Health

Summary

Mrs C complained that the board failed to take appropriate steps for her child's (Child A) plagiocephaly (asymmetry of the skull). Mrs C received several visits at home from the health visitor team following the birth of Child A and raised concerns about the shape of Child A's head when they were three months old. Mrs C later attended her GP and was referred to a paediatrician (a doctor who deals with the medical care of infants, children and young people) who diagnosed them with plagiocephaly. Mrs C considered that if the health visitors had identified problems with head shape sooner, it could have been prevented.

We took independent advice from a health visitor. We found that when the health visitor who visited Mrs C was advised of her concerns, they gave appropriate advice regarding positional changes to maintain Child A's natural head shape. However, no record was taken of the circumference of Child A's head or the shape. Therefore, there was no baseline information and we considered that it would have been reasonable to document this for later comparison. We also noted that there was no recorded plan to review the situation. We found that Mrs C was visited by several members of the same staff team but her concerns had not been shared between staff. It would have been appropriate to share this information to ensure continuity of care. We considered that if these steps had been put in place then Child A may have obtained physiotherapy support sooner. Therefore, we upheld Mrs C complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to follow up on her concerns about Chid A's head shape. 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:

• All members of health visiting teams should have up-to-date guidance on the identification, assessment and management of plagiocephaly in young children.
• There should be a structured approach to care planning so that concerns and plans to review those concerns are documented.
• There should be effective communication within teams where several members of the team are providing care for the same family.
• There should be a review of their compliance with the Universal Health Visiting Pathway and a timeline provided for this review.

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 that the practice refused to register himself and other members of his family as new patients. He also said that the practice failed to make reasonable adjustments to accommodate the needs of disabled family members.

We found that the practice had followed their policy in relation to Mr C's registration. The practice declined to register Mr C on the basis of being unable to form a doctor / patient relationship with him because of his conduct which they are entitled to do. Therefore, we did not uphold this part of Mr C's complaint.

Mr C also wanted to register other members of his family as new patients. The practice said that they could not do so unless they came to the practice so that their identification could be verified. This was in line with the practice policy. The practice made this clear to Mr C, however, we found that some later communication was not appropriate. The practice appeared to link the decision to not register Mr C's family to Mr C's behaviour in their communication. However, we noted that the practice acknowledged this mistake and confirmed that members of Mr C's family could still register as new patients, provided that they comply with the registration policy. On balance, we did not uphold this part of Mr C's complaint.

In relation to the practice failing to make reasonable adjustments, we found that Mr C had declined to provide sufficient information about the disabilities of members of his family. Therefore, we considered that the practice did not have enough information to assess whether the adjustment requested was reasonable, or not. We did not uphold this part of Mr C's complaint.

Summary

Ms C complained on behalf of her late mother (Mrs A) who was admitted to Aberdeen Royal Infirmary after complaining of severe back pain. On admission to hospital, Mrs A was also suffering from vomiting, constipation and had an infection. Ms C considered Mrs A did not receive reasonable care and treatment during her admission. In particular, that the board should have performed an MRI scan on Mrs A's back as she had previously had surgery for a spinal fracture.

We took independent advice from a consultant in geriatric medicine (specialist in care of the elderly) and a nurse. We found that the actions of staff following Mrs A's admission to treat the cause of her dehydration and to determine why she was unwell and in pain were reasonable. We considered that all the relevant tests had been carried out and action taken by medical staff was reasonable. We also considered that the pain relief medication prescribed for Mrs A during her admission was appropriate. However, we noted that on one occasion Mrs A did not receive a dose of paracetamol when she should have and it was possible she may have suffered an increase in her pain as a result. The adviser noted that Mrs A's pain relief medication was an important part of her treatment. This incident was referred to by the board as an adverse event and was recorded on their Datix system (a system for tracking and reporting incidents). It was also noted that Ms C had not been made aware of this incident at the time. Therefore, we upheld Ms C's complaint.

Ms C also complained that the board did not respond reasonably to her complaint. The board acknowledged that there were factual errors in their complaint correspondence and we considered that they had appropriately apologised to Ms C for this. We found, however, that there was an unreasonable delay by the board in informing Ms C that an adverse event had been recorded and this was compounded by their failure to tell Ms C the specific details of this event, despite her asking for them. We considered that the board had not provided Ms C with a full and reasoned response to her complaint and, therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mrs A with reasonable care. Also apologise for the unreasonable delay in informing Ms C that an adverse event had been recorded on the Datix system, and for not providing her with an appropriate explanation of the adverse event and what, if any, harm had been caused to Mrs A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Identify any training needs to ensure staff fully and appropriately respond to 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 on behalf of his late wife (Mrs A) about a decision by staff at the Golden Jubilee National Hospital not to perform a heart transplant on her. Mr C highlighted that Mrs A had been working to lose weight so she could potentially receive a heart transplant. Mr C was concerned that Mrs A was not given the opportunity to be included in the major decision made not to allow her a transplant.

