Health

Summary

Ms C complained about the care and treatment she received at Borders General Hospital. Ms C suffered from lower abdominal pain and appeared to have diverticular disease (disease of the colon). Ms C attended the emergency department at hospital on six occasions over a number of months. She complained that over this period of time the board did not treat her reasonably and failed to carry out suitable investigations. As a consequence, she said her diagnosis was delayed and her treatment options were reduced. Ms C also complained about the actions of nursing staff and about the way the board dealt with her complaint.

We took independent advice from a consultant general and colorectal surgeon (a specialist in the medical and surgical treatment of conditions that affect the lower digestive tract) and from a registered nurse. We found that Ms C's initial investigations had been satisfactory. However, she continued to present with similar symptoms and persistent pain which, therefore, should have indicated that her diverticular disease had progressed and she should have received a scan earlier. Had this been the case, her distress and symptoms could have been managed earlier, although her surgery options were unlikely to have been different. We upheld this aspect of Ms C's complaint.

In relation to the actions of the nursing staff, we found that there was a great deal of confusion about where Ms C's future treatment was to take place; an appointment had been cancelled at extremely short notice and she was incorrectly advised that treatment would be given in England. Therefore, we upheld this aspect of Ms C's complaint.

Finally, we also found that this incorrect information about Ms C's future care was included in the board's complaint response. We considered this to be unreasonable and upheld this aspect of Ms C's complaint. However, we noted that the board has already taken remedial action in relation to the issuing of the incorrect information and we made no further recommendations in light of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to consider further investigations despite the persistance of pain. 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:

• In circumstances similar to Ms C, consideration should be given to making further investigations.

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 late son (Mr A) received from the board's mental health team. Mr A was discharged home on a community based compulsory treatment order but completed suicide around 18 weeks later. Specifically, Mrs C complained that the conditions of the compulsory treatment order were not adhered to by staff, that there was insufficient communication with Mrs C as Mr A's named person, and the board's review of Mr A's death did not include certain information which Mrs C considered relevant.

The board carried out a significant adverse event review (SAER, a structured approach to learning from an adverse event) and in their response to Mrs C, they concluded that the care Mr A received was person-centred. The board also identified some learning points in relation to managing the expectations of the named person. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse and a consultant psychiatrist (a specialist in the diagnosis and treatment of mental illness). We found that there were significant gaps and numerous retrospective entries in Mr A's medical records which were unreasonable and not in line with national guidance on record-keeping. We considered that this likely impacted on the team's ability to fully understand Mr A's health and wellbeing. There was evidence to show that Mr A did not receive the planned number of weekly visits from the team, either because he missed appointments or because the visits were not carried out. Given Mr A's complex care package, we also considered that escalation to the responsible medical officer should have taken place when there had been a nine day gap in contact or when there was a significant deviation from his care plan (only one visit a week instead of three). Therefore, we upheld this aspect of Mrs C's complaint.

In relation to communication with Mrs C, we noted that the rights of the named person are limited and there was no requirement for the team to have shared all aspects of Mr A's care with her. However, we considered it is generally good practice to communicate with the named person/family which had been part of Mr A's care plan. We found that the mental health team did not communicate reasonably with Mrs C and upheld this aspect of her complaint. However, we noted that the board had acknowledged these failings.

In relation the the SAER, we did not have significant concerns about the information Mrs C felt was missing. However, we were critical that she had not been provided with the opportunity to raise such concerns. We were also concerned that the SAER should have identified the failings in record-keeping as part of the review of Mr A's care. 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 Mr A's agreed care plan and poor record-keeping. 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:

• When significant deviation from an agreed care plans occurs, this should be escalated to the responsible medical officer for discussion and a record made of what the response to this should be.

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 made a number of complaints about the care and treatment that his late wife (Mrs A) received in University Hospital Crosshouse. Mrs A had a complex medical history and was admitted in relation to a skin condition. Mrs A became increasingly unwell during her admission and developed hospital acquired pneumonia (an infection of the lungs). Mr C complained about the nursing care that Mrs A received. Mr C also complained about the medical care that Mrs A received in relation to the insertion of a central line (a tube placed by needle into a large, central vein in the body to administer drugs or take blood samples), prescription/management of fluids, how she came to develop hospital acquired pneumonia and the prescription of pain relief. Mr C was also concerned about the DNACPR (do not attempt cardiopulmonary resuscitation) that was in place for Mrs A and that no post-mortem was carried out following her death. Mr C also considered that the handling of his complaint by the board was unreasonable.

