Health

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) at Whyteman’s Brae Hospital. Mr A had been diagnosed with rheumatoid arthritis (an autoimmune disease that causes pain, swelling and stiffness in the joints) and was reviewed in the rheumatology department over the following 18 months. Mr A subsequently became unwell with a respiratory illness and he was admitted to another hospital. Mr A’s condition continued to deteriorate during the admission and he died. Mr C complained to the board about the way the rheumatology department assessed, monitored, and treated his father for rheumatoid arthritis. He felt that poor clinical management in the department had resulted in Mr A’s deterioration and subsequent death.

We took independent advice from a rheumatology specialist. We found that the assessment, treatment and monitoring of Mr A’s condition was of a good standard. We did not consider that there were any significant omissions in his care or any failure to act on symptoms reported by Mr A. While the adviser said that Mr A had an acute respiratory illness that may have been related to the use of one of the medications he was prescribed, they did not consider that this was evidence of a failing in Mr A’s care. We found that the board provided Mr A with reasonable care and treatment and did not uphold Mr C's complaint. However, we found that there were unreasonable delays in letters from the board being typed and sent to Mr A's GP and made a recommendation in light of this finding.

Recommendations

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

• Communication between secondary care and primary care should be timely.

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 to her late husband (Mr A) at Victoria Hospital. Mr A attended the emergency department on two occasions as he was experiencing blood in his urine and was having difficulty passing urine. Following a urology (the area of medicine which specialises in the urinary tract and the male reproductive system) referral and investigation, Mr A was diagnosed with bladder cancer. Mrs C complained that that the care provided to Mr A in the emergency department was unreasonable, that there had been unreasonable delays in his subsequent care which meant his treatment options were limited and that the nursing care provided during later admission was unreasonable.

We took independent advice from an emergency medicine consultant, a consultant urologist and a nurse. We found that the care Mr A received in the emergency department was reasonable and we did not uphold this aspect of Mrs C's complaint. In relation to the delays, we found that there had been an unreasonable delay in providing Mr A with appropriate information about the plan for his out-patient care. We upheld this aspect of Mrs C complaint; however, we found that Mr A's prognosis was unaffected by this failure. Finally, we considered that there had been inadequate care planning for Mr A. The nursing adviser was unable to form a reasonable picture of Mr A's needs from the records provided which was unreasonable. We noted that the board had already acknowledged failings in connection with the nursing care. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delay in providing appropriate information on the plan for out-patient investigation of his symptoms. 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:

• Appropriate care should be provided and this should be clearly evidenced in the nursing notes.
• Staff caring for patients like Mr A should have access to detailed information needed to ensure care is individualised and tailored to their needs.

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 her late husband (Mr A) received at Galloway Community Hospital after he attended the emergency department (ED) with chest pain. Mr A was diagnosed with gastritis (inflammation of the stomach lining) and was discharged home. He died shortly after from a pulmonary embolism (PE, a blood clot in the blood vessel that carries blood from the heart to the lungs). Mrs C was concerned that Mr A was discharged from the ED without a troponin test (a type of blood test to help confirm or exclude damage to the heart) being carried out. Mrs C also questioned why the ED doctor had not suspected a blood clot when they were aware that Mr A had been treated previously for prostate cancer.

The board carried out a critical incident review of Mr A's care and treatment. They found that a repeat electrocardiogram (ECG, a test that records the electrical activity of the heart) should have been performed given abnormalities had been identified and that a troponin test should have been done. In addition, there was no record of family history/other relevant factors. The board said that they would share these findings with the staff involved in order to ensure learning and undertook to source readily available out-of-hours troponin testing at Galloway Community Hospital.

We took independent advice from a consultant in emergency medicine. We did not consider that Mr A's symptoms were indicative of a PE, however, we determined that it was unreasonable to discharge him with a diagnosis of gastritis. We found that Mr A should have been admitted to hospital and that a repeat ECG and troponin test should have been undertaken. We, therefore, upheld Mrs C's complaint. However, we considered that it was unlikely Mr A's outcome would have been different because ECG and troponin testing is not a test for PE.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to admit Mr A to hospital, arrange a repeat ECG scan, and obtain a blood troponin measurement. 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 in similar circumstances that patients are admitted to hospital.

