fact dislocated their jaw during their admission. The board confirmed in their response to our enquiries that no internal processes for reporting or learning or improvement had been followed on becoming aware of this harm. While the board had responded to C's complaint, we were critical that they failed to initiate or follow other processes to record the event, or to elicit learning and improvement outcomes at the point of becoming aware of it. Therefore, we made a recommendation to the board on this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably assess and diagnose A's dislocated jaw, the referral to ENT being inappropriately accepted, and the unreasonable delay by ENT in reviewing A which did not take place during their admission. 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 findings of this investigation should be fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding assessment processes.
• Referrals to other specialties for review should be made appropriately and accepted only when it is reasonable to do so. Referrals should be seen within a reasonable timescale.
• When the board becomes aware of a harm through the complaint process, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.

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 failed to provide them with reasonable care and treatment. C suffered from inflammatory conditions of the skin and joints and was under the care of rheumatology (specialists in the diagnosis and management of chronic inflammatory conditions such as rheumatoid arthritis), dermatology (specialists in the in the diagnosis and treatment of skin disorders) and the practice. C was being prescribed an immunosuppressant and the practice was in a shared care agreement with the NHS board for monitoring bloods in regards to the prescription. C required a liver transplant due to liver cirrhosis induced by the treatment. C complained that the practice had not properly monitored their bloods, had not picked up on warning signs and had not communicated appropriately with the relevant specialists or with C. C noted that they had also been incorrectly prescribed an antibiotic containing penicillin.

We took independent advice from a GP. We found that the practice had monitored bloods appropriately, and where there were gaps in monitoring, C's attendance had been requested. We also found that the practice had sought specialist advice and followed NICE guidelines appropriately. We noted that the practice had verbally apologised for the penicillin mistake. Therefore, we did not uphold this part of C's complaint but fed back to the practice that it would be appropriate to apologise in writing.

C also complained that they were immediately removed from the practice register after making a comment on social media expressing concerns about their treatment. C noted that they were given no warning and that their poor health, vulnerability and their requirement for continuity of care were not taken into account. We found that the practice had not followed guidelines in respect of removing the patient from the register, without warning. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for prescribing an antibiotic containing penicillin, which they were allergic to. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the manner in which their removal from the practice register was handled. 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:

• Reconsideration of the social media policy and patient removal policy and process, such that they are in line with BMA and GMC guidance.

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’s elderly parent (A) had recently been discharged from hospital where they had been treated with antibiotics for a urinary tract infection. However, A continued to experience nausea and vomiting along with hallucinations and A’s GP requested an ambulance be provided for A within one hour. Although the Scottish Ambulance Service (SAS) made a number of calls to A’s home to check on them, no ambulance attended. A’s condition deteriorated throughout the day and C called to request an ambulance again. However, no ambulance attended and an out of hours GP subsequently requested an urgent ambulance for A. An ambulance later arrived and A was assessed as having had a possible heart attack and received treatment from the ambulance crew before being taken to hospital.

C complained about the length of time it took for an ambulance to attend A. C considered that SAS did not recognise the severity of A’s condition or the damage to A’s heart and that they failed to appropriately prioritise an ambulance for A, unreasonably delaying their treatment.

SAS acknowledged that the delay to an ambulance being provided for A had been unreasonable, explained the particular challenges that they had faced on the specific day in relation to frontline staffing, service demand and hospital admission capacity, outlined the steps they were taking to prevent recurrence and apologised for A’s experience.

We took independent advice from a paramedic adviser. We found that there was opportunity for the board to take further steps to prevent recurrence. The information the board provided in response to this indicated that improvements are taking place. After careful consideration, we upheld the complaint given the delay that the board have already accepted and apologised for. The steps that the board had taken and are taking since are reasonable and we made no further recommendations.

