Health

Summary

C complained about the care and treatment provided to their infant (A). C's concerns related to A's urinary function. C had concerns about the monitoring they had received whilst pregnant with A, the care provided to them and A immediately post- birth as well as during A's early years. C raised issues about the assessment of A's bladder function, A's renal health and the pain and discomfort A was suffering. C also felt that the family had not been listened to and their concerns dismissed or minimised. C had sought a second opinion at a hospital in England and believed board medical staff criticised the family for taking this step. They also said that the board failed to liaise with the hospital in England, resulting in A not receiving treatment or care for an extended period.

The board had accepted that communication with the family could have been better but considered the standard of care and treatment provided to A was reasonable.

We took independent advice from a consultant paediatrician. We found that A's symptoms were reasonably investigated initially and that they were referred to urology timeously. We also found no clear evidence that A's bladder had been damaged by failings on the part of the board. Therefore, we did not uphold these parts of C's complaint.

We found that the impact on A and their family of their condition was not adequately acknowledged and that the board had failed to communicate appropriately with C and their family. We also found that the board did not act when it became apparent that A was no longer being cared for by a hospital in England, resulting in avoidable delays in their care. Finally, we considered that the board failed to handle C's complaint reasonably. We upheld these parts of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's parents for the failures identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should share this decision with the staff involved in A's care with a view to identifying any aspects of the care and treatment that could have been improved. This should include consideration of whether there are any immediate actions which need to be taken to address A's ongoing issues.
• Patients' families should receive clear explanations and be provided with appropriate information which addresses their concerns.
• The board should reflect on the experience of A's family with a view to identifying any ways that communication and care planning for A could have been better managed.

In relation to complaints handling, we recommended:

• The board's complaint monitoring should ensure that failings, as well as good practice are identified and that learning and information gathered from complaints is used to drive service 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

C complained to the practice about the care and treatment provided to their relative (A). A began to experience abdominal pain and was reviewed by doctors at the practice a number of times before being admitted to hospital as an emergency. Following discharge, A was seen at the practice again with continuing symptoms and unintended weight loss. They were referred to hospital and again discharged. A colonoscopy performed suggested acute diverticulitis (where small pouches from the wall of the gut become inflamed or infected). A attended the practice again with worsening symptoms and was admitted to the hospital after an urgent request was submitted. A died in hospital a few weeks after.

C was concerned about the standard of care provided to A by the practice. The practice met with A's family. The practice carried out a Significant Event Analysis (SEA). The practice responded to C's complaint and noted their frustration that A had been discharged from the hospital without progress in the management of their condition. However, they did not find that they should or could have done anything differently in A's care.

C submitted a further complaint to the practice after they received a response from the health board regarding the care provided at the hospital. The practice responded confirming that an SEA had been carried out. The doctor who had seen A had discussed the case with colleagues in the practice and with their Educational Supervisor. These discussions had been informal and had not been documented in A's notes.

C was dissatisfied with the complaint responses and brought the complaint to our office. We took independent advice from a GP. We found that most of A's care was of a reasonable standard. However, there was a delay in acting on concerns about A's condition following their second discharge from hospital. Given the significance of the failures identified, we considered that A's care fell below a reasonable standard and upheld this part of C's complaint.

C also complained that the practice failed to reasonably respond to C's concerns. We found that the identified failure should have been communicated to the family, by the practice, during their investigation of the family's complaints. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the failure to act with sufficient urgency following A's discharge. The apology should meet the standards set out in the SPSO guidelines on apology. available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for the complaint investigation's failure to identify a failing in A's care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients requiring urgent care should be referred to specialists within a reasonable timeframe.
• The practice should ensure relevant staff are aware of the need to document discussions about patient care appropriately, in this case discussions between a trainee doctor and their Educational Supervisor, concerning a patient's care.
• Complaint investigations by the practice should address all relevant issues and should clearly identify and address any failings.

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

C complained about the care and treatment provided to their parent (A) during their admission to hospital for a knee replacement. A said that they woke up during their surgery.

The board responded to the complaint noting that there was no evidence A woke up during surgery. C and A were unhappy with this response and brought their complaint to our office.

We took independent advice from a consultant anaesthetist (specialist doctors responsible for providing anaesthesia and pain management to patients before, during and after operations and surgical procedures) and asked the board to comment on issues we had identified.