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 her daughter (Miss A) received at Midpark Hospital. Miss A has Asperger’s (a form of autism, in which people may find difficulty in social relationships and in communication) and suffers from depression, attention deficit disorder and personality disorder. She was admitted informally to the hospital for assessment and help. Mrs C complained that both the standard of psychiatric care and mental health nursing care Miss A received was unreasonable. Mrs C raised a number of concerns in relation to communication and the management, supervision and diagnosis of Miss A.

We took independent advice from a psychiatrist and a mental health nurse. We found that the standard of psychiatric care and mental health nursing in relation to communication, management, supervision and diagnosis was reasonable. We did not uphold Mrs C's complaints.

Summary

Mrs C complained that the care and treatment provided to her by the board was unreasonable. After having four wisdom teeth removed, Mrs C said that she suffered significant pain, but that clinicians failed to recognise this and treat her appropriately. Mrs C later required emergency care and was admitted to hospital, where she felt that clinicians were insufficiently prepared to discuss her care.

We took independent advice from a consultant oral and maxillofacial consultant (a doctor who specialises in treating diseases and injuries to the mouth, jaws, face and neck). We found that, whilst there was no doubt that Mrs C had been in a lot of pain following the removal of her wisdom teeth, the care and treatment she had received had been appropriate and reasonable. Therefore, we did not uphold this element of Mrs C's complaint. However, we did feedback to the board that they may wish to reflect on their interaction with Mrs C, as it was clear that she felt her concerns had been dismissed by them.

Mrs C also complained that the way the board dealt with her complaint was unreasonable. We found that the complaint was handled reasonably, and we did not uphold this part of Mrs C's complaint.

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received when he was admitted to Borders General Hospital and diagnosed with pneumonia (an infection of the lungs). Mr A was discharged from the hospital but later had a CT scan which showed that he had had a stroke. Mr A was readmitted to the hospital but his condition deteriorated and he died several weeks later. Mrs C complained about the medical treatment and nursing care that Mr A received and that the board failed to reasonably monitor his replacement heart valve on a six-monthly basis, as previously agreed.

We took independent advice from a consultant geriatrician (a doctor who specialises in the medicine of the elderly) and a nurse. In relation to Mr A's medical treatment, we found that there had been a lack of continuity during his first admission, which contributed to the fact that the significance of the deterioration in his cognitive function and incontinence was missed, despite the family highlighting this. Whilst much of the communication with his family had been reasonable, there was a failure to listen to the family’s concerns at that time. We also found that it was unreasonable that a CT scan was not carried out during this admission, although we could not say whether or not this would have diagnosed Mr A’s stroke. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care, we found that there had been a failure to meet some of Mr A’s basic personal care needs and to assess and manage his ongoing continence problems. Nursing staff also failed to review his cognitive impairment on an ongoing basis and to involve his family in the planning and review of his care. We also found that there was a failure to adequately document his care needs and how they were met on an ongoing basis. We upheld this aspect of Mrs C complaint.

Finally, we found that the board had failed to reasonably monitor Mr A’s replacement heart valve on a six-monthly basis, as previously agreed. We considered that it was unreasonable to plan to follow up a patient with a serious chronic condition, but fail to do so, without any clear explanation. Therefore, 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 the failings in relation to Mr A's medical and nursing care and treatment. 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:

• Patients admitted to hospital with cognitive impairment should receive CT scanning in line with the Scottish Stroke Care Standards.
• There should be ongoing structured assessment, management and review of patients with cognitive impairment and delirium in hospital settings.
• There should be a structured and comprehensive approach to identifying and reviewing care needs and how these needs will be met during a patient’s stay in hospital. Where appropriate, this should include involving the patient’s family.
• The care needs of patients in relation to continence assessment and management in hospital should be appropriately met.
• The ‘Getting to Know Me’ document should be completed and used to inform a person-centred care plan.
• Patients with a serious chronic condition should have follow-up care as agreed. Where it is decided to stop the follow-up appointments for a patient, the patient should be informed of this and the reasons for this.

