Health

Summary

Mrs C complained that the ambulance service delayed in sending an ambulance to her daughter (Miss A) when Miss A dislocated her knee. The ambulance took almost an hour to arrive, which the ambulance service acknowledged was much longer than they would have expected. They apologised for the delay and explained it was due to a lack of resource, and the need to prioritise life threatening situations.

We took independent advice from a paramedic. We found that the request was assessed and prioritised appropriately. We were satisfied that the ambulance service responded reasonably to the request, and could not have done anything differently with the resources available to them at the time. We did not uphold this complaint.

Mrs C also complained about the time taken to respond to her complaint; the lack of interim update which led to her having to chase for a response; and also the adequacy of the response in addressing her concerns. We were content that the response was a reasonable and proportionate response to Mrs C's complaint. However, we were critical that the ambulance service failed to adhere to the NHS Scotland Model Complaints Handling Procedure in that they did not issue their response within 20 working days, and did not proactively contact Mrs C in the interim to explain the delay and agree a revised response timescale. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adhere to the terms of the NHS Scotland Model Complaints Handling Procedure when dealing with her complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• SAS should adhere to the terms of the NHS Scotland Model Complaints Handling Procedure when dealing with complaints – complaints handling staff should be reminded of these terms and the findings of this investigation should be brought to their attention.

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

Mrs C complained on behalf of her daughter (Miss A), who suffers from quadriplegic cerebral palsy (a condition which results in severe or complete loss of motor function in all four limbs) and other complex additional support needs. Mrs C complained that the board unreasonably withdrew Miss A's physiotherapy.

We took independent advice from a physiotherapist. We found that it could have been deemed appropriate for the board to stop Miss A's physiotherapy. However, we found that this was done without any appropriate assessment documented in the notes and without any documented consultation and discussion with Mrs C and her husband (Mr C). This is contrary to the Scottish Government Getting it Right for Every Child guidance. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that, when asked, the board unreasonably failed to show her that their decision to withdraw Miss A's physiotherapy was based on clinical need. We noted that, while the board referred to the progress Miss A had made, they did not explain why improvement in Miss A's physical abilities affected her need for physiotherapy. In view of this, it was unclear why the specific physiotherapy was withdrawn. There was also a delay in the board providing this complaint response to Mrs C. We upheld this aspect of the complaint.

Mrs C also complained that the board unreasonably failed to carry out a paediatric physiotherapy review of Miss A's physiotherapy requirements, as had been agreed at a meeting with Mrs C and Mr C. We were unable to confirm if a review took place at the time the board said that it would. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C and Miss A for the failings in Miss A's physiotherapy care and their response to the 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:

• In a similar situation, parents should be consulted prior to making changes to their children's physiotherapy treatment. The clinical reasoning for making changes should be documented and explained prior to them taking place, in accordance with Scottish and UK legislation and advice.
• Actions agreed at meetings regarding physiotherapy complaints should be completed and formally documented.

In relation to complaints handling, we recommended:

• Respond to complaints within a reasonable time and provide full responses, in accordance with the board's complaints procedure.

Summary

Mr C complained about the treatment he received in A&E at Ninewells Hospital. Mr C had had attended with symptoms of severe headache and double vision. He was given painkillers and told to return for a scan the following week. A few days later Mr C awoke with blood coming from his nose and mouth and contacted the Acute Medical Unit. He was asked to return the following day for a head scan which found that Mr C had suffered an internal carotid artery dissection (a tear in one of the arteries in the neck). Mr C felt that the head scan should have been taken when he first attended hospital.

We took independent advice from a consultant in acute medicine. Our investigation of the complaint was affected as the original case notes could not be located by the board and we had to rely on the contents of the immediate hospital discharge letter and a statement made by a doctor during the board's investigation of the complaint. We were unable to establish if the doctor managed to obtain a full medical history from Mr C about his symptoms and whether a full assessment had been carried out. There was some evidence that a full examination had been performed. There was no question that a head scan was required, and had insufficient resources been an issue at the time, then Mr C should have been recalled, ideally, the following day. However, this was dependent on the reported symptoms at that time. We found that appropriate advice was given to Mr C to seek further medical advice should his symptoms deteriorate. On balance, in view of the missing clinical records, it was felt that we could neither uphold or not uphold the complaint. We made no finding on the complaint.

Summary

Mrs C complained that the dental treatment she received was unreasonable. Mrs  C had been a patient of the dentist for 20 years but received a second opinion from another dentist and was told that she had extensive gum disease. Mrs C was concerned that she was never informed of this and that the treatment she had received was inappropriate. Mrs C also complained that the dentist unreasonably communicated with her about the health of her mouth and that they provided an unreasonable response to her complaint.

We took independent dental advice. We found that the patient notes recorded were very limited, with little information about the ongoing overall health of Mrs C's mouth or the investigations or treatments that occurred over the 20 year period. We also found no record of a Basic Periodontal Examination (BPE - a check on gum health that is required to take place at every six month exam).

