Health

Summary

Mr C's child (Child A) was born with several rare conditions that threaten life, affect physical and mental development and require extensive clinical and day- to-day management. Mr C complained that the board unreasonably failed to identify any indication of developmental conditions from scans of Child A during his partner's pregnancy. The board said that Child A's conditions were not identified earlier because they were either not detectable by ultrasound at any stage of pregnancy, were not part of the routine checks undertaken or appeared to be within normal limits for the relevant stage of pregnancy. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from an obstetric and sonography adviser (a specialist in the use of ultrasound in pregnancy). We found that Child A's kidneys did not appear normal in the 20 week scan and that immediate referral to a specialist would have been reasonable practice in those circumstances. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Acknowledge that they unreasonably considered Child A's kidneys appeared normal on the 20 week scan, and apologise to Mr C for this. 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:

• A risk management multidisciplinary review should be undertaken about the board having missed the abnormality in Child A's kidneys.

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client Mrs A about the care and treatment Mrs A received at Dr Gray's Hospital. Mrs A suffered a miscarriage and attended hospital for an assisted delivery. She signed a consent form for the treatment and indicated that she wanted to take her baby home with her following the procedure. Mrs A believed she had passed her baby's foetus on the first day she was in hospital but was assured that this was not the case by her midwife. When Mrs A was to be discharged, the hospital were unable to locate the tub used for storage of what Mrs A believed to be the remains of her baby.

We took independent advice from a midwife. We found that the midwifes failed to follow the correct procedures in relation to the storage and disposal of pregnancy loss products. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to take adequate steps to address the acknowledged failings in Mrs A's care. Mrs A contacted the hospital following her discharge to discuss her treatment and the location of the tub. After discovering it had been incorrectly disposed of, Mrs A asked for an explanation from the board. Mrs A was told that actions had been taken to prevent a reoccurrence. Mrs A contacted the board's complaint department some weeks later and was told that the incident had not been reported formally or logged as a complaint.

We found that there was no evidence of any actions taken by the board to learn from the incident. We also found that the board had told Mrs A, in their first response to her, that action had been taken and the incident formally logged, which was incorrect. The board then failed to identify this inaccuracy in their second response to Mrs A. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to handle Mrs A's complaint reasonably. We found that the board's handling of the complaint failed to meet the standards expected of them by their complaints handling procedure. We considered that the board did not show an appropriate level of empathy or compassion for Mrs A in their response to the incident and failed to record or respond to the complaint properly. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to provide an appropriate level of care for her, and for failing to handle her complaint appropriately. The apology should meet the standards setout 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:

• Staff are aware of and are implementing the appropriate guidelines in relation to caring for women suffering from a miscarriage.
• Staff are aware of what constitutes a significant incident and how this should be reported and recorded.

In relation to complaints handling, we recommended:

• Staff have the knowledge and skills to identify and register complaints in line with the board's complaint handling procedure.
• The board's complaints handling system should ensure that failings (and good practice) are identified, and that action has been taken to ensure there is learning from complaints to inform service development and improvement.
• The board should use clear and accessible language, sensitive to the patient in cases of miscarriage.

Summary

Mr C complained on behalf of his late grandmother (Mrs A) about the care and treatment she received at Aberdeen Royal Infirmary (ARI) and Kincardine Community Hospital (KCH).

Mrs A suffered from severe pain in her back and a suspected chest infection. She was referred by her GP to ARI, discharged on day five and then re-admitted to KCH ten days later. Mrs A was transferred back to ARI over a month later, and then back to KCH, where she later died.

Mr C complained that the board failed to provide a reasonable standard of medical care and treatment, failed to provide a reasonable standard of nursing care and failed to handle his complaint appropriately.

Regarding medical care, Mr C complained about Mrs A's pain management and a lack of communication around her treatment. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that Mrs A did not receive sufficient attention for her pain relief requirements. We found that this was an issue that could have been easily avoided, and one that caused Mrs A pain and the need for readmission. We also found that there was a lack of consideration for Mrs A's decision-making capacity regarding an operation that she underwent, and that there was a failure to discuss her care with Mr C and the family at this time. We upheld this aspect of the complaint.

