Health

Summary

For a number of years, Mr C had suffered with arthritis (inflamation of the joints) and had problems with his ankle and his knee. He attended the Glasgow Ambulatory Care Hospital, where it was considered that he would be suitable for an ankle procedure. However, it was decided that the opinion of a knee specialist should be obtained first. Mr C complained that he had to wait an unduly long period of time before he was given appropriate treatment.

We took independent advice from a consultant orthopaedic surgeon (a doctor who specialises in conditions involving the musculoskeletal system). We found that Mr C was suffering a complex condition and that it was reasonable for his care to involve multiple consultants. However, we also found that Mr C had to wait an unreasonable amount of time before he saw a knee surgeon in the first instance, and that having a combined consultation may have been more effective. Whilst we found that the subsequent care and treatment were reasonable, we upheld the complaint due to the initial delay in Mr C seeing a knee surgeon.

Mr C also complained about poor communication. We found that he appeared not to understand the reasons for the number of consultants involved in his care, and he had not understood his care plan. We considered that these issues were avoidable, and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• An apology should be sent to Mr C for the delay in obtaining the knee surgeon's opinion. 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:

• Inter-departmental clinical referrals should be made within a reasonable time.
• The clinician concerned should take care to ensure that their communication with patients is understood.

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

Ms C, an advocacy worker, complained on behalf of her client (Mrs B). Mrs B was concerned about the care and treatment her husband (Mr A) received during his admission to Queen Elizabeth Hospital. Mr A had suffered a broken neck in an accident and he was being treated with a neck brace. Ms C's main concern related to Mr A swallowing his dental plate and explained that this was not discovered for almost two weeks even though Mr A had a sore throat and difficulties swallowing. Ms C also complained about the nursing care and that there was inadequate communication with Mr A's family. In particular, when his condition deteriorated and he was thought to have sepsis (a blood infection). Finally, Ms C complained that the board's handling of the complaint was unreasonable and that no significant clinical incident review was carried out.

We took independent advice from a consultant orthopaedic trauma surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system) and a registered nurse. The board considered that swallowing a dental plate was a very unusual occurrence so it was reasonable this was not suspected by hospital staff. We found that the medical treatment initially received for Mr A's swallowing and eating difficulties was appropriate. However, we found there was an unreasonable delay in referring Mr A to ear, nose and throat and this delayed the discovery of his swallowed dental plate. We upheld this aspect of Ms C's complaint.

In relation to the nursing care received, we found that Mr A was given a reasonable level of personal care and his food input and fluid intake was appropriately monitored by staff. We noted that nursing staff recognised Mr A's difficulties swallowing and eating and made appropriate referrals. Therefore, we did not uphold this aspect of Ms C's complaint.

In relation to communication, we found that communication with Mr A's family was not to the appropriate standard. We upheld this aspect of Ms C's complaint. However, we noted that the board had acknowledged this failing and had apologised to Mrs B.

Finally, we found that the board failed to commmunicate clearly about meeting to discuss the complaint or about the significant clinical review and it's findings. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the delay in making the referral to ear, nose and throat; and for the failings in their communication about meeting with her and about the significant clinical incident review. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide Mr A's family with a copy of the significant clinical incident review.

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

• Ensure there is appropriate communication with patients and/or their families during, and at the conclusion of, significant clinical incident reviews.

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

Ms C complained that the Royal Hospital for Sick Children Glasgow unreasonably failed to accept a referral from her daughter (Miss A)'s GP. The GP had made the referral to endocrinology (a branch of medicine dealing with hormones) for Miss A to be assessed for her diagnosis of hypothyroidism (under active thyroid). Miss A's thyroid function tests had been reported as normal and the board rejected the referral. Ms C felt that it was wrong that the board refused to see Miss A as she was reporting symptoms which needed to be addressed.

We took independent advice from a consultant endocrinologist. We found that, although the thyroid function tests were normal, Miss A was still showing symptoms relating to hypothyroidism. It would have been reasonable for the board to have seen Miss A and her family, where they could have discussed the symptoms in more detail and explored potential explanations as to why Miss A was feeling the way she did. Alternatively, if they remained of the view that a consultation was not required, then they could have provided the GP with suggestions of what further investigations or assessments could be arranged through the primary care setting. This may have led to additional diagnoses being discovered. We considered that the board could have been more proactive when considering the GP referral. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to see Miss A at a consultation or to have provided advice to her GP about alternative treatment or 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:

• In cases where staff do not consider that a GP referral warrants a consultation, they should consider providing the GP with information about alternative treatments or investigations if appropriate.