Summary

C complained about the standard of medical care and treatment provided to their spouse (A). A was diagnosed with, and treated for, advanced breast cancer. A’s condition deteriorated and they later died. C complained that clinicians failed to, amongst other things, act upon A's worsening symptoms or their concerns that their cancer may be spreading. C also raised concerns about the end of life care A had received from the board.

The board, in responding to C’s concerns, did not consider that there had been a failure to act on A’s worsening symptoms. However, they acknowledged incidences where A had not been given the opportunity to bring support to out-patient appointments where clinicians reported a deterioration in their symptoms. They apologised to C for A's poor experiences and agreed to take a number of improvement actions in response. They acknowledged A’s end of life care had been highly distressing for C and their family but did not consider that this had fallen below a reasonable standard.

We took independent advice from a consultation clinical oncologist. We found that the communication surrounding A’s diagnosis and progressive disease could have been better. We also noted a lack of documented Clinical Nurse Specialist support, but overall felt A’s treatment following metastatic (when cancer cells spread to other parts of the body) diagnosis had been appropriate. We did not uphold this aspect of the complaint.

With regards to A’s end of life care, we found that although the board’s handling of A’s DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) and discussions around their deterioration were appropriately documented, the communication around this did not meet C’s own expectations or needs. However, we found no evidence to support that decisions taken in respect of A’s end of life treatment, including their nursing care, had been unreasonable. For these reasons, we did not uphold this aspect of the complaint.

We did, however, provide feedback to the board on complaint handling matters, specifically in relation to adhering to response timescales and updates to the complainant during a complaint investigation.

Summary

C was sent to hospital by the GP with a diagnosis of severe cellulitis (an infection caused by bacteria getting into the deeper layers of your skin). Prior to being sent to hospital, C received paracetamol, intravenous fluids and intravenous antibiotics. On arrival at hospital, C had a long wait until being treated and C complained that the delay in admission and treatment was unacceptable.

The board apologised that C had to wait in their car and explained that patients were seen on a clinical priority basis. They advised that C's clinical priority was not deemed to be urgent as C had received paracetamol, fluids and antibiotics before arrival.

We took independent advice from an acute and general medicine adviser. We found that at the time, there was no clear system for prioritising patients. However, since then the board have improved their practice. We found that the triage which had been undertaken after admission had not followed guidelines. Additionally, we found that the waiting time to receive antibiotics was longer than the recommended maximum wait between antibiotic doses. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in admission and treatment, specifically that clinical priority was not appropriately assessed, that the triage decision was not in line with the guidance and that there was a delay in administering medication. 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:

• Staff should triage patients in line with the relevant guidance.

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 their partner (A) received during an emergency admission to hospital for treatment of a back injury following a fall at home. During admission, C reported that A’s abdomen became very swollen which they were advised by staff was due to constipation and a build-up of faeces, and which was appropriately being treated with laxatives. A’s condition deteriorated and they were subsequently diagnosed with a perforated colon which required emergency surgery. This resulted in a stoma (a surgically made pouch on the outside of the body) and a prolonged period of recovery in hospital.

C complained that the board had failed to diagnose and treat A’s abdominal symptoms earlier. They considered that this may have resulted in a better surgical outcome for A, with no stoma being required. C also complained that the board failed to identify or treat a deep laceration on A’s arm, and they complained about the board’s failure to respect A’s dignity by discussing personal matters in the open ward.

The board’s response advised that A’s abdominal symptoms were timeously managed and treated, particularly noting that there had been no evidence during the admission assessments of a problem with A’s bowel. The board apologised that A’s arm injury had gone unnoticed and for personal matters being openly discussed, which they had provided as feedback to the ward charge nurse for learning and improvement.

We took independent advice from an upper gastrointestinal and general surgeon adviser. We found that A’s bowel perforation had been timeously diagnosed and treated, and the procedure that they received was appropriate to their presenting condition at the time. In relation to A’s arm laceration, we were critical of the board’s failure to identify and treat this as part of the assessment process. In relation to there being open discussion of private matters on the ward, we acknowledged the apology and action taken by the board in response to C’s complaint. On balance, we did not uphold C’s complaint.