The board explained that A had been under a deep sedation during the procedure and provided further details about the management of A's sedation. They confirmed that A had to receive a 'top up' in medication during the procedure and had reflected on the manner of their complaint response and the detail they had originally provided and offered to make an apology to A.

We found that the procedure was undertaken with a spinal anaesthesia and sedation rather than under general anaesthetic. We noted that the board's explanation with respect to managing A during the procedure was reasonable but confirmed that A did wake up. A did not appear to be aware this could be a possibility given they were not under general anaesthetic.

We considered that while A did wake up, this was not due to inappropriate or unreasonable levels of care. Indeed, it was possible it could happen and it was handled appropriately. Therefore, we did not uphold C's complaint.

However, we concluded that the board should have acknowledged that A woke up during the procedure and provided C and A with an explanation as to why this happened and how this was managed. Therefore, we found that the hospital failed to appropriately investigate and respond to C's complaint and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the lack of detail contained in the complaints response and for providing misleading information regarding the circumstances of A becoming aware during the surgery. It would be appropriate to acknowledge the significant impact the lack of a clear response from the outset has had on both C and A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

C complained about the care and treatment provided by the board to their partner (A). A had a seizure and was admitted to hospital for further assessment. C reported their concern to staff that A had dislocated their jaw during the seizure, and advised that this had happened to A before.

A underwent x-rays and was referred to oral and maxillofacial surgery (OMFS, specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) for review. OMFS concluded that no further treatment was required for A. C continued to report their concern about A's jaw and an urgent referral was made to ear nose and throat (ENT) for further assessment. This was later re-directed on vetting to OMFS, however no follow-up review by OMFS took place by the time of A's discharge some weeks later.

On discharge, C contacted A's GP who arranged for A to be seen by another health board. A was diagnosed as having a dislocated jaw and underwent emergency surgery.

The board said that there had been evidence of dislocation in the right jaw joint. They said that due to A's dementia and reduced mobility, they were unable to fully cooperate during their assessment and would not have been able to manage further x-ray procedures. They noted that A did not appear to be experiencing any pain and appeared to have a good range of movement of their jaw.

We took independent advice from an oral and maxillofacial surgeon. We found that A's initial assessment on arrival at the hospital and the decision to wait until the x-rays had been reported before referring A to OMFS for further assessment was reasonable. However, we found that the assessment of A's jaw by OMFS failed to elicit the clinical features of the dislocation and failed to consider other types of scan after concluding the diagnosis was unclear.

On the matter of the urgent referral to ENT which was later redirected to OMFS, we were critical that no follow-up review by OMFS took place prior to A's discharge. We considered that the board failed to provide A with reasonable care and treatment and upheld C's complaints.

We also noted that, at the point of C complaining to the board, it was known that A had in fact dislocated their jaw during their admission. The board confirmed in their response to our enquiries that no internal processes for reporting or learning or improvement had been followed on becoming aware of this harm. While the board had responded to C's complaint, we were critical that they failed to initiate or follow other processes to record the event, or to elicit learning and improvement outcomes at the point of becoming aware of it. Therefore, we made a recommendation to the board on this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably assess and diagnose A's dislocated jaw, the referral to ENT being inappropriately accepted, and the unreasonable delay by ENT in reviewing A which did not take place during their admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The findings of this investigation should be fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding assessment processes.
• Referrals to other specialties for review should be made appropriately and accepted only when it is reasonable to do so. Referrals should be seen within a reasonable timescale.
• When the board becomes aware of a harm through the complaint process, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.

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

C complained that the practice failed to provide them with reasonable care and treatment. C suffered from inflammatory conditions of the skin and joints and was under the care of rheumatology (specialists in the diagnosis and management of chronic inflammatory conditions such as rheumatoid arthritis), dermatology (specialists in the in the diagnosis and treatment of skin disorders) and the practice. C was being prescribed an immunosuppressant and the practice was in a shared care agreement with the NHS board for monitoring bloods in regards to the prescription. C required a liver transplant due to liver cirrhosis induced by the treatment. C complained that the practice had not properly monitored their bloods, had not picked up on warning signs and had not communicated appropriately with the relevant specialists or with C. C noted that they had also been incorrectly prescribed an antibiotic containing penicillin.