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 on behalf of his wife (Mrs A) about the care and treatment she received at the Royal Alexandra Hospital. Mrs A experienced a traumatic birth when problems with the fetal heart occurred and an emergency caesarean section was required. Mr C complained that both the obstetrics (the field of medicine concerned with pregnancy, childbrith and the post-birth period) and midwifery care was unreasonable.

We took independent advice from a consultant obstetrician and from a midwife. We found that consideration could have been given by the obstetric staff to the possibility that the drug terbutaline (medication to stop uterine contractions) could have resulted in improvement in the fetal heart rate. We also noted that there was insufficient evidence to show that a thorough debrief of the birth took place with Mrs A. However, we found that the overall obstetric care during Mrs A's admission was appropriate and that the problems with the fetal heart rate were promptly recognised, with timely action being taken to deliver the baby in line with national guidance. We did not uphold this aspect of Mr C's complaint but made recommendations to the board in light of the failings identified.

In relation to the midwifery care Mrs A received, we found that there was a lack of evidence to show what action had been taken when it was recorded that she was in discomfort when being triaged around the time of admission to hospital. There were also insufficient records to show that Mrs A had been kept informed about the baby's progress while in the special care baby unit; however, we noted that the board had apologised for this failing. We also found that there was poor record-keeping to demonstrate what information had been shared with Mrs A when she was discharged from hospital, particularly in relation to advice regarding self-administration of blood thinning medication and advice regarding breastfeeding given she had experienced problems during her admission. We were also critical of the lack of evidence to show what information had been shared with the community midwifery team at the time of discharge. Finally, we considered that there was no evidence of assessment or support of Mrs A's psychological needs during her admission. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in addressing Mrs A’s discomfort and psychological needs, the lack of information given to her, and the community midwives, on discharge and for the failings in record-keeping. 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:

• Where appropriate for patients in labour, consideration could be given to the administration of terbutaline, in accordance with national guidance.
• In a similar situation patients should be adequately debriefed and this should be properly recorded in the medical notes.
• Patients should be properly advised on any discharge medication and this should be properly documented in the medical notes.
• Midwifery patients should receive appropriate assessment of their needs, including any psychological needs, during admission which should be appropriately planned and documented.
• Midwifery patients should have their pain/discomfort suitably assessed and acted on when in triage.
• In a similar situation midwifery patients should receive detailed information in relation to the care and treatment of their baby and this should be properly recorded in the midwifery notes.
• Midwifery patients and community midwives (on handover) should receive adequate information on their care and treatment on discharge. This should include the discharge plan for women and babies leaving hospital, that each woman has received a copy of Ready Steady Baby, that there has been an effective handover between the hospital and community midwifery staff, and the guidance and support given to women having difficulties breastfeeding.

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

Ms C's child (Child A) was admitted to hospital and diagnosed with hydrocephalus (a build-up of fluid on the brain). Ms C complained that the health visiting team failed to take adequate steps to identify Child A's hydrocephalus before the admission to hospital. She also considered that the board failed to investigate her complaint appropriately.

We took independent advice from a health visitor. We found that some of Child A's growth measurements were not taken properly. At the six week assessment (where a decision is taken about future monitoring of growth), we found that some of their measurements were not accurately recorded or plotted in the 'red book' (a national standard health and development record given to parents/carers at a child's birth). Therefore, there was a failure to recognise Child A's small length which would have required a plan to be put in place for further observation and measurement. We also found a failure to assess the discrepancy in the three measurements taken of Child A's weight, length and head circumference. We considered that if steps had been put in place to closely monitor growth, then the health vising team may have identified Child A's hydrocephalus. We upheld this aspect of Ms C's complaint.

In relation to the board's handling of the complaint, we found that the board did not identify or acknowledge that some growth measurements were not properly taken, recorded or plotted. It would have been reasonable to expect that the board would have looked carefully at the measurements and centiles taken and recorded in the red book. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to correctly record Child A's measurements, analyse them and put in place steps to closely monitor their growth. 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:

• To ensure all relevant staff understand how to use and interpret UK-WHO Growth charts in accordance with the requirements of the Royal College of Paediatric and Child health doctors.
• To ensure all relevant staff understand the importance and use of the red book so that information is accurately and consistently documented.
• There should be a review of compliance with the Universal Health Visiting Pathway and a timeline provided for this review.

In relation to complaints handling, we recommended:

• The board should ensure that in investigating complaints they scrutinise evidence carefully.

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 she received from her dentist. When Mrs C developed toothache, she was advised by a different dentist that her tooth needed to be extracted. Mrs C questioned why her tooth was left to decay to such an extent without any prior treatment. She complained that the first dentist failed to record the findings of an x-ray taken of her teeth which led to her tooth not being monitored properly. The dentist acknowledged that they did not record the findings of the x-ray, however they expected any subsequent dentist to review the patient's dental records, including the x-ray.