Summary

C complained about the care and treatment of their late partner (A) during multiple admissions to hospital. C raised concerns that a coronary angiogram (a scan to check for blockages in the blood vessels) was unreasonably delayed, which in turn meant necessary vascular surgery could not take place. C complained about a lack of cohesion between vascular, cardiology and renal teams, and a lack of communication with the family.

We took independent clinical advice from a cardiology adviser and a vascular adviser. We found that there was a lack of cohesion and coordination in the management of A’s treatment plan. We considered that multidisciplinary meetings should have taken place to agree a treatment plan, and provide the cohesion that was lacking in the approach to A’s treatment. Overall, however, we found that the clinical decisions made by each team were reasonable and reflected A’s clinical condition at the time. We found nothing to suggest that the lack of cohesion impacted directly on the treatment A received or the eventual outcome for A. In particular, we found that there were good reasons not to proceed with the coronary angiogram, and that it was unlikely any vascular intervention could have been provided due to A’s competing illnesses. On balance, therefore, we did not uphold the complaint that A’s clinical care and treatment was unreasonable.

However, we upheld the complaint about the communication with A and their family. The board had already apologised for the poor communication and acknowledged that the multidisciplinary team did not keep the family as informed as they could have. Notwithstanding this, the board considered that A had capacity to make decisions regarding their own care and treatment. However, this assertion did not appear to have been based on any formal assessment. We found that there was evidence only once in the records of a capacity assessment having been undertaken. We found this concerning, particularly as C had raised concerns that A had become confused as a result of their illness and strong pain medication. We also found that there was a failure to complete existing documentation to record A’s communication preference, which was suggestive of a systemic failure rather than an issue that affected only A. Overall, we found that the communication with A and the family was very poor. A had a complex illness with a number of competing factors which affected the types and timings of treatments that were available. We concluded that clearer communication with the family, and between healthcare professionals, may have avoided a lot of the distress and anxiety the family experienced.

Recommendations

What we asked the organisation to do in this case:

• That the board apologise to C for the issues highlighted. 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 conduct an audit into the hospital staff’s compliance with their obligation to complete the existing documentation and take steps to ensure the documentation is being used effectively to ensure patient-centred care.
• That the board provide us with evidence of the steps that they have taken to ensure multidisciplinary team meetings take place to discuss and plan treatments for patients with complex medical conditions.
• That the board share this decision notice with the teams that were involved in A’s care and treatment 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.

Summary

C complained about the care and treatment that they received during their labour and delivery of their baby (A). In particular, C complained that the standard of care and treatment they received had been unsafe, that there had been a lack of communication in relation to their requested position during labour, the use of forceps and the provision of pain relief. C also complained that they had been unable to give their informed consent for the use of forceps.

The board, when responding to C’s complaint, accepted that some aspects of C’s care did not meet the standard that they would expect in terms of communication and C’s requested positioning throughout the labour and delivery of A. As a result of C’s complaint, the board had shared the complaint with the midwifery staff responsible for C’s care. The board asked them to reflect on C’s experience and consider ways of improving care for the purpose of providing person centred care. The board also accepted that they had failed to arrange C's postnatal review clinical appointment. The board said they had taken action to review and amend the process for appointing consultant led postnatal follow-up. The board indicated that, while the event had not been recorded as an adverse incident and a Datix (an incident/risk management reporting system to collect and manage data on adverse events) had not been submitted, a review had been carried out and action had been taken as a result of that review.

We took independent advice from a consultant obstetrician (a doctor who specialises in care during pregnancy, labour and after birth). We found that during C’s labour there were significant periods of loss of contact (LOC) during the recording of the foetal heart rate. However, we also found that, while labour would have been complicated by the LOC there was no evidence that C or A were put at risk. We also found that the actions of staff during this period were reasonable and proportionate to the needs of C and the clinical circumstances which occurred at the time. We found that safe care and delivery had been provided to C. However, we also found that there had been a material change in C’s birth plan and that there had been a failure to communicate these changes with C.

