Health

Summary

Mrs C complained that the board failed to ensure a reasonable standard of communication with herself and her late husband (Mr A). Mr A had been diagnosed with cancer, and Mrs C complained that the communication about his diagnosis, prognosis and treatment options was poor and that, as such, Mrs C and Mr A were unable to make an informed decision about the treatment options offered.

We took independent advice from an oncology (cancer) nurse and from an adviser who specialises in the care of the elderly. We found that board staff discussed treatment options and potential risks in a reasonable way, and that the records suggested that Mr A understood the nature of his condition and treatment options. We also found that staff followed the relevant General Medical Council Guidance in this respect, and that they acted reasonably in respecting Mr A's stated preferences for information and his decision-making ability. We did not uphold the complaint.

Summary

Mrs C complained on behalf of her father-in-law (Mr A) about the care and treatment he received from Victoria Hospital and Glenrothes Hospital over a six  month admission period. Mrs C's concerns related to surgical treatment, nursing care, physiotherapy, speech and language therapy (SALT) and medical care.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), two registered nurses and a consultant geriatrician (a doctor who specialises in medicine of the elderly). In relation to Mr A's surgical treatment, Mrs C felt that a perforated ulcer should have been identified at the time Mr A underwent an emergency operation. We found that it was reasonable that the perforated ulcer was not recognised at the time of the emergency surgery given a number of relevant factors. We did not uphold this aspect of Mrs C's complaint.

In relation to the nursing care, Mrs C was concerned that Mr A developed as significant pressure ulcer, monitoring of his fluid intake/output was poor and Parkinson's medication was not administered when it should have been. We found no evidence that administration of Mr A's Parkinson's medication was unreasonable. However, we found significant failings in relation to the prevention, monitoring and management of pressure ulcers and that fluid intake/output charts were not adequately completed. We upheld this aspect of Mrs C's complaint. However, we noted that the board had identified failings in regards to pressure ulcer damage and fluid monitoring and had taken steps to address these issues.

In relation to the physiotherapy treatment Mr A received, Mrs C was concerned that there was a lack of regular visits from the physiotherapist. We found that Mr  A received regular visits from physiotherapy staff and that their care was appropriate. We did not uphold this aspect of Mrs C's complaint.

Mrs C was also concerned that there was a lack of visits from SALT and a lack of effective communication with other staff regarding Mr A's altered diet. We found that review by SALT was sporadic and not carried out in a timely manner at either hospital. We considered that Mr A's risk of aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) would have been reduced had timely SALT review taken place. We upheld this aspect of Mrs C's complaint.

In relation to Mr A's medical care, Mrs C was concerned that communication about placing a do not attempt cardio-pulmonary resuscitation (DNACPR) mandate in place was inappropriate, Mr A's usual Parkinson's medication was not prescribed causing problems with his movement and interaction, and transfer arrangements were unreasonable. We found that the conversation which took place about DNACPR were appropriate and that the changes made to Mr A's Parkinsons medication was reasonable. We also found overall that the transfer arrangements were reasonable, however, we were critical that there was no evidence to show that a formal record of discharge was documented to support a thorough hand-over. We did not uphold Mrs C's complaint but made a recommendation to the board in light of this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delays in SALT review and follow-up. 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:

• Staff should carry out pressure ulcer prevention and management in accordance with national guidance.
• SALT should ensure patients with complex needs are seen within agreed timescales.
• Complex patients should have a careful and thorough hand-over documented.

Summary

Mrs C complained to us that the practice had failed to provide appropriate care and treatment to her late daughter (Miss A). Miss A had attended the practice with her partner and had reported symptoms of severe headaches, tiredness and constantly dropping items from her left hand. The GP took Miss A's blood pressure and gave her a vitamin injection. Miss A died at home the following day.

We took independent advice from a GP adviser. We found that the doctor should have arranged further investigations of Miss A's weakness and dropping items with her left hand as this was a new symptom. The doctor should have arranged for an urgent review by a stroke specialist to establish if there were signs of a Transient Ischaemic Attack (a mini stroke) which was a risk factor for subsequent stroke or myocardial infarction (heart attack). However, we found that the doctor had carried out a reasonable assessment and examination which was in line with national guidance. There was no indication at that time that Miss A required an urgent hospital admission. Miss A had a complex medical history and her symptoms of high blood pressure, headache and tiredness were longstanding.

On balance, we took the view that the doctor provided reasonable treatment and we did not uphold the complaint. Whilst we did not uphold the complaint we provided feedback to the doctor that they should review the standard of their record-keeping and refresh their knowledge about the presenting symptoms of a Transient Ischaemic Attack.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received at University Hospital Crosshouse. In particular, Mr C complained that Mrs A's medication had been changed and that she had not been provided with a reasonable standard of clinical care and treatment during two admissions to the hospital.

We took advice from a consultant hepatologist and gastroenterologist (a  specialist in the diagnosis and treatment of disorders of the digestive tract and liver). We found that it had been reasonable to have treated Mrs A with strong immunosuppressants (a drug that can suppress or prevent the immune response) and that the change in her medication was reasonable. We did not uphold this aspect of Mr C's complaint.

