Health

Summary

Ms C complained about the nursing care her mother (Mrs A) received at Raigmore Hospital. Mrs A suffered from osteoporosis (weak or fragile bones) and fell during an admission to the hospital. A number of weeks following her discharge from hospital, Mrs A's GP arranged for x-rays to be taken which showed that she had suffered two fractures to her spine. Ms C complained that nursing staff failed to appropriately care for Mrs A following her fall.

We took independent advice from a nurse who is experienced in hospital falls prevention. We found that the nurses who attended Mrs A failed to act in accordance with falls prevention guidance. There was no record that an adequate assessment had been carried out to establish if Mrs A had sustained an injury following the fall. There was also a failure to arrange a medical review for Mrs A. We were unable to find out when the fractures actually occurred as Mrs A did not report to staff that she was in pain at the time and the actual diagnosis of fractures was not made until a number of weeks following the fall. However, we considered that the failings identified were unreasonable and upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to act in accordance with the guidance following her fall and failing to arrange a medical review. 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:

• Nursing staff should ensure that action is taken in accordance with guidance in relation to in-patient falls and ensure that a record is made on which examinations have taken place and that a medical review is arranged.

Summary

Mr C complained about the health care and treatment he had received in prison. In particular, he complained about problems he had experienced in receiving all his prescribed medication within the prison regime. The board acknowledged that there had been problems with Mr C receiving all his prescribed medication and they suggested that he discuss this with the GP. Mr C was unhappy with this response and brought his complaint to us.

We took independent medical advice. We found that the prison healthcare team were responsive to Mr C's concerns, including altering his medication to ensure he receives all of it, and liaising with pain specialists. We considered this treatment to be reasonable and did not uphold Mr C's complaint.

Summary

Ms C complained that the practice provided unreasonable treatment to her late mother (Mrs A). A GP from the practice attended Mrs A at home and prescribed an antibiotic. Mrs A was also on Warafin (a drug used to prevent blood clots) and other medication. She later became unwell and was admitted to hospital with bleeding from a peptic (stomach) ulcer and considered at risk of internal bleeding. Mrs A died a few weeks later. Mrs C complained that the prescription of the antibiotic was unreasonable and that Mrs A should have been advised to have her INR (a blood test which allows monitoring of Warafin levels) checked after she was started on the antibiotic.

We took independent advice from a GP. We found that the practice reasonably prescribed the antibiotic. However, the practice should have advised Mrs A that she should have her INR checked four to seven days after starting the antibiotic. Therefore, we upheld Ms C's complaint.

Recommendations

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

• This complaint should be discussed with the GP involved at their annual appraisal.

Summary

Mr C complained that the board delayed in providing him with surgery for his feet and knees, and that they unreasonably failed to explain the reasons for the delays.

We took independent advice from an orthopaedic surgeon (a surgon who specialises in the musculoskeletal system). We found that the Treatment Time Guarantee places a legal requirement on health boards so that, once planned treatment has been agreed with the patient, the patient must receive that treatment within 12 weeks. We found that Mr C waited around six months for the surgery on his first foot, and then ten months before being seen by a knee surgeon. We found that, whilst medically Mr C came to no harm as a result of the delays, he clearly suffered pain and functional restriction for longer than was reasonable. We upheld this aspect of the complaint.

Regarding communication, we noted that Mr C had received a letter confirming a guarantee of treatment within 12 weeks for his first surgery. The next documented communication was several months later, and was only sent in response to contact from Mr C. We considered that there should have been further communication from the board, apologising for the delay and setting out the steps being taken to minimise this. We found that Mr C had been left for many months without knowng when he might receive surgery. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in his orthopaedic treatment.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to explain the reasons for delays in treatment, and for failing to keep Mr C updated with regard to when he could expect to have his surgery.

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

• In the event that the Treatment Time Guarantee is not going to be met, letters to patients should make this clear, in accordance with the Patient Rights (Scotland) Act 2011.
• Be clearer with patients about any delays, the reasons for the delay and the steps being taken to improve matters.

Summary

Ms C began to experience stiffness and pain, to the extent that she was struggling with everyday tasks. Her GP prescribed her steroids (a type of anti-inflammatory medicine), which improved her symptoms. Her GP then referred her to rheumatology (the branch of medicine concerned with immune-mediated disorders of the musculoskeletal system) at Royal Alexandria Hospital. Ms C complained that, when she attended her rheumatology appointment, her condition was not appropriately assessed. Ms C said she was told to stop taking steroids but when she did this, her symptoms returned. Ms C raised concerns that she was not given any follow-up appointment to check on her condition. She also complained that, when her GP raised concerns about her worsening symptoms with rheumatology, no action was taken.

We took independent advice from a consultant rheumatologist. We found that there was a lack of useful clinical information in the clinic note and GP letter relating to Ms C's initial rheumatology appointment. As a result, the adviser was unable to confirm if her assessment was reasonable or not. We found that consideration should have been given to reducing Ms C's steroid dose gradually before it was stopped. We found that Ms C should have been given a follow-up appointment or the means to contact rheumatology directly for advice if her symptoms returned. We also found that when her GP contacted rheumatology with concerns, Ms C should have been offered a prompt review. In addition, we found that phone conversations, in which advice was given to Ms C's GP, were not recorded in her medical records.