We took independent advice from a GP. We found that the practice had monitored bloods appropriately, and where there were gaps in monitoring, C's attendance had been requested. We also found that the practice had sought specialist advice and followed NICE guidelines appropriately. We noted that the practice had verbally apologised for the penicillin mistake. Therefore, we did not uphold this part of C's complaint but fed back to the practice that it would be appropriate to apologise in writing.

C also complained that they were immediately removed from the practice register after making a comment on social media expressing concerns about their treatment. C noted that they were given no warning and that their poor health, vulnerability and their requirement for continuity of care were not taken into account. We found that the practice had not followed guidelines in respect of removing the patient from the register, without warning. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for prescribing an antibiotic containing penicillin, which they were allergic to. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the manner in which their removal from the practice register was handled. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Reconsideration of the social media policy and patient removal policy and process, such that they are in line with BMA and GMC 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

C’s elderly parent (A) had recently been discharged from hospital where they had been treated with antibiotics for a urinary tract infection. However, A continued to experience nausea and vomiting along with hallucinations and A’s GP requested an ambulance be provided for A within one hour. Although the Scottish Ambulance Service (SAS) made a number of calls to A’s home to check on them, no ambulance attended. A’s condition deteriorated throughout the day and C called to request an ambulance again. However, no ambulance attended and an out of hours GP subsequently requested an urgent ambulance for A. An ambulance later arrived and A was assessed as having had a possible heart attack and received treatment from the ambulance crew before being taken to hospital.

C complained about the length of time it took for an ambulance to attend A. C considered that SAS did not recognise the severity of A’s condition or the damage to A’s heart and that they failed to appropriately prioritise an ambulance for A, unreasonably delaying their treatment.

SAS acknowledged that the delay to an ambulance being provided for A had been unreasonable, explained the particular challenges that they had faced on the specific day in relation to frontline staffing, service demand and hospital admission capacity, outlined the steps they were taking to prevent recurrence and apologised for A’s experience.

We took independent advice from a paramedic adviser. We found that there was opportunity for the board to take further steps to prevent recurrence. The information the board provided in response to this indicated that improvements are taking place. After careful consideration, we upheld the complaint given the delay that the board have already accepted and apologised for. The steps that the board had taken and are taking since are reasonable and we made no further recommendations.

Summary

C complained about the standard of medical care and treatment provided to their spouse (A). A was diagnosed with, and treated for, advanced breast cancer. A’s condition deteriorated and they later died. C complained that clinicians failed to, amongst other things, act upon A's worsening symptoms or their concerns that their cancer may be spreading. C also raised concerns about the end of life care A had received from the board.

The board, in responding to C’s concerns, did not consider that there had been a failure to act on A’s worsening symptoms. However, they acknowledged incidences where A had not been given the opportunity to bring support to out-patient appointments where clinicians reported a deterioration in their symptoms. They apologised to C for A's poor experiences and agreed to take a number of improvement actions in response. They acknowledged A’s end of life care had been highly distressing for C and their family but did not consider that this had fallen below a reasonable standard.

We took independent advice from a consultation clinical oncologist. We found that the communication surrounding A’s diagnosis and progressive disease could have been better. We also noted a lack of documented Clinical Nurse Specialist support, but overall felt A’s treatment following metastatic (when cancer cells spread to other parts of the body) diagnosis had been appropriate. We did not uphold this aspect of the complaint.

With regards to A’s end of life care, we found that although the board’s handling of A’s DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) and discussions around their deterioration were appropriately documented, the communication around this did not meet C’s own expectations or needs. However, we found no evidence to support that decisions taken in respect of A’s end of life treatment, including their nursing care, had been unreasonable. For these reasons, we did not uphold this aspect of the complaint.

We did, however, provide feedback to the board on complaint handling matters, specifically in relation to adhering to response timescales and updates to the complainant during a complaint investigation.

Summary

C was sent to hospital by the GP with a diagnosis of severe cellulitis (an infection caused by bacteria getting into the deeper layers of your skin). Prior to being sent to hospital, C received paracetamol, intravenous fluids and intravenous antibiotics. On arrival at hospital, C had a long wait until being treated and C complained that the delay in admission and treatment was unacceptable.

The board apologised that C had to wait in their car and explained that patients were seen on a clinical priority basis. They advised that C's clinical priority was not deemed to be urgent as C had received paracetamol, fluids and antibiotics before arrival.