In relation to both of Mrs A's hospital admissions, we found that the management of her care and treatment had been reasonable. We also noted that, during her first admission, Mrs A was booked in for an ultrasound scan as an out-patient, with an ear, nose and throat review afterwards. We considered that this action was reasonable and in line with national guidelines. We did not uphold Mr C's complaints.

Summary

Mr C complained about his care and treatment when he attended Crosshouse Hospital after experiencing stroke-like symptoms. Mr C was taken to the emergency department (ED) and was told he would be admitted to a ward but he was discharged a few hours later. Mr C suffered a seizure later that day and was returned to hospital by ambulance. He was admitted to the high dependency unit and kept in for two days for investigations. Mr C complained that it was not reasonable for staff to discharge him when he first attended. He was concerned he was not monitored frequently and that staff did not give him a clear explanation or diagnosis.

The board acknowledged that nurses should have recorded more frequent ward rounds and apologised for this. However, they explained that Mr C was also kept under observation via electronic monitors. The board considered that the medical care and treatment was reasonable. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant in emergency medicine, a consultant in general medicine and a nurse. We found that Mr C was given prompt treatment for tonsillitis (inflammation of the tonsils) and suspected meningitis (infection of the coverings of the brain). We noted that this was investigated further but it was found that he did not have meningitis. Mr C was followed up by the neurology department (branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) after his discharge and was diagnosed with hemiplegic migraine (a rare and serious type of migraine that has symptoms similar to those of a stroke). We considered that Mr C's medical care and the decision to discharge him was reasonable. We did not uphold these aspects of Mr C's complaint.

In relation to the nursing care Mr C received, we found that nurses had not clearly recorded what action was taken when he had a high National Early Warning Score (NEWS, an indicator of a patient's overall health) or why the plan had changed from admitting him to discharging him from the ED. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not repeating his observations before discharge and for the gaps in record-keeping. 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:

• Nurses should record what action is taken in response to an elevated NEWS and repeat the NEWS check before discharging the patient.
• Where a plan of care changes, the nursing records should show the reasoning behind this.

Summary

Mrs C complained about the care and treatment provided to her late mother (Ms  A) at Woodland View. Ms A was transferred there for rehabilitation after several weeks in hospital, where she was treated for recurrent urinary tract infections (UTIs), and delirium. Ms A suffered further UTIs and did not make progress with her medication. She was transferred to a mental health ward for treatment of her delirium, low mood and physical symptoms. Ms A also had a background history of bipolar disorder (a mental health condition marked by alternating periods of elation and depression). Ms A's condition deteriorated further and she was transferred back to hospital with aspiration pneumonia (a  type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). She was given palliative care and died in hospital.

Mrs C complained that there was inadequate care planning to manage Ms A's delirium and UTIs. She felt staff focussed on Ms A's age and bipolar disorder as an explanation for her condition and did not fully appreciate the impact of the UTIs and delirium. Mrs C was also concerned about the way the hospital and ward transitions were managed, and about Ms A's overall care and treatment. Mrs C said she was not involved in care planning and decisions, despite being Ms A's carer and welfare power of attorney, and she felt some nursing staff were hostile or resistant when she made suggestions for Ms A's care. The board met with Mrs C when she first complained (during Ms A's admission) and a number of actions were agreed, but Mrs C said these were never completed. The board also gave a written response to Mrs C's later complaint (following Ms A's transfer back to hospital). Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse. We found there was a lack of proactive care planning for Ms A's UTIs and delirium at times, and Ms A had also had an untreated UTI for about ten days. While we did not find evidence that staff were hostile or lacked compassion, we found that Mrs C was not always included in care planning for her mother, and there were not always clear and comprehensive records of communication. We also found that the board did not have evidence to show they had fully followed through on some of the actions agreed at the complaint meeting. 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 care planning, communication and complaint handling. 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 suffers from recurrent urinary tract infections and/or delirium, there should be dedicated care planning to address this (and this should be carried over where a patient changes wards).
• The patient's carer or welfare power of attorney should be fully and proactively involved in care planning.

In relation to complaints handling, we recommended:

• Any actions agreed following a complaint should be completed.
• Where a complaint investigation finds that errors or failings have occurred (although not in relation to the specific complaints raised), the board should still acknowledge and apologise for this.

Summary

Mr C attended University Hospital Crosshouse after sustaining a tear in the anterior cruciate ligament (a ligament in the knee) and damaged cartilage (connective tissue). Mr C complained that the board took too long to provide appropriate treatment following a referral from his GP, failed to provide a reasonable standard of treatment and failed to communicate reasonably with him about his condition and treatment.

In relation to the treatment time, we found that the board had breached the treatment time guarantee of 12 weeks and considered that this was unreasonable. We upheld this aspect of Mr C's complaint.

In relation to Mr C's treatment, we took independent advice from a consultant orthopaedic surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system). We found that the original injury Mr  C sustained to the knee appeared to be significant but that he had also sustained further injury to the knee while waiting for surgery. However, no updated scan of Mr C's knee was performed and the first time that Mr C was examined by the surgeon under the anaesthetic was when the situation was found to be more complex. The surgery did not proceed and Mr C required to be referred to another specialist for surgery. We considered that there was a failure to provide Mr C with a reasonable standard of treatment and upheld this aspect of his complaint.