We took independent advice from a nurse in relation to Mrs A's nursing care. While we did not find failings in relation to many aspects of Mrs A's care, we found that the appropriate skin assessment had not been carried out following her admission. The adviser highlighted that appropriate care and assessment could have avoided a pressure ulcer that Mrs A later developed. We upheld this aspect of Mr C's complaint.

We took advice from a consultant in acute medicine in relation to Mrs A's medical treatment. We noted that most aspects of Mrs A's care had been reasonable and that Mrs A's very low weight on admission to hospital made management of her fluid balance difficult. We found no failings in relation to the prescription of pain relief. The adviser highlighted that hospital acquired pneumonia is a risk for all patients, but particularly those who are frail and bed-bound. However, we found that there was a lack of evidence of an appropriate consent process for the insertion of the central line. Therefore, we upheld this aspect of Mr C's complaint.

In relation the DNACPR decision, we found that this was appropriate in Mrs A's case and that there was evidence that it was discussed reasonably. We also found that there was no clear answer as to whether or not a post-mortem should have been carried out for Mrs A. Therefore, we did not uphold these aspects of Mr C's complaint. However, we did note that a care after death checklist had not been completed and made a recommendation to the board in light of this.

Finally, we found that the board's complaint response was not issued within the prescribed timescales and did not address all the concerns that Mr C raised. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to carry out appropriate pressure area assessment and care, for the failures around the consent process for the central line, and for failing to handle his complaint reasonably. 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:

• The board should ensure that all registered nursing staff carry out appropriate assessment and monitoring of patients at risk of pressure ulcers.
• Appropriate consent should be obtained and documented or an adults with incapacity form completed to cover the insertion of a central line.
• The board should ensure that all relevant staff are aware of and complete the care after death checklist for every patient who dies.

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 father (Mr A) about the care and treatment Mr A received from his GP practice. Mr C complained that Mr A was not referred to dermatology (the branch of medicine dealing with the skin, nails, hair and its diseases) when he first attended the GP Practice, even though his facial lesion had changed shape and colour. Mr C was later diagnosed with skin cancer. Mr C also complained that Mr A was not given appropriate treatment when he later developed health issues, such as a persistent cough, in the last months of his life.

We took independent advice from a GP. We found that the practice should have referred Mr A to dermatology at the outset. The adviser considered that Mr A's lesion was of concern because it had enlarged and changed character. Therefore, we upheld that aspect of Mr A's complaint and we made recommendations to address this. We found that the practice gave Mr A appropriate treatment for the health issues he experienced later and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not referring Mr A to dermatology. 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 with suspicious lesions should be referred to dermatology.

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 on behalf of her child (Child A) about the care and treatment they received at the Royal Edinburgh Hospital. Child A was admitted to hospital and diagnosed with a severe depressive episode and suicidal thoughts. Child A remained in hospital some months, and mental health staff consulted with social work about alternative accommodation (as it was not appropriate for Child A to return to the family home at that time). However, Child A's behaviour became increasingly violent, and Child A was discharged with a few days' notice to social work staff, who arranged accommodation at a young people's centre. Child A ran away from the centre threatening to harm themselves on several occasions, and had to be detained by the police. Child A was then transferred to secure accommodation, where they remained for several months.

Mrs C complained that the board inappropriately discharged Child A without ensuring adequate arrangements were in place for their safety and welfare. We took independent advice from a psychiatrist and found Child A's discharge to be unreasonable. We found that the discharge decision was made at short notice, without adequate planning for Child A's future accomodation and follow up care. We were also critical that a psychiatrist at the hospital instructed other staff not to detain Child A under the Mental Health Act if they returned to hospital. The adviser noted that detention under this Act is an important option to protect people who are a risk to themselves or others, and it was unreasonable for staff to try and remove the availability of this protection. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board used different diagnostic labels at different times to influence the management of Child A's care. We found that a mixture of diagnostic labels were used during Child A's admission, and it was not clear that a structured approach was used to formulate a diagnosis. However, we did not find that staff used these labels for the purpose of influencing the management of Child A's care. We did not uphold this aspect of Mrs C's complaint. However, we made recommendations to the board in relation to the use of different diagnostic labels.