With regards to nursing care, we took independent advice from a nursing adviser. We found that, while the communication did not meet Mr C's family's needs for specific periods of time, there was no evidence in the nursing records to indicate that the overall level of nursing care Mrs A received was unreasonable. We did not uphold this part of the complaint.

Lastly, regarding the board's handling of Mr C's complaint, we found that the board had apologised to Mr C for a delay in handling his complaint. However, we were concerned that, having given Mr C a revised timescale for providing a response, this was not then met and the board were not proactive about keeping him advised about the subsequent process of his complaint. We were also concerned that the complaint response appeared to be incomplete and did not address all of the questions Mr C raised. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failure to provide Mrs A with sufficient attention for her pain relief and for the failure to adequately communicate with Mr C and his family about Mrs A's pain and its management. 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' pain relief needs should be fully assessed at the time of discharge from hospital. The management of a patient's pain after discharge should be fully discussed with patients and their families.
• Where a patient lacks decision-making capacity, their mental health should be respected and their care discussed with their family.

In relation to complaints handling, we recommended:

• Communication about revised complaint response timescales should be accurate and further contact should be made if it emerges that the revised timescale is not achievable. Responses to complaints should be accurate and address all the issues raised.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr  A) by the urology service (the service which deals with the male and female urinary-tract system and the male reproductive organs) at Victoria Hospital. Mr  A had a diagnosis of metastatic prostate cancer (prostate cancer that had spread to his bones) and had been reviewed roughly every three months by prostate cancer nurse specialists. Mr A received hormone therapy injections and his PSA (prostate specific antigen - a protein produced by normal cells in the prostate and also by prostate cancer cells) levels were measured to monitor his disease.

Over two years following his diagnosis, Mr A experienced back pain and he had a number of consultations with his GP. After Mr A's condition did not improve, the GP made a referral to the urology service to request urgent investigation. The urology service received the referral one day later and then made a referral to the radiology department to request a scan. A week passed following the initial GP referral, and by this time Mr A was struggling to move. Mr A was then admitted to hospital and a scan was performed. This indicated that he had a spinal fracture and cord compression from metastatic cancer. As a result of his condition, Mr A became paralysed below the waist.

Mrs C complained that the urology service did not carry out scans following Mr  A's diagnosis, even though it was known that the cancer had already spread to his bones. We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant oncologist (a doctor who specialises in cancer). We found that it was reasonable for the board to monitor Mr A's prostate cancer using PSA testing and not with routine scans. We did not uphold this complaint. However, we noted that the board had failed to respond to this part of Mrs C's complaint and had not handled a request for a meeting about this appropriately.

Mrs C also complained that there was an unreasonable delay in arranging a scan when Mr A's condition began to deteriorate. The board acknowledged that there were issues with how the urology service made the referral for a scan and also how it was handled by the radiology department. The board provided us with details of a process improvement that aimed to help avoid delays in future. However, we found that the referral from the urology service was made using the incorrect pathway. We concluded that the Malignant Spinal Cord Compression Pathway should have been used, which would have resulted in a scan within 24 hours of the referral. We concluded that if this had happened, Mr A would have had an improved chance of receiving treatment to maintain mobility. We informed the board of this finding and asked them to consider what action would effectively reduce the chance of the issue reoccurring. We upheld this complaint and made a recommendation. We also asked for evidence of the actions the board had already said they were taking or planned to take.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in arranging a scan when Mr A's condition deteriorated; not fully responding to all the points Mrs C raised in her complaint; and not responding to Mrs C's request for a meeting appropriately.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mr C complained on behalf of his wife (Mrs A) about a delay in carrying out a CT scan (a scan that creates detailed images of the inside of the body). Mrs A was taken to A&E at Dumfries and Galloway Royal Infirmary and following a CT scan, was diagnosed with having suffered a stroke. Mr C felt that the scan should have been carried out sooner.