Finally, we found that the board could have been more proactive about communicating with Mr C and should have ensured that their response was mindful of the relevant legislation and guidance. Therefore, we considered that the board failed to communicate reasonably with Mr C and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide him with treatment within a reasonable time, to consider obtaining an updated scan, to examine him prior to the surgery and to reasonably communicate with him about his clinical condition and treatment. 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:

• Treatment should be provided within the 12 week treatment time guarantee. All staff should understand the legislation and guidance on the waiting time guarantee.
• Patients should receive appropriate and relevant scans and be reviewed/examined as appropriate prior to surgery.
• Identify any training needs to ensure staff fully understand the treatment time legislation and guidance, and its application.

Summary

Mrs C complained about the medical and nursing care and treatment provided to her late mother (Mrs A) at Royal Alexandra Hospital. Mrs A was admitted to the hospital from her nursing home and was treated for a urinary tract infection. She was discharged home, but returned to hospital a few days later. A scan showed that Mrs A had suffered a brain haemorrhage (bleed in the brain) and she was started on end-of-life care. About a week later, nurses noticed bruising on Mrs A's hip, and she was found to have suffered a hip fracture. Mrs A continued on end of life care for about three weeks before she died in hospital.

Mrs C felt that doctors did not treat Mrs A immediately when she first attended hospital, and she was unhappy that staff had instead asked the family what level of treatment they would prefer for Mrs A. Mrs C also felt that Mrs A was discharged too early. Mrs C raised concerns about the hip fracture; querying how this could have happened and why it was not discovered earlier by staff. Finally, Mrs C was concerned that Mrs A was kept on end-of-life care for an extended period of time without fluids or sustenance.

We took independent advice from a consultant in general medicine and from a nurse. We considered that it was appropriate for staff to discuss the level of treatment the family wanted for Mrs A when she was first admitted, and that this did not impact on the promptness or thoroughness of her treatment. We also did not find failings in the end-of-life care.

However, we found that staff had failed to establish Mrs A's normal level of functioning (known as baseline level of health) and therefore failed to adequately investigate her deterioration before discharging her. We found that staff should have done more to find out Mrs A's baseline level of health and that this may have alerted them to the fact that she was not back to normal when she was discharged.

We also found that Mrs A had been discharged without thickened liquids that had been prescribed.

Whilst we noted that the board had apologised for the hip fracture, which had probably occurred in the hospital, we found that they had not investigated the cause of the unexplained fracture at the time it was reported.

We upheld Mrs C's complaints about the medical and nursing care provided to Mrs A.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to establish Mrs A's baseline level of functioning and for failing to adequately investigate her deterioration. Also apologise for discharging Mrs A without the thickened liquids prescribed to her and for failing to promptly investigate the cause of Mrs 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 is unable to communicate, staff should clearly document their normal level of functioning, based on information from their family and/or carers.
• Prescribed dietary products should be provided on discharge or available within a few hours.

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 about the care and treatment provided by the ambulance crew who attended to her husband (Mr A). Mrs C had called an ambulance in the early hours of the morning as her husband was unwell. The crew examined Mr A and told Mrs C that they were not going to take Mr A to hospital, but that she should contact her GP for a home visit when the medical practice opened later that morning. A GP made a home visit and found Mr A to be disorientated and confused, which had been mentioned by Mrs C in her phone call to the ambulance service. The GP arranged for Mr A to be taken to hospital for further assessment and it was later diagnosed that he had suffered a stroke. Mrs C felt Mr A should have been taken to hospital by the ambulance crew.

We took independent advice from a clinician involved in the training of paramedics and concluded that the ambulance crew had failed to adequately record Mr A's symptoms and that he should have been transported to hospital for further clinical assessment. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failure to adequately record Mr A’s symptoms and for failing to transport him to hospital for further assessment and investigations.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:

• The ambulance crew should be competent to adequately record the patient’s full symptoms and be aware of the need to transport patients to hospital for further assessment.

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

Mr C complained about the way in which the ambulance service handled him after he had a seizure and fell at home, injuring his lower back. Mr C was concerned about the lack of assistance he received from the ambulance crew before they took steps to immobilise his spine and transfer him to hospital. It was later established that Mr C had sustained two fractures of his spine.

We took independent advice from a consultant in emergency medicine. Given that there had been restricted space in the room that Mr C had fallen, together with a number of factors that made it unlikely that he had sustained such fractures, we considered that it was reasonable of the ambulance crew to have provided spinal immobilisation in an area with greater room to do so. However, we noted that there was no evidence of a clinical assessment of Mr C's back and neurological function, nor evidence of a risk assessment prior to the decision to move Mr C. We considered that the assessment of Mr C was unreasonable and upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of clinical assessment of his back and lower limb neurological function. 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 potentially sustained a spinal injury staff should carry out a full clinical assessment and risk assessment prior to making decisions about moving and handling the patient. The assessments should also be clearly documented.

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.