Health

Summary

Mr C complained about two consultations he attended at Edinburgh Dental Institute following a referral from his dental practice relating to temporomandibular disorder (a problem affecting the 'chewing' muscles and the joints between the lower jaw and the base of the skull). In particular, Mr C was unhappy with the assessments carried out and the lack of treatment provided.

We took independent advice from a consultant oral and maxillofacial surgeon (a specialist in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck). They considered that most aspects of the clinical management in the department were reasonable. However, they considered that Mr C's medication history was not recorded adequately at the first consultation. In relation to the second consultation, they were critical that an examination was not performed. We upheld these aspects of Mr C's complaint.

Mr C was also unhappy that a clinic letter relating to one of the consultations contained an error and was sent to the wrong address. We upheld this aspect of Mr C's complaint. However, we noted that the board had apologised to Mr C and identified appropriate action to help prevent the issue reoccurring.

Finally, Mr C was unhappy about the way the board handled his complaint. The board acknowledged that their response was delayed and apologised to Mr C for this. We considered that the board's communication about the delay was poor and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to adequately record his medication history, failing to perform an examination, and the poor communication during the handling of his complaint. 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 presenting with pain should have their medication history appropriately recorded within the documentation of the management plan. Consultations should include an examination where this is indicated clinically or because of the particular circumstances of the patient's situation.

In relation to complaints handling, we recommended:

• Where it is not possible to complete an investigation within 20 working days, the person making the complaint should be given an update about the delay and a revised timescale for completion. Communication about revised timescales should be accurate and further contact should be made if it emerges that the revised timescale is not achievable.

Summary

Mrs C had knee replacement surgery at the Royal Infirmary of Edinburgh. She also underwent manipulation under anaesthetic (MUA - a procedure to try and improve movement) to try and relieve knee stiffness after the operation. Mrs C complained about the board's communication with her following the knee replacement surgery. In particular, she complained that she was not properly informed that, should MUA be unsuccessful, there was a possibility that nothing more could be done for her knee. She also complained that she was not told why she had been sent for a second opinion.

We took independent advice from an orthopaedic consultant (a doctor who specialises in the musculoskeletal system). We found that the majority of the communication with Mrs C had been reasonable, and that the advice she was given about MUA was reasonable. However, we found that consent process for the MUA was unreasonable, and that the communication around the second opinion had been poor. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the communication failings. 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 receive full and comprehensive information during the consent process and second opinion process.

Summary

Ms C complained about the care and treatment she received at St John's Hospital following breast surgery. In particular, that the board failed to listen to her when she asked for medication for the pain she was experiencing, failed to provide appropriate medication to address her pain and failed to appropriately recognise and act on seeing her red wristband for known allergies to certain painkillers.

We took independent advice from a consultant in general medicine and a senior nurse. We found that Ms C's records suggested medical and nursing staff had listened to her regarding her post-operative symptoms, made appropriate changes to her pain medication and provided a reasonable level of care. We also found that staff were aware of Ms C's allergies and acted appropriately. We considered that Ms C's care was reasonable and did not uphold her complaint.

Summary

Mrs C complained about the care and treatment her late son (Mr A) received when he was admitted to the Western General Hospital. Mr A had duchenne muscular dystrophy (a genetic disorder characterised by progressive muscle degeneration and weakness) and an associated heart condition and was admitted to the hospital with abdominal pain and swelling. He died in the hospital a week after he was admitted.

We took independent advice from a consultant general surgeon and a nurse. We found that it had been reasonable to admit Mr A to a surgical ward. He was examined by a surgical registrar and the on-call medical registrar which was an example of good care. However, we found that there had been a number of failings in the care and treatment provided to Mr A. In particular that:

• he should have been treated by a multi-disciplinary group of consultants, including a cardiologist (a doctor who specialises in the study or treatment of heart diseases and heart abnormalities);

• it was unreasonable for a consultant from the hospital's ventilation service not to take appropriate steps to evaluate Mr A when they were informed of his admission;

• it was unreasonable not to record Mr A's fluid intake/output;

• staff failed to act appropriately on an abnormal CT scan;

• staff unreasonably failed to reconsider the diagnosis of kidney infection;

• it was unreasonable for a junior doctor to propose discharging him;

• communication between general surgery and urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system) was poor;

• no moving and handling assessment was carried out when Mr A was admitted to hospital; and

• no equipment was available for the safe movement and transfer of Mr A three days after he was admitted to hospital.

We upheld Mrs C's complaint about the care and treatment provided to Mr A, however, we found that it was highly likely that the outcome would have been the same for Mr A if these failings had not occurred.