We took independent advice from a medical adviser. We found that records of Mrs A's history and examination were inadequate. This meant that we were unable to conclude what Mrs A's condition was at the time of her assessment in A&E and, therefore, if the CT scan was completed within a reasonable time frame. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to document Mrs A's history and examination in line with the relevant guidance. 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 of relevant standards of documentation in terms of timed entries in clinical notes, documentation of relevant history and examination appropriate to the presenting complaint and documentation and timing of changes in clinical condition, clinical findings and action plan.

Summary

Mr C complained about the care and treatment provided to him during two admissions at Dumfries and Galloway Royal Infirmary.

Mr C had Hodgkin's Lymphoma (a cancer of the lymphatic system, which is part of the immune system). Mr C complained that he should not have been discharged after he felt unwell during an admission for a blood transfusion. We took independent advice from a consultant haematologist (a doctor who specialises in blood). We found that the follow-up arrangements made prior to discharge were unreasonable. We, therefore, upheld this part of Mr C's complaint.

During a subsequent admission, Mr C experienced a build-up of fluid in the lining of his lungs. He complained that there was a delay in carrying out a procedure to drain the fluid. We found that medical staff appropriately monitored whether a drain was needed to improve Mr C's symptoms and we did not consider that there was an unreasonable delay. We did not uphold this aspect of the complaint.

Mr C also experienced a build-up of fluid around his heart which required a procedure (pericardiocentesis) to drain the fluid. Mr C complained that the two attempts to carry out this procedure were not of a reasonable standard. We found that the first attempt was halted after Mr C became uncomfortable. The second attempt was stopped after concern was raised that Mr C's heart was damaged. Mr C was then transferred for emergency assessment, where the procedure was carried out successfully and no significant damage to Mr C's heart was identified.

We took independent advice on this from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that the first attempt at pericardiocentesis was not performed to a reasonable standard and was not documented adequately. However, we found that the board had carried out an internal investigation and that the operator involved had since reflected on what had happened and identified learning points. Despite the complication, we were not critical of the second attempt at the procedure as we found that staff took appropriate action once it was apparent that Mr C's heart had potentially sustained damage. On balance, we upheld this aspect of the complaint.

Lastly, Mr C complained about the level of communication with him during his second admission. We found that haematology staff did not update Mr C about the overall picture frequently enough, which may have added to his anxiety about his situation. We noted that Mr C had not been informed of the small risk of death prior to the attempts at pericardiocentesis. We upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that they did not make sufficient follow-up arrangements prior to discharge; did not adequately explain the risks of pericardiocentesis; and did not communicate with Mr C frequently enough during his second admission. 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 should be aware of what to do if they become unwell after discharge and how to contact the haematology department for advice. Patients with low blood cell count should be carefully monitored for changes in blood cell count.
• The approach and technique used in invasive procedures should be adequately documented in a patient's clinical records.
• Patients should be fully informed of the recognised risks, including death, as part of the consenting process prior to performing pericardiocentesis.
• Patients should receive the information they want or need to know in a way they can understand.

Summary

Ms C complained on behalf of her mother (Mrs A) about the care and treatment provided to Mrs A at Borders General Hospital.

After a fall breaking her hip, Mrs A was admitted to the hospital for an operation. At the time of her admission, Mrs A had hearing only in her right ear and staff were advised of this. Mrs A appeared to be making a reasonable recovery after her operation but, the next day, her condition deteriorated and she developed sepsis (a blood infection). She was given two doses of an antibiotic. Shortly afterwards, she developed a bowel obstruction for which she needed an operation and a few days afterwards, she had a heart attack. Mrs A remained in hospital for nearly six weeks and by then she had lost all her hearing. Mrs C complained about Mrs A's care and treatment and said that the antibiotic she had been given had led to her hearing loss. She also complained about poor communication and, amongst other things, not being told of Mrs A's heart attack.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and from a registered nurse. We found that Mrs A's operation had been performed promptly and without any problems but that afterwards, when her temperature and National Early Warning Score (NEWS - an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration) began to rise, no specific action was taken as it should have been. In relation to the antibiotics, Mrs A was very unwell and at risk of dying and, therefore, this risk outweighed the potential harm of giving Mrs  A the antibiotic (which was associated with hearing loss and balance problems after prolonged use). However, we also found that Mrs A was not given a detailed assessment or screened for sepsis. On balance, we upheld this aspect of Ms C's complaint.

