Health

Summary

Mrs C complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's late father (Mr A). Mr A suffered from heart problems and had a history of diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) and a previous stroke. Over a period of about 18 months he had several hospital admissions and underwent two cardiac catheterisation procedures (where a tube is inserted into a blood vessel near the heart, to look at the condition of the blood vessels and/or insert a stent to widen them), but no stent was inserted. Doctors then referred Mr A for consideration of coronary bypass surgery (surgery to bypass a section of existing blood vessel that is narrowed with a graft). However, while he was waiting for review, Mr A suffered a further stroke and heart attack, and he died in hospital a few weeks after this. Mr A's family felt he should have been offered surgery earlier. They also raised concerns about the medical and nursing care during his admissions, and the board's response to their complaint.

The board considered the medical care and communication was reasonable. However, they agreed there were some failings in the nursing care for Mr A's pressure ulcers and they apologised for this and took action to prevent a recurrence.

We took independent medical, cardiology and nursing advice. We found that the overall management of Mr A's heart problems was reasonable, and it was appropriate that surgery was not offered earlier as this would have been a very high risk for Mr A (in view of his pre-existing conditions). We did not uphold this aspect of Mrs C's complaint. However, we found that there was no evidence Mr  A or his family were told about Mr A's heart attack for several days, and we made a recommendation in light of this finding.

We upheld the complaint about nursing care, as we found failings in relation to fluid monitoring, pressure ulcers, falls monitoring and communication with the family about Mr A's palliative care.

We also upheld the complaint about complaints handling, as there were errors in the board's complaint response, which appeared to be due to the medical records being misread.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the delay in informing them about the heart attack, the failings in nursing care and communication, and the errors in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients and/or family should be promptly updated about significant events, such as a heart attack, and a record made of the communication.
• Good palliative care should ensure a comfortable and peaceful time for the patients, with support for relevant others and person-centred communication.
• There should be clear handover communication between staff, to ensure all staff are aware of a patient's needs.
• Fluid balance charts should be completed for patients requiring fluid restriction.

In relation to complaints handling, we recommended:

• Complaint investigations should involve a careful and thorough review of the medical records, having particular regard to the points of complaint raised.

Summary

Mr C, who is an MSP, complained on behalf of his constituent (Mr A). He said that the board had failed to provide Mr A with reasonable care and treatment in Monklands Hospital. We took independent advice from a general medical adviser, a nursing adviser and from a consultant orthopaedic and trauma surgeon.

Firstly, Mr C complained that the board had unreasonably discharged Mr A with a bacterial infection and that he then had to be readmitted to hospital. We found that Mr A's discharge had been reasonable, as his symptoms appeared to be acceptably controlled at that time on oral medication; he had been appropriately reviewed; and no concerns about his discharge were raised. The blood tests results showing the infection did not become available until after he was discharged. We did not uphold this complaint.

Mr C also complained that staff failed to prevent Mr A falling on two occasions when he was readmitted to hospital. We found that there had been a failure to complete and document a falls risk assessment when Mr A was admitted in line with standards of care for older people in hospital. There was also a failure to document communication with the family. We upheld this complaint.

Mr A also complained that staff delayed in obtaining an X-ray after Mr A's falls. We found that an X-ray had not been clinically indicated after the first fall. An X- ray was then obtained after the second fall. On balance, we did not uphold this complaint.

Mr C also complained that staff had given Mr A too much morphine (a medication for pain relief). We found that the approach to this and the doses prescribed had been reasonable. We did not uphold this complaint.

Mr C also complained that staff failed to follow-up Mr A's care after his discharge from hospital. We found that, although an interim discharge letter was issued, a follow-up discharge summary was not issued. There was also insufficient information about how Mr A's hypertension (abnormally high blood pressure) was to be followed up. We upheld this complaint.

Finally, Mr C complained that the board had unreasonably prescribed an antiepileptic drug to Mr A beyond the maximum of ten years. There is no guidance that states it should not be prescribed for more than ten years and there was no clear evidence that this had caused Mr A's health problems. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to complete an appropriate risk assessment to prevent falls when he was admitted to hospital and to appropriately document communication with Mr A's family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Risk assessment and care planning in relation to falls prevention should be carried out in line with guidance and policy, when the patient is admitted to hospital.
• Nursing staff should involve patients and families in care planning where appropriate and should keep clear records of conversations with families/carers using the relevant documents.

Summary

Ms C complained about the nursing care her mother (Mrs A) received at Raigmore Hospital. Mrs A suffered from osteoporosis (weak or fragile bones) and fell during an admission to the hospital. A number of weeks following her discharge from hospital, Mrs A's GP arranged for x-rays to be taken which showed that she had suffered two fractures to her spine. Ms C complained that nursing staff failed to appropriately care for Mrs A following her fall.