Mrs C also complained that the communication with her family had been unreasonable. We found that whilst there was evidence of discussions with the family and of staff responding to their concerns, Mr A had complex needs and the family should have been involved in his care in a planned and collaborative way. There was no evidence of this. We found that there had been a lack of appropriate engagement with the family in the assessment and care planning for Mr A and that the communication with his family had been poor. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with reasonable care and treatment in the hospital and for the poor communication with her family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• The board should ensure that appropriate multi-disciplinary management is triggered when a deteriorating adult with duchenne muscular dystrophy is admitted to hospital.
• Patients identified as being at risk should have their fluid intake and output accurately monitored.
• The board should ensure that CT scans are acted on appropriately and that the diagnosis is reconsidered in the light of any new findings.
• Patients should be appropriately reviewed and discussed with a relevant member of staff before discharge is proposed.

Summary

Mr C was seeking a referral to children's Occupational Therapy (OT) services for an assessment. Mr C was told he was not eligible for this service as he was 17  and no longer attended school. He was asked to make a new referral for adult OT services. Mr C did this and was assessed but discharged as the OT decided that his needs would be best met by local services in a community setting. Mr C was unhappy about this and complained to the board. He made a further referral to children's OT Services at the same time as his complaint and was this time seen by the service. Mr C complained that the board failed to progress his referrals to OT in a reasonable manner.

Mr C had also highlighted that the NHS website states the children's OT service is for children aged 0-18 and, therefore, he should have been assessed by them from the outset. The board responded by initially reiterating that Mr C was 17  years old and not at school so was more suited for adult services. However, in subsequent responses to Mr C they clarified that the children's OT service only has standardised assessments from age 0-16. They also advised there is no set criteria but instead, a flexible approach is adopted depending on the patient's individual circumstances. They acknowledged that Mr C had not received a clear explanation about why he was referred to adult OT services and apologised for this failing.

We considered that there had been poor communication and mixed reasons given to Mr C for directing his referral and upheld his complaint. However, the board advised that they had taken steps to review the triage service (a process in which things are ranked in terms of importance or priority) for the OT department. This included staff phoning children or parents who made referrals to gather more information to help signpost or assess patients from the outset. Additional staff have had training to make these calls and the board advised that the data they had reviewed so far indicated this was a positive change to the process. As a result of the positive steps taken by the board, we made no further recommendations.

Summary

Mr C complained to the practice about the lack of care provided to his late partner (Ms A). Ms A had attended the practice on numerous occasions over a four  month period reporting continuing neck pain. The practice had diagnosed that Ms A was suffering from Polymyalgia Rheumatica (inflammation of the muscles in the neck, shoulder or hip) and prescribed painkillers. Ms A subsequently attended hospital due to the pain and a x-ray revealed she had neck fractures caused by lung cancer spreading through her body. Mr C felt there had been a delay in carrying out investigations which would have identified the cancer at an earlier time.

We took independent advice from a GP adviser. We found that, based on Ms A's presenting symptoms, it was not unreasonable that the practice followed a working diagnosis of Polymyalgia Rheumatica. They prescribed appropriate medication which was changed to an alternative when it did not alleviate the symptoms. There were no red flag signs which would have indicated the possibility of cancer or symptoms which warranted either a hospital admission or an urgent hospital referral for a specialist opinion from a respiratory clinician. We found that Ms A's cancer presented in an unusual manner and that the cancer could not have reasonably been diagnosed earlier. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment provided to him at one of the board's addiction clinics. In particular, he felt that he did not receive appropriate support in order to help him withdraw from his diazepam medication (medication to help anxiety or withdrawal symptoms) in a safe and controlled manner. He said that he had been discharged back to the community mental health team without any assistance to reduce his medication.

We took independent advice from a psychiatrist. We found that Mr C's consultant psychiatrist had referred him to the addiction unit for advice and support to assist in his withdrawal from diazepam. The referral to the addiction team was on a time limited basis, with further care and treatment to be provided by the community mental health team. The addiction team made appropriate slight amendments to the dosage of Mr C's medication. We also found that Mr C received appropriate advice on psychological support services which were available in the community. We found that it was also appropriate that a long term treatment plan to enable Mr C to reduce his diazepam dosage was managed by the community mental health team as Mr C had a number of other health issues which would have been outwith the scope of the addiction unit. We did not uphold the complaint.

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr  A) by the board. Mrs C was concerned that failings in Mr A's care and treatment led to his death. The cause of Mr A's death was pulmonary embolism (a blood clot in the lungs).

Mrs C complained that the board did not give Mr A an appropriate consultation or examination when he attended the out-of-hours service and was seen by a doctor and a nurse. We took independent advice from a GP adviser and from a nurse. We found that the board held no records of Mr A's consultation with the doctor or the nurse, and we considered this to be unreasonable. In response to our investigation, the board acknowledged that they did not hold adequate records. They said that a reminder had been issued to out-of-hours staff about good record-keeping standards, and that audits of reports had since been carried out. We asked to see evidence of this. We upheld this aspect of Mrs C's complaint.