We found that due to these failings, there was an unreasonable delay in diagnosing Ms C's underlying condition of inflammatory arthritis (an autoimmune condition that causes joint pain and swelling). We upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately document and update both Ms C and her GP on her rheumatology appointment; not giving Ms C a follow-up appointment or the means to contact rheumatology directly for advice; and the delay in offering Ms C a rheumatology review when her symptoms returned and worsened. 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:

• Appropriate clinical information should be documented in clinic notes, given to GPs and copied to the patient, with enough detail to understand how a clinical decision or diagnosis has been reached.
• Patients should receive appropriate follow-up care and a prompt rheumatology review if required.
• Clinical advice, which is given to GPs, should be recorded appropriately.

Summary

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received at Queen Elizabeth University Hospital. During a surgical procedure Ms A was diagnosed with endometriosis (a condition where the lining of the womb grows outside the womb) and she was given treatment to alleviate her symptoms. Afterwards, Ms A was discharged back to the care of her GP and her symptoms returned a few months later. Mr C considered that Ms A should have received a standard follow-up gynaecology (the branch of medicine which specialises in the female reproductive system) appointment, instead of being discharged back to her GP's care.

During our investigation we took independent advice from a consultant gynaecologist. We found that there was no clinical guidance that Ms A should have received a standard follow-up gynaecology appointment after her diagnosis. We considered that it was reasonable that the board expected that Ms A's treatment would improve her symptoms. We further considered that, even if the board suspected her symptoms might return, it is possible for endometriosis to be managed by a GP, with advice from gynaecology if required. Therefore, we considered it was reasonable that Ms A was discharged back to the care of her GP. We did not uphold the complaint.

However, the adviser noted that the post-surgical verbal advice given to Ms A was not documented. Also, Ms A did not appear to receive any written advice as back up, even though she was still recovering from the anaesthetic when the verbal advice was given. We made some recommendations regarding this.

Recommendations

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

• There should be a clear record of the verbal advice given to patients after surgery.
• In similar circumstances, consideration should be given to patients receiving written post-surgical advice to back up any verbal advice given to them.

Summary

Ms C complained on behalf of her mother (Mrs A). Mrs A was discharged from Gartnavel Hospital and then re-admitted two days later with a urinary tract infection and fluid on her lungs. Ms C complained that the board failed to discharge Mrs A in a reasonable way.

We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that, medically, it had not been unreasonable to have Mrs A discharged. While she may have had both a urinary tract infection and fluid on her lungs at the point of discharge, these were not doing her harm at that point. However, we found that Mrs A's risk of falls had not been adequately assessed prior to her discharge, and that this risk had also not been adequately communicated to Ms C. We noted that more should have been done to assess and reduce Mrs A's risk of falling before she was discharged, and that it was unreasonable to have discharged her due to her mobility issues. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mrs A for failing to assess Mrs A's falls risk prior to her discharge, and for failing to communicate this risk to Ms C. 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 at high risk of falls should be adequately assessed prior to discharge. Plans should be put in place to manage a patient at high risk of falls prior to their discharge.

Summary

Ms C complained about the treatment which she received at Peterhead Hospital and Aberdeen Royal Infirmary. Ms C had been treated for heart issues although she had not been reviewed by a cardiologist (a doctor who specialises in disorders of the heart). Ms C was subsequently admitted to hospital on two occasions where the medication for her heart issues was continued. Ms C sought a private opinion which found that she did not have a heart problem and her medication was withdrawn. As a result of the medication withdrawal, Ms C's health improved. Ms C complained that she was unreasonably prescribed heart medication and that this medication was not kept under regular review.

We took independent advice from a consultant cardiologist. We found that it was appropriate for Ms C to have been treated for suspected angina (chest pains) in view of her presenting symptoms. We considered the prescription of heart medication to be appropriate and did not uphold this aspect of Ms C's complaint.

However, there was a failure to keep Ms C under review pending the outcome of further out-patient cardiology investigations which may have identified that she was suffering from potential side effects of the medication. There was an incident on discharge from hospital that Ms C had been prescribed two calcium channel blockers (medication to relax and widen the blood vessels) which was inappropriate, although it was unlikely that harm was caused due to the low dosages involved. We also found that there were failings in record-keeping regarding discussions with cardiology staff and that it would have been advisable that Ms C should have been physically examined by a consultant cardiologist. We considered that the board failed to keep Ms C's medication under review and upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to keep her under review pending the outcome of further out-patient cardiology investigations. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for the failure to recognise that she had been discharged from hospital while on two types of calcium channel blocking medication. 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 to keep patients under review pending the outcome of further out-patient cardiology investigations.
• Pharmacy and ward staff should be aware that when patients are discharged from hospital that their medication is appropriate.

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.