Mrs C also felt that communication with her in relation to Child A's different diagnoses was poor. We found that the board had failed to respond to specific questions raised by Mrs C in a letter and could not explain why these had not been answered. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to keep clear and accurate medical records. We found that the board's record-keeping was reasonable and that Child A's discharge letter contained sufficient information. We did not uphold this aspect of Mrs C's complaint. However, the adviser noted that some records were unclear and that several emails had not been recorded. While we did not uphold this complaint, we made recommendations to the board in relation to improvements in record-keeping.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Child A and their family for unreasonably discharging Child A (with inappropriate instructions not to re-detain them under the Mental  Health Act), for the lack of clarity in diagnostic terms used, and for failing to respond to the questions Mrs C raised in her letter. 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:

• Child and Adolescent Mental Health Service (CAMHS) patients should not be discharged without safe accommodation and adequate support in place, with specific follow-up plans in place and explained to the patient and their family in advance.
• A diagnosis should be clearly formulated based on symptoms reported and observed. Diagnoses (including provisional and differential diagnoses) should use an accepted diagnostic system (usually International Classification of Diseases (ICD-10)).
• Detention under the Mental Health Act should be available as an option to protect people when they are a risk to themselves or others. Staff should not try to remove the availability of this protection for a patient.
• Medical records should include all records relevant to the admission (including emails) and entries should clearly identify the author and their role.

In relation to complaints handling, we recommended:

• Responses to complaints should address the points raised (or explain why information cannot be provided).

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 way NHS 24 had handled a phone call from him when he reported that he had been experiencing headaches for over three weeks and was told that he was suffering from migraines. Mr C subsequently went on to develop vertebral artery dissection (a tear to the inner lining of an artery in the neck which supplies blood to the brain and can cause a blood clot) three weeks later. Mr C believed that the call to NHS 24 was not managed appropriately and that he was unreasonably only advised to rest and increase his fluid intake.

We took independent advice from a practitioner experienced in out-of-hours services. We found that NHS 24 had treated Mr C's concerns seriously and they had conducted a clinical investigation report. Mr C had contacted NHS 24 during the hours when GP surgeries are open and, during such periods, the remit of NHS 24 is to provide advice and to direct patients to contact their GP. We were satisfied that, in view of Mr C's reported symptoms at that time, there was no requirement for him to attend hospital or arrange an emergency ambulance and that it was appropriate to direct him to his GP surgery. We did not uphold the complaint.

Summary

Mrs C complained that, following a foot operation at the Golden Jubilee National Hospital, she continued to suffer pain and discomfort. During the surgery a bone fractured and had to be fixed by a wire. Mrs C reported continuing problems and was reviewed at both the Golden Jubilee National Hospital and the orthopaedic department of her local hospital, where it was established that she had also suffered a further complication of the surgery where there was a non-union of the bone. Mrs C believed that the original surgery had not been performed properly and that she had not been told of the risks of surgery prior to her operation.

We took independent advice from a consultant orthopaedic surgeon. We found that both the bone fracture during the surgery and the subsequent non-union of the bone were recognised, but rare complications, of the surgery. We found that there was no indication that the original surgery was not performed to a satisfactory standard. The fracture was caused when inserting a screw in order to fix a bone into place and we found that it was appropriate to change the fixation method to wire when the bone fractured. The two complications of the surgery which affected Mrs C were not specifically mentioned in the operation consent form as they were rare; however, it was found that the actual risks mentioned on the form were adequate as they had identified the most common types of complications. We did not uphold the complaints.

Summary

Mr C complained that the ambulance service failed to send an ambulance to him when he phoned to report that he had suffered a collapse at home. When he received a call back from an ambulance service clinical adviser, Mr C reported that he had suffered flashing lights, neck stiffness, headaches for the past three weeks, and that he now also had pins and needles in his right hand side. The ambulance service said that Mr C's reported symptoms did not meet the criteria for an emergency ambulance. However, as Mr C had symptoms for a number of weeks, he did require a medical review and it was agreed that Mr C's sister would transport him to hospital.