We took independent advice from a consultant cardiologist. We found that there was evidence to support that much consideration had been given to the heart transplant and that Mr C and Mrs A had been reasonably involved in the decision making. We did not uphold the complaint.

Summary

Having been referred to Forth Valley Royal Hospital by her GP with a worsening tremor, Mrs C was diagnosed with possible Parkinson's disease (a progressive neurological condition in which part of the brain becomes more damaged over many years) and was started on medication to ease her symptoms. She received regular hospital reviews over the following years and her diagnosis was re-evaluated around seven years later. Further to a scan, it was retracted and replaced with a diagnosis of essential tremor (a benign tremor disorder). Mr and Mrs C complained about this misdiagnosis. They considered that there should be more timely follow-up to check patients with Parkinson's disease. The board noted that Parkinson's disease is difficult to diagnose and that there is no definitive test for it. They advised that it is with time, when people are not following the expected course, that the diagnosis will be reviewed.

We took independent medical advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly), who considered the initial diagnosis of Parkinson's disease was reasonable based on Mrs C's symptoms at that time. They highlighted the difficulties in differentiating between Parkinson's disease and other conditions such as essential tremor. Whilst we found that it took a long time for the Parkinson's diagnosis to be reviewed and retracted, we did not identify any failings in the adequacy or appropriateness of the follow-up that took place. We did not uphold the complaint.

However, we noted that the initial Parkinson's diagnosis had been recorded as a possible diagnosis, but this uncertainty did not appear to have been explained to Mrs C. We considered that the difficulties in diagnosing Parkinson's disease in the early stages should have been conveyed to her, in line with the Scottish Intercollegiate Guidelines Network (SIGN) guidance on Parkinson's disease which state that this uncertainty should be considered when giving information to the patient. We, therefore, made some recommendations for action by the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for the failure to make the uncertain nature of the Parkinson's disease diagnosis clear to Mrs C when it was made. The apology should mete 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 consultant who made the diagnosis should ensure any diagnostic uncertainty is clearly communicated to patients in future, in line with SIGN guidance. This should be included as a learning point in the consultant's annual appraisal.

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 late wife (Mrs A) about the care and treatment she received at Forth Valley Royal Hospital. Mrs A had been experiencing tingling in her fingers, which continued to worsen. Mr C complained there was an unreasonable delay in carrying out a scan to investigate Mrs A's condition. He also considered that there was an unreasonable delay in giving Mrs A the results of the scan. After Mrs A was referred for surgery, her mobility declined. Mr C felt that, with earlier surgery, she may have been walking normally.

We took independent medical advice from a consultant orthopaedic surgeon (a doctor who specialises in conditions involving the musculoskeletal system). We found that Mrs A was appropriately referred for an urgent scan and that it was carried out within a reasonable timescale. However, we considered that there was a delay in reporting the results and in giving Mrs A the results, which was unreasonable as there were significant clinical findings that required urgent surgical intervention. The adviser considered that earlier surgery was likely to have improved Mrs A's outcome and mobility. However, they explained that a good outcome was not guaranteed, as her condition was degenerate and it was unlikely she could have been walking normally. In light of these delays identified, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in reporting Mrs A's scan and in telling her the results. 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:

• Urgent scans should be reported promptly.
• A process should be in place so that significant findings in scans and x-rays are immediately flagged up to the referring clinician (this could, for example, be through a generic phone number or email address that is checked and acted on daily).

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 to us about the decision making of his GP practice. Mr C had received annual checks for prostate cancer for several years. However, the practice decided to change this to every two years. When Mr C's PSA levels were next checked, they had risen considerably and Mr C was found to have developed prostate cancer. Mr C complained that the practice unreasonably changed the frequency of his prostate checks. In addition to this, he complained about a number of administrative and communication issues relating to his prescriptions and treatment following his diagnosis.

