Health

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.

Summary

A firm of solicitors (Firm C), raised a complaint on behalf of their client (Mrs A) that, during an examination under anaesthetic, a consultant had carried out a rectal examination without her knowledge or consent. She only found out about this when she received a copy of her medical records. When Firm C raised concerns about this with the board, they passed the correspondence to the consultant (who no longer worked for the board), who responded to Mrs A directly. The board subsequently accepted the consultant's response as their response to the complaint and did not investigate the complaint through their complaints handling procedure.

We took independent advice from a consultant in obstetrics and gynaecology (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts). We found that it was not routine practice to perform a rectal examination as part of the examination Mrs A was having conducted. The Royal College of Obstetricians and Gynaecologists guidance on Obtaining Valid Consent states that procedures should not fall out-with that which the patient consented to, unless there is an unanticipated emergency. We found that Mrs A should have been aware that a rectal examination was a possibility prior to the procedure and consented as such. In the absence of consent, it was not reasonable for a rectal examination to be carried out. We upheld the complaint.

We also had concerns about the way in which Firm C's concerns had been handled. Firm C had clearly raised a complaint and our view was that the board should have investigated and responded to this in line with their complaints handling procedure. We made recommendations regarding this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for conducting a rectal examination on her without her knowledge or consent and for failing to consider her complaint through the complaints handling procedure. 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:

• Ensure that clinical staff in the Obstetrics and Gynaecology department are aware of the Royal College of Obstetricians and Gynaecologists guidance on Obtaining Valid Consent.
• Consideration should be given to a discussion about consent at the departmental induction for doctors and/or a training session.

In relation to complaints handling, we recommended:

• Complaints handling staff should be aware of the board's complaints handling procedure and how to recognise a complaint.

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 to us that the practice had failed to provide her with appropriate care and treatment. She had reported to her GP that she was feeling down since the death of a relative and that she had self harmed. She was also concerned about a mouth infection. Mrs C said that the GP showed no interest, telling her to attend a dentist for the mouth problem and that she should wait for contact from the mental health services, who were already in contact with Mrs C. The GP told Mrs C that it was her responsibility to chase up the mental health services.

We took independent advice from a GP adviser. We found that it was appropriate for the GP to have referred Mrs C to her dentist as it would not be within a GP's remit to treat patients with dental problems. We also found that, when Mrs C attended the GP, there was no clinical indication for an immediate referral to the mental health services. The department within the mental health services which Mrs C was already attending operated a self-referral facility and there was no need for the GP to make a formal referral. We did not uphold the complaint.

Summary

Mr C complained that his GP unreasonably stopped his diabetic medication, and that the practice later inapppropriately removed him from their patient list. Mr C subseuqently withdrew his complaint and no findings were reached. We closed our case.

Summary

Miss C suffered ongoing complex urological problems (problems relating to the urinary tract, bladder or kidneys), and underwent a dilation and cystoscopy procedure (a procedure to look inside the bladder and stretch the urinary opening) at Ninewells Hospital. During the procedure biopsies (samples of tissue) were taken. Miss C complained about the medical and nursing care during this procedure, which she found very painful and distressing. Miss C also complained about her medical care following the procedure, and that it took several months for the board to refer on to a urological specialist in another board area after she requested this.

Medical and nursing staff met with Miss C to discuss her concerns. The board apologised for some aspects of the nursing care, and said the day-of-surgery admission pathway had not been suitable for Miss C, as it could not provide much of the support she required. Miss C was not satisfied with this response, and she brought her complaint to us.

We took independent advice from a consultant urologist and a nurse. We found that most of the medical care Miss C received was reasonable. However, the operation note was not sufficiently detailed to show why it was necessary to take biopsies, which caused Miss C post-operative pain. We upheld this aspect of Miss C's complaint.

In relation to the nursing care, we noted that the board had acknowledged certain aspects of care were staff could have acted differently and had taken action to discuss Miss C's concerns with staff. We considered these actions to be reasonable and found that the nursing care Miss C received was appropriate. We did not uphold this aspect of Miss C's complaint.

Finally, we found that there was a delay in referring Miss C to a specialist. We noted that some of the delay was due to her requiring urgent hospital admission in this period; however, part of the delay was due to a lack of cover arrangements during an unexpected staff absence. We upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in referring her to a specialist and for the failure to document why the biopsies were necessary. 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:

• Operation notes should include sufficient detail to explain the clinical decisions taken during the operation.

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 grandfather (Mr A) at Ninewells Hospital. Mr A was admitted to hospital and treated for sepsis (a blood infection). It was initially thought that this was caused by a chest infection but investigation showed that the source was Mr A's gallbladder. Mrs C complained that staff had not listened to family concerns about the source of the infection and that this had affected his treatment. Mrs C was concerned that the placement of a drain or other treatment was unreasonably delayed and that an appropriate scan had not been done. Mrs C considered that a different approach could have prevented Mr A's death.

We took independent advice from a consultant interventional radiologist (a clinician who would place a drain in the gallbladder) and a consultant physician (a senior doctor). We found that Mr A had received appropriate treatment and investigation of his symptoms. The adviser indicated that staff were aware that the gallbladder could be the source of infection and that there were no unreasonable delays in the particular circumstances of Mr A's case. We considered that earlier placement of a drain would not have resulted in a different outcome for Mr A. We did not uphold Mrs C's complaint.

Summary

Mrs C, who works for an advocacy and support service, complained to us on behalf of her client (Mrs B) about the care and treatment Mrs B's late father (Mr A) received from the board.

Mr A requested medical assistance at his home as he was feeling breathless and asthmatic. An advanced nurse practitioner (ANP) attended Mr A in the early hours of the morning. After carrying out an assessment, the ANP concluded that Mr A's symptoms were consistent with pneumonia (an infection of the lungs). The ANP provided treatment and advised Mr A to visit the health centre later that day for further review.

When Mr A presented at the health centre, his condition was noted to have worsened and he was subsequently referred to hospital. On arrival at the hospital Mr A suffered a cardiac arrest and died.

Mrs C complained that the board unreasonably delayed in referring Mr A to hospital and that they should have requested an air ambulance rather than travel by ferry and road.

We took independent advice from a GP adviser. We found that the ANP carried out a thorough assessment of Mr A's symptoms and that his diagnosis was appropriate. We found that it was not clinically indicated that an earlier referral to hospital was required. We also considered that the board's decision to transfer Mr A by ambulance on the ferry was safer and faster than an air ambulance. We did not uphold Mrs C's complaints.

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 care and treatment he received in relation to a suspected hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall) whilst he was in prison. In particular, that there were delays in being seen by his GP, being referred for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body), being referred for surgery and concerns over his prescribed medication. Mr C also complained that he was not given a long-term sick line after an initial sick line expired.

We took independent advice from a GP. We found that the time Mr C had to wait for appointments with his GP was reasonable. We also found that he was referred for an ultrasound scan and surgery within a reasonable amount of time and that his medication was reviewed appropriately. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to Mr C's sick line, we found that it would be reasonable to expect that he would be able to attend classes and carry out light duties whilst waiting for surgery and, therefore, we considered that the GP's decision to refuse a sick line was appropriate. We did not uphold this aspect of Mr C's complaint.