Following Mr A's attendance at the out-of-hours service, he attended A&E at Monklands Hospital. Mrs C complained that appropriate investigations were not carried out. We took independent advice from a consultant in emergency medicine. We found that the majority of the investigations carried out in A&E were reasonable. We also found that the history and examinations undertaken would not reasonably have led doctors to suspect a pulmonary embolism. However, we found that there was a failure to investigate an abnormality on Mr  A's electrocardiogram (ECG - a test which records the electrical activity of the heart). This abnormality would indicate the possibility of an acute coronary sydrome (when the heart is not getting enough blood), which should have been excluded through further investigations. We noted that, even if these further investigations had been carried out, it is not possible to conclude that Mr A's pulmonary embolism would have been identified. We upheld this aspect of Mrs  C's complaint.

We also found that the board's own complaints investigation did not identify or address the failings in care provided to Mr A, and so we made a recommendation in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and her family for the failure to record the consultation with the doctor and the assessment carried out by the nurse at the out-of-hours service and the failure to investigate the abnormality on Mr A's ECG in A&E. 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:

• Abnormalities on patient ECG's carried out in A&E should be properly investigated.

In relation to complaints handling, we recommended:

• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

Summary

Mr C, a solicitor, complained on behalf of his client (Ms B) regarding the way the board managed her daughter's (Ms A) transition from paediatric services to adult services. In particular, Ms B was concerned about the co-ordination of Ms A's care and her ability to access services when she needed to.

We took independent advice from a consultant paediatrician. While we found evidence of good practice in relation to a number of areas of transition care, we found little evidence of co-ordinated planning to support transition. In particular, we considered that a healthcare professional responsible for managing and co-ordinating transition should have been identified, as indicated by the board's transition guidance. We further noted that the board's guidance did not appear to have been reviewed in line with the planned timescales for review. We found that the board had appropriately met with Ms A's family and listened to their concerns, however, there was also evidence that the board and Ms A's GP had differing views on who was leading clinically. On balance, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A and Ms B for the lack of coordination and support from a lead healthcare professional during the transition from paediatric services to adult services. 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:

• Clinical teams within paediatric and adult services should have structured discussion to contribute to the planning of patients' transitions and this should be documented.
• There should be guidance in place detailing a clear pathway for transition from children's to adult services for practitioners to use to guide transition management.
• Patients with complex health needs, their family members and carers should be properly informed about who is responsible for coordinating their care at difference stages of transition.

Summary

Miss C complained about the care and treatment provided to her late father (Mr  A) during admissions in Monklands Hospital and Coathill Hospital.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nurse with expertise in pressure ulcer prevention.

Miss C raised concern that Mr A, who had diabetes, was discharged from Monklands Hospital with a large pressure ulcer on his left foot. In response to Miss C's complaint, the board acknowledged that there was little documentation of the care provided for Mr A's feet and they apologised for this. We found no evidence that medical staff reviewed Mr A's feet during this admission and considered that this was unreasonable in the circumstances. We also found a number of failings in the way nursing staff assessed, documented and managed Mr A's feet during the admission. We noted that there was a delay in referral to the podiatry team (the area of medicine which deals with the feet and ankles) and no evidence that Mr A was physically reviewed by podiatry. Finally, we were critical about the lack of information and equipment given to Mr A and his family before discharge and that the board did not ensure that arrangements for ongoing care were in place. We upheld this aspect of Miss C's complaint.

During a subsequent admission in Coathill Hospital, Mr A was found to have fallen. Initially, no injuries were noted by either nursing or medical staff. When Mr A was reviewed by an occupational therapist the day following the fall, pain was noted yet this was not escalated to the medical team. The board apologised to Miss C for this failing. Two days following the fall, nursing staff found Mr A to be in pain and an x-ray was arranged. This identified that Mr A had a broken hip and he received treatment the following day. We found that the initial medical review did not appear to have included an examination to specifically assess if Mr A had suffered any injuries as a result of his fall. We also considered that there was an unreasonable delay in arranging an x-ray and diagnosing Mr A's hip fracture. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings in nursing and medical care, failing to provide sufficient equipment and information prior to discharge, failing to ensure that arrangements for ongoing care were in place and the unreasonable delay in diagnosing Mr A's hip fracture. 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:

• Where a patient has a combination of poor blood supply, diabetes, and wounds on the feet, a medical examination should be carried out prior to discharge.
• All patients with diabetes who have existing foot damage or develop foot damage should be referred to podiatry as soon as the damage is discovered. Patients at risk of developing pressure damage to their feet should be assessed and fitted with protective footwear. Nursing staff should complete a wound assessment chart for every wound a patient has. Patients at risk of developing pressure damage or who have existing pressure damage should have a plan of care in place for interventions at least every two hours. Staff must be able to diagnose and grade pressure damage and accurately report their findings. Where a patient requires specialist assessment by a podiatrist a review should be carried out within a reasonable time.
• Patients and their families/carers should be provided with verbal and written information on pressure ulcer risk, details of a patient's pressure damage and how to manage this whilst preventing further damage, details of follow- up arrangements for wound dressing, a supply of wound dressings and pressure relieving footwear.
• Where a patient has fallen whilst in hospital, a medical examination for injury should be performed promptly.