We took independent advice from a nurse who is experienced in hospital falls prevention. We found that the nurses who attended Mrs A failed to act in accordance with falls prevention guidance. There was no record that an adequate assessment had been carried out to establish if Mrs A had sustained an injury following the fall. There was also a failure to arrange a medical review for Mrs A. We were unable to find out when the fractures actually occurred as Mrs A did not report to staff that she was in pain at the time and the actual diagnosis of fractures was not made until a number of weeks following the fall. However, we considered that the failings identified were unreasonable and upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to act in accordance with the guidance following her fall and failing to arrange a medical review. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Nursing staff should ensure that action is taken in accordance with guidance in relation to in-patient falls and ensure that a record is made on which examinations have taken place and that a medical review is arranged.

Summary

Mr C complained about the health care and treatment he had received in prison. In particular, he complained about problems he had experienced in receiving all his prescribed medication within the prison regime. The board acknowledged that there had been problems with Mr C receiving all his prescribed medication and they suggested that he discuss this with the GP. Mr C was unhappy with this response and brought his complaint to us.

We took independent medical advice. We found that the prison healthcare team were responsive to Mr C's concerns, including altering his medication to ensure he receives all of it, and liaising with pain specialists. We considered this treatment to be reasonable and did not uphold Mr C's complaint.

Summary

Ms C complained that the practice provided unreasonable treatment to her late mother (Mrs A). A GP from the practice attended Mrs A at home and prescribed an antibiotic. Mrs A was also on Warafin (a drug used to prevent blood clots) and other medication. She later became unwell and was admitted to hospital with bleeding from a peptic (stomach) ulcer and considered at risk of internal bleeding. Mrs A died a few weeks later. Mrs C complained that the prescription of the antibiotic was unreasonable and that Mrs A should have been advised to have her INR (a blood test which allows monitoring of Warafin levels) checked after she was started on the antibiotic.

We took independent advice from a GP. We found that the practice reasonably prescribed the antibiotic. However, the practice should have advised Mrs A that she should have her INR checked four to seven days after starting the antibiotic. Therefore, we upheld Ms C's complaint.

Recommendations

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

• This complaint should be discussed with the GP involved at their annual appraisal.

Summary

Mr C complained that the board delayed in providing him with surgery for his feet and knees, and that they unreasonably failed to explain the reasons for the delays.

We took independent advice from an orthopaedic surgeon (a surgon who specialises in the musculoskeletal system). We found that the Treatment Time Guarantee places a legal requirement on health boards so that, once planned treatment has been agreed with the patient, the patient must receive that treatment within 12 weeks. We found that Mr C waited around six months for the surgery on his first foot, and then ten months before being seen by a knee surgeon. We found that, whilst medically Mr C came to no harm as a result of the delays, he clearly suffered pain and functional restriction for longer than was reasonable. We upheld this aspect of the complaint.

Regarding communication, we noted that Mr C had received a letter confirming a guarantee of treatment within 12 weeks for his first surgery. The next documented communication was several months later, and was only sent in response to contact from Mr C. We considered that there should have been further communication from the board, apologising for the delay and setting out the steps being taken to minimise this. We found that Mr C had been left for many months without knowng when he might receive surgery. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in his orthopaedic treatment.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to explain the reasons for delays in treatment, and for failing to keep Mr C updated with regard to when he could expect to have his surgery.

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

• In the event that the Treatment Time Guarantee is not going to be met, letters to patients should make this clear, in accordance with the Patient Rights (Scotland) Act 2011.
• Be clearer with patients about any delays, the reasons for the delay and the steps being taken to improve matters.

Summary

Ms C began to experience stiffness and pain, to the extent that she was struggling with everyday tasks. Her GP prescribed her steroids (a type of anti-inflammatory medicine), which improved her symptoms. Her GP then referred her to rheumatology (the branch of medicine concerned with immune-mediated disorders of the musculoskeletal system) at Royal Alexandria Hospital. Ms C complained that, when she attended her rheumatology appointment, her condition was not appropriately assessed. Ms C said she was told to stop taking steroids but when she did this, her symptoms returned. Ms C raised concerns that she was not given any follow-up appointment to check on her condition. She also complained that, when her GP raised concerns about her worsening symptoms with rheumatology, no action was taken.

We took independent advice from a consultant rheumatologist. We found that there was a lack of useful clinical information in the clinic note and GP letter relating to Ms C's initial rheumatology appointment. As a result, the adviser was unable to confirm if her assessment was reasonable or not. We found that consideration should have been given to reducing Ms C's steroid dose gradually before it was stopped. We found that Ms C should have been given a follow-up appointment or the means to contact rheumatology directly for advice if her symptoms returned. We also found that when her GP contacted rheumatology with concerns, Ms C should have been offered a prompt review. In addition, we found that phone conversations, in which advice was given to Ms C's GP, were not recorded in her medical records.