The board accepted that there was no documentation in the medical records of a discussion with C in line with Royal College of Obstetricians and Gynaecologists guidance on obtaining verbal consent on assisted vaginal births. We found that obtaining consent is an important aspect when providing care and treatment to a patient, and completing the appropriate documentation is a professional standard. The event should have been recorded as an adverse incident and a Datix should have been submitted. We upheld the complaint and provided feedback to the board in relation to the use of the adverse event process and the submission of a Datix.

Recommendations

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

• Patients should receive clear explanations and appropriate information where there are changes to their birth plan. Where discussions have taken place with a patient, this should be documented.
• Staff should be aware of the relevant Royal College of Obstetricians and Gynaecologists (RCOG) guidance on documenting consent.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate and address all aspects of the complaint.

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 spouse (A). C said that the board’s actions or inactions caused unnecessary suffering and stress to A and their family through misdiagnosis of A’s condition, poor administration of treatment, and failure to provide care in a proper manner whilst following health and safety guidelines.

We took independent advice from a consultant radiologist, consultant in emergency medicine and a consultant oncologist.

We found that, overall, the board provided reasonable care and treatment to A, there were no avoidable delays in A’s diagnosis, and the care and treatment prior and after their diagnosis was reasonable, with the exception of a case of poor documentation on a particular admission and poor communication in relation to A’s diagnosis. We did not uphold the complaint.

Summary

C complained about the care and treatment they received from the board in relation to an incident of extravasation (the leakage into surrounding tissue of medication administered intravenously) of chemotherapy into their arm. C told us that following the incident, their arm became painful and swollen and that they were left with loss of function in their hand and arm, despite being referred to the board's orthopaedic, plastic surgery and physiotherapy departments for further treatment. C considered that the aftercare they had received had been unreasonable and that there had been a lack of diagnosis in relation to the injury to their arm. C also complained about the attitude of nursing staff after the incident, which they felt lacked compassion.

The board told us that extravasation is a known risk of chemotherapy treatment but that once the extravasation was noticed, chemotherapy treatment was stopped immediately and that attempts were made to aspirate the fluid from C's arm. The board also noted that C was reviewed by an on-call plastic surgeon, all in accordance with their extravasation policy. The board acknowledged that, while C was subsequently seen by specialist in orthopaedics and physiotherapy, their recovery appeared to be slower than would normally be expected and that the long term implications were unclear.

We took independent advice from an oncologist and a nurse. We found that the board's response to the extravasation incident, both immediately and in the months that followed, was in keeping with their extravasation policy and established good practice. However, on review of the available documentation, there was no evidence to show that nursing staff had completed the necessary hourly checks of C's peripheral vascular cannula (through which the chemotherapy was administered) or that the extravasation incident had been discovered as a result of monitoring by nursing staff. This was unreasonable and contrary to professional nursing standards in relation to record-keeping. For this specific reason, we upheld C's complaint. However, there was no evidence within C's clinical records to confirm that the attitude of nursing staff had been poor.

We also found failings in the board's handling of C's complaint and made recommendations under our powers to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the complaint handling 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/information-leaflets.

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

• All relevant staff should be trained in and be aware of the relevant guidance in relation to PVC insertion, monitoring, maintenance and removal; and the completion of the relevant PVC monitoring documentation (this should include reference to the NMC Code Section 10). There should be a reliable method of ensuring that a PVC chart/aide memoire/policy/guideline is included in each patient's record as required. Relevant documentation should where appropriate be marked “N/A” if the sections are not required, so it is apparent that they have not just been missed.

In relation to complaints handling, we recommended:

• The board should comply with their complaint handling guidance when investigating and responding to complaints.

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.