We took independent advice from a dentist. We found that it would not be reasonable to expect a subsequent dentist to review the x-ray, as they would expect a report of the findings to be included in the patient's records. We concluded that Mrs C's dentist had failed to record the findings of the radiograph in line with the relevant guidance, and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to record the findings of the x-ray. 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:

• Ensure knowledge and future compliance with the Radiation (Medical Exposure) Regulations (2000) and the Faculty of General Dental Practice guidance on Clinical Examination and Record Keeping Standards.
• Ensure knowledge of and future compliance with the Faculty of General Dental Practice guidance on Selection Criteria for Dental Radiography.
• The dentist should ensure full understanding and compliance with the Standards for the Dental Team.

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 practice’s management of his longstanding bladder and penile problems. He was diagnosed with an enlarged prostate (a gland in the male reproductive system) and underwent a surgical procedure. This was followed by further surgery to address a complication. After an initial improvement, his symptoms returned. He also began experiencing a lot of penile pain and irritation, for which he was referred to dermatology (the area of medicine concerned with the skin). Mr C complained that the practice failed to arrange appropriate investigations and treatment in response to his symptoms, including delays in referring him to urology (the area of medicine concerned with the male and female urinary-tractt, as well as the male reproductive organs) and prolonged ineffective treatment with antibiotics and creams.

We took independent advice from a GP who considered that Mr C’s symptoms were appropriately managed by the practice. We identified two occasions where earlier referrals to urology might reasonably have been considered. However, we did not find that the delays in referring to urology materially impacted on Mr C’s ongoing issues or the outcome for him. We considered that the practice appropriately managed Mr C's bladder and penile symptoms and did not uphold his complaints.

Summary

Mr C complained about the care and treatment provided to his wife (Mrs A) when she was an in-patient at Victoria Hospital. Mr C complained that the board failed to appropriately adjust her medication, that they did not provide her with reasonable physical rehabilitation, and that they unreasonably assessed her as needing a higher level of at home care, which Mr C said delayed Mrs A's discharge from hospital.

Summary

Ms C complained on behalf of her child (Child A) about the care and treatment they received at Victoria Hospital. Child A was prescribed various drugs to try to manage their epilepsy (a seizure disorder), including one called phenytoin. Child A later had to be treated in hospital for an overdose of phenytoin. Ms C's main concern was that Child A was not appropriately monitored by the board, which allowed this high level of phenytoin to build up in their blood. Ms C also complained about the board's handling of her complaint.

We took independent medical advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that, when Child A's dose of phenytoin was increased at their clinic review, they were appropriately referred for blood tests to monitor the impact of this increase. However, we found that the clinic review was not appropriately recorded and that there was an unreasonable delay in communicating with her GP about it. We found that the results of Child A's blood tests showed a surprising level of phenytoin in their blood, which should have prompted a clinical review. We also found that appropriate action should then have been taken, which would have been to repeat the blood tests. We upheld this aspect of Ms C's complaint.

Regarding complaints handling, we found that the board delayed in acknowledging Ms C's complaint. We also found that they failed to communicate appropriately with Ms C both during and at the conclusion of their investigation. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to appropriately monitor child A; for the issue identified with record-keeping and GP communication; and for their communication with Ms C in relation to 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.

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

• The results of blood tests carried out to monitor phenytoin levels should be clinically reviewed and actioned appropriately.
• Clinical appointments should be recorded appropriately and actions should be shared with primary care/patients in a timely manner.

In relation to complaints handling, we recommended:

• Updates should be provided to complainants when the twenty working day timescale will not be met; and follow-up correspondence should be responded to appropriately.

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 that the board failed to provide her with appropriate care and treatment during her admission for day surgery at Queen Margaret Hospital. Following a procedure to remove her gallbladder, Mrs C was deemed to be fit to be discharged the same day. A number of days later she became unwell and was diagnosed with a serious infection.

Mrs C raised concern about whether the possibility of infection could have been foreseen and the decision to discharge her on the same day. She questioned why antibiotics were not prescribed and raised concern about the level of information she was given prior to discharge.

We took independent advice from a consultant upper gastrointestinal surgeon (a surgeon who specialises in the upper gastrointestinal tract which includes the gall bladder, liver, pancrease, oesophagus, stomach and small bowel). We found that there was no evidence of failings in the surgery provided to Mrs C. We found that there was no evidence of an active infection at the time Mrs C was discharged, and that it was reasonable, and in line with national guidelines, not to prescribe antibiotics. We did not consider that there was a reason to admit Mrs C overnight and were satisfied that the board had provided appropriate information to Mrs C prior to discharge. We did not uphold the complaint.