We found that due to these failings, there was an unreasonable delay in diagnosing Ms C's underlying condition of inflammatory arthritis (an autoimmune condition that causes joint pain and swelling). We upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately document and update both Ms C and her GP on her rheumatology appointment; not giving Ms C a follow-up appointment or the means to contact rheumatology directly for advice; and the delay in offering Ms C a rheumatology review when her symptoms returned and worsened. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Appropriate clinical information should be documented in clinic notes, given to GPs and copied to the patient, with enough detail to understand how a clinical decision or diagnosis has been reached.
• Patients should receive appropriate follow-up care and a prompt rheumatology review if required.
• Clinical advice, which is given to GPs, should be recorded appropriately.

Summary

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received at Queen Elizabeth University Hospital. During a surgical procedure Ms A was diagnosed with endometriosis (a condition where the lining of the womb grows outside the womb) and she was given treatment to alleviate her symptoms. Afterwards, Ms A was discharged back to the care of her GP and her symptoms returned a few months later. Mr C considered that Ms A should have received a standard follow-up gynaecology (the branch of medicine which specialises in the female reproductive system) appointment, instead of being discharged back to her GP's care.

During our investigation we took independent advice from a consultant gynaecologist. We found that there was no clinical guidance that Ms A should have received a standard follow-up gynaecology appointment after her diagnosis. We considered that it was reasonable that the board expected that Ms A's treatment would improve her symptoms. We further considered that, even if the board suspected her symptoms might return, it is possible for endometriosis to be managed by a GP, with advice from gynaecology if required. Therefore, we considered it was reasonable that Ms A was discharged back to the care of her GP. We did not uphold the complaint.

However, the adviser noted that the post-surgical verbal advice given to Ms A was not documented. Also, Ms A did not appear to receive any written advice as back up, even though she was still recovering from the anaesthetic when the verbal advice was given. We made some recommendations regarding this.

Recommendations

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

• There should be a clear record of the verbal advice given to patients after surgery.
• In similar circumstances, consideration should be given to patients receiving written post-surgical advice to back up any verbal advice given to them.

Summary

Ms C complained on behalf of her mother (Mrs A). Mrs A was discharged from Gartnavel Hospital and then re-admitted two days later with a urinary tract infection and fluid on her lungs. Ms C complained that the board failed to discharge Mrs A in a reasonable way.

We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that, medically, it had not been unreasonable to have Mrs A discharged. While she may have had both a urinary tract infection and fluid on her lungs at the point of discharge, these were not doing her harm at that point. However, we found that Mrs A's risk of falls had not been adequately assessed prior to her discharge, and that this risk had also not been adequately communicated to Ms C. We noted that more should have been done to assess and reduce Mrs A's risk of falling before she was discharged, and that it was unreasonable to have discharged her due to her mobility issues. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mrs A for failing to assess Mrs A's falls risk prior to her discharge, and for failing to communicate this risk to Ms C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients at high risk of falls should be adequately assessed prior to discharge. Plans should be put in place to manage a patient at high risk of falls prior to their discharge.

Summary

Ms C complained about the treatment which she received at Peterhead Hospital and Aberdeen Royal Infirmary. Ms C had been treated for heart issues although she had not been reviewed by a cardiologist (a doctor who specialises in disorders of the heart). Ms C was subsequently admitted to hospital on two occasions where the medication for her heart issues was continued. Ms C sought a private opinion which found that she did not have a heart problem and her medication was withdrawn. As a result of the medication withdrawal, Ms C's health improved. Ms C complained that she was unreasonably prescribed heart medication and that this medication was not kept under regular review.

We took independent advice from a consultant cardiologist. We found that it was appropriate for Ms C to have been treated for suspected angina (chest pains) in view of her presenting symptoms. We considered the prescription of heart medication to be appropriate and did not uphold this aspect of Ms C's complaint.

However, there was a failure to keep Ms C under review pending the outcome of further out-patient cardiology investigations which may have identified that she was suffering from potential side effects of the medication. There was an incident on discharge from hospital that Ms C had been prescribed two calcium channel blockers (medication to relax and widen the blood vessels) which was inappropriate, although it was unlikely that harm was caused due to the low dosages involved. We also found that there were failings in record-keeping regarding discussions with cardiology staff and that it would have been advisable that Ms C should have been physically examined by a consultant cardiologist. We considered that the board failed to keep Ms C's medication under review and upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to keep her under review pending the outcome of further out-patient cardiology investigations. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for the failure to recognise that she had been discharged from hospital while on two types of calcium channel blocking medication. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware to keep patients under review pending the outcome of further out-patient cardiology investigations.
• Pharmacy and ward staff should be aware that when patients are discharged from hospital that their medication is appropriate.