We took independent advice from an acute and general medicine adviser. We found that at the time, there was no clear system for prioritising patients. However, since then the board have improved their practice. We found that the triage which had been undertaken after admission had not followed guidelines. Additionally, we found that the waiting time to receive antibiotics was longer than the recommended maximum wait between antibiotic doses. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in admission and treatment, specifically that clinical priority was not appropriately assessed, that the triage decision was not in line with the guidance and that there was a delay in administering medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Staff should triage patients in line with the relevant 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

C complained about the care and treatment that their partner (A) received during an emergency admission to hospital for treatment of a back injury following a fall at home. During admission, C reported that A’s abdomen became very swollen which they were advised by staff was due to constipation and a build-up of faeces, and which was appropriately being treated with laxatives. A’s condition deteriorated and they were subsequently diagnosed with a perforated colon which required emergency surgery. This resulted in a stoma (a surgically made pouch on the outside of the body) and a prolonged period of recovery in hospital.

C complained that the board had failed to diagnose and treat A’s abdominal symptoms earlier. They considered that this may have resulted in a better surgical outcome for A, with no stoma being required. C also complained that the board failed to identify or treat a deep laceration on A’s arm, and they complained about the board’s failure to respect A’s dignity by discussing personal matters in the open ward.

The board’s response advised that A’s abdominal symptoms were timeously managed and treated, particularly noting that there had been no evidence during the admission assessments of a problem with A’s bowel. The board apologised that A’s arm injury had gone unnoticed and for personal matters being openly discussed, which they had provided as feedback to the ward charge nurse for learning and improvement.

We took independent advice from an upper gastrointestinal and general surgeon adviser. We found that A’s bowel perforation had been timeously diagnosed and treated, and the procedure that they received was appropriate to their presenting condition at the time. In relation to A’s arm laceration, we were critical of the board’s failure to identify and treat this as part of the assessment process. In relation to there being open discussion of private matters on the ward, we acknowledged the apology and action taken by the board in response to C’s complaint. On balance, we did not uphold C’s complaint.

Summary

C complained about the care and treatment of their late partner (A) during multiple admissions to hospital. C raised concerns that a coronary angiogram (a scan to check for blockages in the blood vessels) was unreasonably delayed, which in turn meant necessary vascular surgery could not take place. C complained about a lack of cohesion between vascular, cardiology and renal teams, and a lack of communication with the family.

We took independent clinical advice from a cardiology adviser and a vascular adviser. We found that there was a lack of cohesion and coordination in the management of A’s treatment plan. We considered that multidisciplinary meetings should have taken place to agree a treatment plan, and provide the cohesion that was lacking in the approach to A’s treatment. Overall, however, we found that the clinical decisions made by each team were reasonable and reflected A’s clinical condition at the time. We found nothing to suggest that the lack of cohesion impacted directly on the treatment A received or the eventual outcome for A. In particular, we found that there were good reasons not to proceed with the coronary angiogram, and that it was unlikely any vascular intervention could have been provided due to A’s competing illnesses. On balance, therefore, we did not uphold the complaint that A’s clinical care and treatment was unreasonable.

However, we upheld the complaint about the communication with A and their family. The board had already apologised for the poor communication and acknowledged that the multidisciplinary team did not keep the family as informed as they could have. Notwithstanding this, the board considered that A had capacity to make decisions regarding their own care and treatment. However, this assertion did not appear to have been based on any formal assessment. We found that there was evidence only once in the records of a capacity assessment having been undertaken. We found this concerning, particularly as C had raised concerns that A had become confused as a result of their illness and strong pain medication. We also found that there was a failure to complete existing documentation to record A’s communication preference, which was suggestive of a systemic failure rather than an issue that affected only A. Overall, we found that the communication with A and the family was very poor. A had a complex illness with a number of competing factors which affected the types and timings of treatments that were available. We concluded that clearer communication with the family, and between healthcare professionals, may have avoided a lot of the distress and anxiety the family experienced.

Recommendations

What we asked the organisation to do in this case:

• That the board apologise to C for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• That the board conduct an audit into the hospital staff’s compliance with their obligation to complete the existing documentation and take steps to ensure the documentation is being used effectively to ensure patient-centred care.
• That the board provide us with evidence of the steps that they have taken to ensure multidisciplinary team meetings take place to discuss and plan treatments for patients with complex medical conditions.
• That the board share this decision notice with the teams that were involved in A’s care and treatment with a view to identifying any points of learning.

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.