We took independent advice from a paramedic and listened to the audio recordings of the phone calls. We found that Mr C's symptoms did not warrant the dispatch of an emergency ambulance and that it was appropriate to arrange for the clinical adviser to phone him back to obtain further information. We found evidence that a number of assumptions had been made by the clinical adviser. At no time did Mr C state that he had had the pins and needles for two weeks but rather that the problems had just started. We found that the clinical adviser did not adequately question Mr C or his sister about how manageable it would be to transport Mr C to hospital, should he suffer another collapse. We also found that insufficient weight had been taken of the severity of Mr C's headache, the visual disturbances, and neck stiffness. We found that it would have been advisable to have dispatched an ambulance crew who would have carried out a face-to-face assessment in Mr C's home and determined the appropriate way to progress matters. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that assumptions had been made regarding his reported symptoms. The apology should reach 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 carrying out clinical assessments the clinical adviser should give sufficient weight to red flag signs and not make assumptions about the reported symptoms.

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 on behalf of her late husband (Mr A) that the ambulance service failed to transfer Mr A to hospital in an appropriately safe manner. Mr A had recently been diagnosed with a cancerous tumour on his femur (thigh bone) and was at risk of fracture. While being admitted to hospital for pain management, Mr A sustained a fractured femur while he transferred himself from a trolley cot to a hospital trolley. Mrs C was also concerned that the ambulance crew did not stay with Mr A in the accident and emergency department until he was attended to by hospital staff and did not complete an incident report regarding the fracture.

We took independent advice from a paramedic clinical team leader. We found that good practice should have dictated the use of transfer equipment or, as a minimum, the supporting of Mr A's leg during his efforts to self-mobilise. We also considered that the ambulcance crew should not have left Mr A in hospital without ensuring treatment had commenced and should have completed an incident report regarding the fracture. Therefore, we upheld Mrs C's complaint.

Mrs C also complained about how the ambulance service handled her complaint. We found that there was an unreasonable delay in responding to the complaint and a failure to keep her updated. We also noted that Mrs C only received a copy of the internal investigation report document. No formal, personalised complaint response letter was issued and she was not informed of her right to appproach us with her complaint. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adhere to best practice when transferring Mr A to the hospital trolley; failing to stay with Mr A until active treatment commenced; and failing to complete an incident report in line with protocol.
• Apologise to Mrs C for failing to respond to her complaint within 20 working days; failing to proactively inform her of the delay and keep her updated; and failing to issue a formal, personalised written response (including details of her right to approach the SPSO). 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:

• The ambulance service should demonstrate organisational learning to try to prevent similar future failings – they should complete and share with staff an anonymised case study highlighting the identified failings in this case.

In relation to complaints handling, we recommended:

• The ambulance service should ensure their complaints investigations comply with the requirements of the NHS Scotland model Complaints Handling Procedure – they should highlight these requirements to complaints handling staff.

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 had failed to provide appropriate care and treatment to his daughter (Miss A). He said that the practice had failed to provide Miss A with an emergency appointment when a phone call was made to them one morning advising them that Miss A was showing symptoms of severe mental health issues, including self-harm and suicidal thoughts. The practice said that they were unable to see Miss A until later in the evening and gave advice that Miss A should attend the local accident and emergency department. Miss A was taken to the hospital and subsequently was transferred to another hospital for patients with mental health issues. Mr C believed that the practice should have made arrangements to see Miss A as an emergency that morning rather than her having to wait a number of hours at the hospital for an assessment. Mr C also complained about a previous consultation Miss A had with a GP at the practice where she was complaining about depression. Mr C said Miss A was not given any medication, but advised to make another appointment and to bring her mother with her and that a discussion would take place then about medication. Mr C felt that, as Miss C was of adult age, she did not require her mother to be there.

We took independent advice from an adviser in general practice medicine and concluded that the practice had provided a reasonable level of care. We found that the practice gave appropriate advice that Miss A should attend the nearest accident and emergency department as this way she was seen quicker than had she waited for the first available practice consultation slot later that day. We also concluded that a reasonable clinical assessment had been carried out at a previous GP consultation where the GP had taken an appropriate history and gave Miss A reasonable advice. Miss A had mentioned to the GP that her mother may not agree with the GP's proposed treatment plan and it was decided that she should make a review appointment after discussing the situation with her mother. The records did not indicate that Miss A's mother had to be present at the review appointment. We did not uphold the complaints.