In relation to the dentist's communication with Mrs C, we found that there was little evidence in the dental records that the dentist adequately informed Mrs C about the health of her mouth over the 20 year period. We also found that the response to Mrs C's complaint included inaccuracies and comments that were not supported by the dental record and failed to signpost Mrs C to us at the end of the complaints process.

We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in treatment and communication. 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 dentist should be fully aware of the requirements for good clinical record-keeping as stipulated in 4.1 of the General Dental Council Standards and the guidance for good note taking that is available in the Clinical Examination & Record Keeping Standards (FGDP RCS (Eng)).
• The dentist should be fully aware of the Scottish Dental Clinical Effectiveness Programme guidance contained within the Prevention and Treatment of Periodontal Disease in Primary Care.
• The dentist should be fully aware of the requirements of the Statement of Dental Remuneration.
• The dentist should be fully aware of the Selection Criteria for Dental Radiography (FGDP RCS (Eng)).
• The dentist should be fully aware of the Ionising Radiation (Medical Exposure) Regulations (2000) justification and reporting requirements, and the subsequent 2018 regulations.

In relation to complaints handling, we recommended:

• The dentist should ensure responses to complaints are accurate and supported by the dental records, and should also ensure that the complainant is advised of their right to come to the SPSO.

Summary

Mr C and Ms C complained about the care and treatment provided to their late son (Mr A) and about the practice's response to their complaint. Mr A had a history of mental ill-health and attended his GP practice concerned about a deterioration in his mental health. Shortly after his last attendance at the practice, Mr A completed suicide. Mr C and Ms C were concerned that the GP who cared for Mr A failed unreasonably to recognise that he was at significant risk of suicide and refer him immediately for psychiatric in-patient care.

We took independent advice from a GP adviser. We found that the standard of medical care and treatment provided to Mr A in the weeks leading up to his death was reasonable and that his death could not have been predicted or avoided by the GP. We also found that the practice responded to Mr C and Ms C's complaint reasonably. We did not uphold either complaint.

Summary

Mr C complained that the board delayed in providing his late wife (Mrs A) with a diagnosis of pancreatic cancer. He said that, had Mrs A been diagnosed sooner, her care and treatment may have been different and she could have had a better quality of life. In their response to Mr C's complaint, the board acknowledged a delay in diagnosis and apologised, but they said that Mrs A's illness had been difficult to detect and that her symptoms had been vague. They said that their delay had not affected Mrs C's outcome.

We took independent advice from consultants in radiology (a doctor who uses medical imaging such as x-rays, ultrasounds and scans) and oncology (a specialist in the study and treatment of tumours). We found that, while Mrs A had three scans, it was not until after the third scan that her diagnosis was made. However, we confirmed that her symptoms had been subtle and that there could be up to a 20 percent failure rate in detection. We did not uphold the complaint. However, we made a recommendation as the delay had not been without consequences. Had Mrs A's illness been picked up earlier, then she would have had earlier access to palliative care (end of life care) which may have made her final months easier to bear. We considered that there had been an insufficient recognition of this.

Mr C also complained that the board delayed unreasonably in responding to his complaint. We found that the board had taken too long to respond to Mr C's complaint, and so we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to recognise the consequences of the delay in Mrs A's diagnosis. The apology should meet the standards set out in SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Mr C for failing to reply to the complaint in a timely manner. The apology should meet the standards set out in SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The board should follow their stated complaints procedures.

Summary

Mrs C complained about the care and treatment she received from Ninewells Hospital regarding a delay in physiotherapy and the board's handling of her complaint concerning the matter.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in childbirth and the female reproductive system). We found that the handling of Mrs C's referral to physiotherapy was unreasonable and caused a delay of around seven months in her receiving her first appointment. We acknowledged that the board had apologised to Mrs C for the failure to action the referral to physiotherapy and for problems both Mrs C and her GP had when trying to expedite the referral through the doctor's secretarial staff. We considered that there was an unreasonable failure to amend Mrs C's management plan (regarding the decision to refer her for physiotherapy) after she was reviewed post-operatively.

We found that there was poor internal communication across two hospital sites and a missed opportunity for the problem with the referral to be addressed at an earlier stage when Mrs C and her GP contacted the doctor's support staff. We considered that the board had taken reasonable action to improve communication between hospital sites. We considered that the delay in receiving physiotherapy was unlikely to have affected the progression of Mrs C's condition. However, we upheld the complaint and made a further recommendation to ensure learning and improvement.

In terms of the board's handling of Mrs C's complaint, we acknowledged that they had apologised to Mrs C about their delay in responding. We found that the board had delayed by three weeks in updating Mrs C when they were unable to meet the 20 working day timescale for responding to complaints. Were were also critical that the board had not responded to all of the concerns Mrs C had raised in her complaint correspondence. The board accepted that they should have responded to this aspect. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not responding to all aspects of her complaint.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 ensure that management plans are updated between theatre and post-operative review.