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 was admitted to University Hospital Crosshouse with pain in his side, where he received scans and tests. He was discharged three days later with a diagnosis of non-specific abdominal pain. Mr C was admitted to hospital again a number of months later when he was diagnosed with acute appendicitis (inflammation of the appendix). Mr C complained that there was a failure to diagnose the appendicitis on his first admission.

We took independent advice from a surgeon. We found that there were clear symptoms that Mr C had appendicitis on his first admission. We found that, at a minimum, Mr C should have been alerted to the possibility of appendicitis and made aware of the symptoms to look out for. We upheld this aspect of Mr C's complaint.

Mr C also complained that the board did not provide a reasonable response to his complaint. We found that the response from the board failed to reasonably acknowledge that Mr C had symptoms of appendicitis on his first admission. We also considered that the board's complaint response failed to reasonably explain why Mr C was given a different diagnosis and why no follow-up appointment was arranged. 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 diagnose appendicitis; failing to explain why they did not consider a diagnosis of appendicitis was appropriate or issue Mr C with a follow-up appointment; and for stating that Mr C's symptoms on his first admission were not indicative of appendicitis when they were indicative of appendicitis.

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

• Feed back the findings of this investigation in a supportive way to the relevant clinical staff and identify how and why the failure occurred, taking into account any supervisory arrangements.
• Where imaging and blood tests indicate appendicitis but the board consider that the clinical picture does not support this, then the patient must be advised of the reasons why the clinical picture does not support this and a follow-up appointment should be arranged to review the patient.

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 to her late mother (Mrs A) while she was a patient at two different hospitals. Mrs A was admitted to University Hospital Crosshouse with a hip fracture following a fall at home. Mrs A was then transferred to Ayrshire Central Hospital for rehabilitation and physiotherapy. While she was there, Mrs A had a fall and hit her head. Mrs A was then transferred back to University Hospital Crosshouse. Mrs C was concerned about the medical treatment Mrs A received at University Hospital Crosshouse and the nursing care she received at Ayrshire Central Hospital.

Regarding Mrs A’s medical treatment, Mrs C complained about the length of time it took the board to carry out a test to see if Mrs A had deep vein thrombosis (DVT, a blood clot in a vein). We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the board did not consider the cause of Mrs A’s initial fall and that Mrs A was not seen by a geriatrician during her first admission. We found that there was an unreasonable delay in ordering and performing a scan of Mrs A’s leg. When it was suspected that Mrs A had a clot in her leg, Mrs A’s dose of dalteparin (medication that helps to reduce the risk of blood clotting in the legs) was increased from a preventative dose to a treatment dose. Mrs A received clopidogrel (medication to prevent clots that cause strokes and heart attacks) at the same time as the treatment dose of dalteparin. We found that it was unreasonable that Mrs A’s clopidogrel medication was not stopped at the same time that the dose of dalteparin was increased. We upheld this aspect of Mrs C's complaint.