We took independent advice from a GP. We found that there is currently no national guidance relating to prostate screening but noted that it was important to discuss the pros and cons with the patient so they could make an informed decision. The practice told us that a discussion had taken place but Mr C recalled that it was more a case of the practice stating a firm position and taking the decision. We were unable to confirm that a discussion had taken place. However, the records did state that Mr C should be monitored based on symptoms rather than testing and that he should be seen as required. In addition to this, an International Prostatic Symptoms Score (IPSS, a tool used to screen for, rapidly diagnose and track the symptoms of prostate enlargement) taken after the consultation showed a lower score. In light of the known information at the time of the consultation, and the fact that there is no national policy regarding screening for prostate cancer, we considered that the practice's decision was reasonable. Therefore, we did not uphold this aspect of Mr C's complaint.

In respect of the administration and communication issues, there appeared to have been some minor failings which were partly acknowledged in the practice's response to Mr C's complaint. However, we considered that the administration of prescriptions and paperwork had been largely adequate. Therefore, we did not uphold this aspect of Mr C's complaint.

Summary

Ms C complained about the care and treatment provided to her at Victoria Hospital. Ms C had several admissions for pain associated with gallstones. She complained that the nursing care during two of her admissions was not of a reasonable standard, and that she was not provided with pain relief in a timely manner. Ms C also complained about the treatment provided to her for a wound infection when she attended after surgery to remove her gallbladder.

We took independent advice from a nursing adviser and from a consultant physician. We found that nursing care had not been of a reasonable standard and upheld this aspect of Ms C's complaint. However, as the board had already apologised for this matter and taken action to address it, we made no further recommendations. We did ask for evidence of the steps they said they had already taken.

We found that pain relief had not always been provided to Ms C in a timely manner. We upheld this aspect of the complaint and made a recommendation to address this.

Finally, we found that the treatment provided to Ms C for her wound infection was reasonable and we did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Pain levels should be assessed regularly and pain relief provided in a timely way.

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 provided to his late father (Mr A) during his admission to Victoria Hospital. Mr A lacked capacity and had appointed Mr C as power of attorney for his care. In particular, Mr C complained that the board failed to give Mr A appropriate treatment for his heart attack and questioned why more invasive treatment was not considered in Mr A's case. Mr C also complained about a lack of communication with him about the care and treatment Mr A was given, despite having power of attorney. In their response to the complaint, the board accepted that Mr A lacked capacity and that there were failings in their communication with Mr C.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). The adviser considered that it was reasonable that more invasive treatment was not considered appropriate for Mr A, given his age and pre-existing health conditions. We considered that the care provided to Mr A was reasonable, and we did not uphold this aspect of Mr C's complaint.

The adviser considered that there was an unreasonable failure to discuss Mr A's care and treatment with Mr C, as power of attorney. The adviser also said that there was a failure to follow the required Adults with Incapacity process after Mr A's admission, as an Adult with Incapacity certificate and treatment plan were not prepared. We accepted this advice, and upheld this aspect of Mr C's complaint. In light of our findings, we made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate appropriately with him. The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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

• Decisions about care and treatment should be discussed with a welfare power of attorney, in the same detail they would be discussed with a patient who has capacity to understand the decision themselves.
• An Adult with Incapacity certificate and treatment plan should be prepared for all patients who lack capacity.

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 his late wife (Mrs A) received from Dumfries and Galloway Royal Infirmary in relation to the decision and communication about de-activating her implantable cardioverter defibrillator (ICD - a device designed to treat abnormal heart rhythms). Mr C also raised concerns that no discussions took place with Mrs A about a 'do not attempt cardiopulmonary resuscitation' (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) order being put in place until after the decision had been taken by medical staff. In addition, he was dissatisfied that staff had not clearly communicated that Mrs A's condition had worsened to the point that she was in the end of life stage.

We took independent advice from a consultant cardiologist. We found that there was sufficient evidence to show that discussions had taken place about the DNACPR order on two separate occasions. We also considered that it was appropriate clinical practice to de-activate Mrs C's ICD given that her condition had significantly deteriorated and there were no other treatment options possible. Whilst we did not uphold these aspects of Mr C's complaint, we welcomed that the board have taken steps to improve how conversations about de-activating ICDs are carried out.

In terms of Mr C's concerns about communication regarding end of life, we found that there was evidence to demonstrate that conversations took place about the reasons why there were no treatment options possible, and that palliative (end of life) care was Mrs A's only option. Whilst palliative care had been started, we found that there was no indication at the time of discharge from hospital that Mrs A would die as soon as she did afterwards. We, therefore, did not uphold this part of the complaint.