In relation to communication, we found that staff had not told the family about Mrs  A's heart attack or made a plan to address or discuss Mrs A's communication needs, with no review of this taking place. We considered that the board's communication was unreasonable and upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for not fully assessing Mrs A; for failing to follow guidance; and for the communications failures. 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:

• Patients whose National Early Warning Scores trigger action should be appropriately assessed, including screening for sepsis and delirium.
• Patients and their carers should receive appropriate information about their condition in a way that suits their needs.

Summary

Miss C complained that she was unreasonably refused treatment in A&E at University Hospital Ayr. She said that staff referred her back to her GP as she was already receiving treatment for the same medical condition.

We took independent advice from an experienced practitioner in emergency medicine. We found that Miss C was appropriately assessed in A&E and did not have a life threatening illness or injury that required hospital admission or referral to another hospital specialist. We found that the appropriate route for Miss C was to report her health problems to her GP. We did not uphold Miss C's complaint.

Summary

Mr C complained to us about two periods when his brother (Mr A) was admitted to University Hospital Crosshouse. During these admissions, legislation contained in the Adults with Incapacity (Scotland) Act 2000 was utilised by the clinical team as they considered Mr A unable to consent or make decisions on treatment. Mr C complained that the Adults with Incapacity legislation was not used appropriately and that its use was not communicated reasonably to Mr A and his family. In addition to this, Mr C complained about the general level of care and treatment provided during Mr A's admissions.

We took independent advice from an adviser who is a registered medical practitioner with a background in psychiatry. We found that, given Mr A's circumstances during his admissions, the use of Adults with Incapacity legislation was reasonable. In addition to this, we did not identify any concerns about the general level of care provided, although we acknowledged that Mr A's experience may have differed from the information contained in the relevant documentation.

However, we identified shortcomings in relations to the recording and documentation of the use of Adults with Incapacity legislation. In addition to this, there was evidence of gaps in understanding of the Adults with Incapacity Act on a practical level, with factually incorrect information being provided on at least one occassion. Therefore, although it may have been appropriate to utilise Adults with Incapacity legislation, we concluded that there were service failings relating to the understanding of the legislation, the documentation of its use and the resulting communication with Mr A and his family. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for any distress caused due to any lack of understanding of Adults with Incapacity legislation and communication around its use in practice.

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

• Ensure that all relevant staff have an appropriate level of understanding of Adults with Incapacity legislation and its use in practice.

Summary

Mrs C complained on behalf of her father (Mr A) that the ambulance service unreasonably failed to dispatch an emergency ambulance. Mr A collapsed at work with a stroke and two calls were made for an ambulance, which took 50  minutes to arrive. Mrs C felt that the call handler who took the first call had not established sufficient information to determine whether Mr A was conscious or not, and that this affected the priority status of the ambulance response.

We took independent advice from a paramedic. We found that both phone calls were graded appropriately in view of the questions asked by the call handlers. However, in the first call it was not clearly established whether Mr A was conscious or not. Good practice would have been for the first call handler to have questioned the caller in more detail, which would have established an accurate consciousness level and may have affected the grading of the ambulance response. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mr A for failing to fully establish from the call maker whether Mr A was conscious or not. 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:

• The first call taker should ensure that, when talking to callers, they obtain accurate information about the condition of the patient so that an appropriate response level can be activated.

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.