Mrs C had a number of concerns about the nursing care provided to Mrs A, in particular about the communication from nursing staff, that Mrs A’s care needs and preferences were not taken into consideration, that adequate pain relief was not provided to Mrs A, that steps were not taken to prevent her from having another fall and that the action taken by nursing staff following her second fall was not appropriate. We took independent advice from a nursing adviser. We did not find evidence that the communication from nursing staff was unreasonable. We found that the nursing care regarding pain relief, falls prevention, and the action following Mrs A’s second fall was reasonable. However, we found that the board failed to document Mrs A’s care needs and preferences in her assessment and care plan documentation as well as follow the instructions in Mrs A’s “Getting to Know You” document. Therefore, we upheld Mrs C’s complaint. We noted that the board had already acknowledged and apologised that there was a failure to follow the instructions in Mrs A’s “Getting to Know Me” document.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to consider the cause of Mrs A's fall, that Mrs A was not seen by a geriatrician, the delay in ordering and performing the scan, the delay in stopping the clopidogrel medication, the failure to follow the instructions in Mrs A's “Getting to Know Me” document and the failure to record Mrs A's care needs and preferences. The apology should meet the standard 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 treatment dose of dalteparin is prescribed, appropriate adjustments should be made to any other medication prescribed to the patient. Patients should receive appropriate scans in a timely manner when DVT is suspected. Where patients have fallen and are unable to give an account of the reason for their fall, medical staff should carry out appropriate checks to try and determine the cause of the fall. All patients over the age of 65 presenting with a fragility fracture should have routine access to acute orthogeriatric medical support (orthopaedic care for elderly patients) in line with national guidance.
• Nursing assessments and care plan documentation should clearly document the care needs and preferences of patients.

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.

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, who is a transgender man, complained to us that a GP practice that he was about to register with had discussed his transgender status before he had even registered there. We took independent advice on the complaint from an equalities adviser. We found that, under the Gender Recognition (Disclosure of Information) (Scotland) Order 2005, the practice should have sought consent from Mr C before discussing his transgender status. We upheld this aspect of his complaint.

Mr C also complained that a GP from the practice withdrew the offer of a meeting prior to his registration at the practice. The practice confirmed to us that they did originally agree to a meeting, but this offer was withdrawn when Mr C’s previous GP said that this might take approximately 40 minutes. We considered that ideally the practice should have been able to meet Mr C before he joined the practice. However, we did not consider that their actions in cancelling this meeting were unreasonable. On balance, we did not uphold this aspect of Mr C’s complaint.

Mr C complained that the practice had logged his address incorrectly. We found that his address had been recorded incorrectly on the practice’s computer system and upheld the complaint. However, we considered that the explanation provided by the practice about this had been reasonable. In addition, they had apologised for the error.

Mr C also complained that the practice had failed to provide him with a reasonable standard of care, as they had told him that he was not able to have a flu vaccine, despite the fact he had ME (Myalgic Encephalopathy) / Chronic Fatigue Syndrome. We took independent advice on this complaint from a GP adviser. We found that the actions of the practice in relation to this matter had been reasonable and we did not uphold this aspect of Mr C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for discussing his transgender status without his consent, prior to his registration at the practice. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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, who is a transgender man, complained to us that an NHS board had failed to remove his female Community Heath Index number (CHI - a ten digit number that identifies a patient in the NHS in Scotland) from their database. Mr C had previously been allocated a male CHI number. Overall responsibility for CHI numbers lies with NHS National Services Scotland. We did not consider that there had been any failings by the board in relation to this matter and we did not uphold this part of the complaint.

That said, we found that the board should not have used Mr C’s old female CHI number to record his screening results on a national screening database. We upheld his complaint about this. In order for Mr C’s results to be recorded on the screening database, and to prevent this happening again, NHS National Services Scotland allocated Mr C a new male CHI number that could be used on the national screening database. However, Mr C subsequently told them that he wanted to retain his original male CHI number. In view of this, we made a recommendation to the board about this matter.

Mr C also made complaints that a laboratory and a screening service from the board had disclosed his transgender status without his permission. We found that, under the Gender Recognition Act and the Gender Recognition (Disclosure of Information) (Scotland) Order 2005, Mr C’s transgender status should not have been disclosed without his permission. We upheld these aspects of his complaint, although we noted that the board had apologised for this.

Finally, Mr C complained that the board’s responses to his complaint had been unreasonable. We found that the letters issued by the board had been a reasonable response to the issues Mr C had raised. We did not uphold this aspect of his complaint.

Recommendations

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

• Given that Mr C has stated that he wishes to retain his old male CHI number and this was agreed with NHS National Services Scotland, the board should consider if a separate protocol (which includes guidance for staff on sharing information about transgender patients) is required for him to prevent these problems recurring.

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.