Health

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.

Summary

Miss C complained that the board unreasonably refused to perform liposuction (a  cosmetic procedure used to remove unwanted body fat) for her lipoedema (a  chronic fat tissue disorder in which fat cells build up, typically on the thighs, buttocks and lower legs, which causes tissue enlargement, swelling and pain. This tissue cannot be lost through weight loss). The board had criteria in place for providing this procedure and Miss C did not meet the criteria. Miss C complained that the criteria were unreasonable.

We took independent advice from a plastic surgeon. We found that it was reasonable for the board to have criteria in place for providing liposuction for lipoedema, and that the criteria was appropriate in order to balance the benefits and potential risks of the procedure. We did not uphold Miss C's complaint.

Summary

Ms C complained about the care and treatment provided to her by the board in relation to her hearing. Ms C had surgery to fit a hearing implant and after this she felt that her hearing deteriorated. Ms C also developed tinnitus (a ringing or buzzing in the ears). Ms C further complained that the communication with her from clinicians with regards to her hearing was not reasonable.

We took advice from an ear, nose, and throat consultant and an audiologist (a healthcare professional who specialises in hearing, balance and related disorders). We found that there was no suggestion that the reduction in Ms C's hearing was due to the surgery, and that clinicians involved in her care had provided a reasonable standard of care. We also found that the records showed a reasonable level of communication with Ms C. We did not uphold Ms C's complaints.

Summary

Mr C complained on behalf of his late wife (Mrs A) about the care and treatment she received from her GP practice. Mrs A attended the practice with stomach pains but it was not until two years after her pain began that she was diagnosed with cholangiocarcinoma (CCA, a very rare cancer of the bileduct). Mr C complained that the practice had delayed in carrying out appropriate tests and investigations. The practice said that Mrs A had been treated and cared for reasonably. They explained the rarity of her illness and said that that her symptoms had not been specific for a diagnosis of CCA. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a GP. We found that, as well as Mrs A's illness being extremely rare, it was also very difficult to diagnose at an early stage and was often found incidentally. Mrs A initially attended the practice with abdominal pain for which she was appropriately treated. There was no indication at that time for further investigations and Mrs A noted an improvement. She did not return to the practice with abdominal pain until two years later. At this time, all her liver tests were normal; and showed no cause for concern. However, as her symptoms worsened, she was admitted to hospital and was diagnosed with CCA. We found that the care and treatment Mrs A received from the practice was reasonable and, therefore, we did not uphold this complaint.

Summary

Mr C complained on behalf of his late wife (Mrs A) who was diagnosed with cholangiocarcinoma (CCA, a very rare cancer of the bile duct) at Ninewells Hospital. Mr C was concerned that there had been a delay in providing the diagnosis and that, had appropriate tests and investigations been carried out sooner, Mrs A's death may have been avoided. Mr C was also concerned that after diagnosis, the board failed to make further more timely investigations about the spread of the disease (particularly to her bones) for which treatment may have been available. Mr C complained to the board who told him that Mrs A's illness had been life limiting but that throughout her illness, her treatment had been reasonable and appropriate. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant oncologist (a doctor who specialises in cancer treatment). We found that Mrs A's illness was very rare and diagnosis was not obvious; it was often an unexpected finding on a scan. Mrs A had stomach problems a few years before her cancer diagnosis, for which she received appropriate tests and at that time there was no evidence that she had cancer. Mrs A had no further stomach problems for two years until she was sent to hospital for a scan and it was at this time that she was diagnosed with CCA. We found that there had been no delay in diagnosis. After her diagnosis, Mrs A was given palliative chemotherapy (cancer treatment that is not designed to cure the disease, but rather prolong life and minimise symptoms) and responded well. Her symptoms were managed as it was not possible to operate, however, Mrs A was later admitted to hospital as she had become jaundiced (where the skin and/or eyes become yellow in colour). Her disease had progressed and was later found in her bones but we did not find that there had been any missed opportunities for treatment that would have changed Mrs A's outcome. We found that her care and treatment had been reasonable. Therefore, we did not uphold Mr C's complaint.

Summary

Mrs C complained that the board unreasonably discharged her from a community mental health team. She believed that she was discharged due to the absence of her usual community psychiatric nurse (CPN), who had been off work for a number of months at the time of discharge. Mrs C said that she had not been regularly seen or supported during this absence, only receiving two appointments, the focus of which were her discharge from services. While complaining to the board, she also became aware that her previous diagnosis of bipolar disorder (a mental health condition marked by alternating periods of elation and depression) had been changed to a possible diagnosis of borderline personality disorder (BPD, a disorder of mood and how a person interacts with others). Mrs C complained that she had never been informed of this change and that the board failed to communicate with her appropriately.

We took independent advice from a CPN. We found no evidence to suggest that Mrs C's discharge was related to staffing issues. Prior to the CPN's absence, she had a clear care plan in place and was being seen around every two weeks. One of the aims of the plan was to explore a possible alternative diagnosis of BPD. There was also recorded agreement that any future discharge would be clearly planned in advance and communicated, to ensure that this happened in a supportive manner. We considered that the overall decison to discharge Mrs C was reasonable. However, the adviser explained that, under Scottish Government guidance, the board should have implemented an Integrated Care Pathway (ICP) which would define the care and support offered to people with personality disorders. We noted that it did not appear that the board had an ICP in place for BPD.

We also found that there was a lack of continuity in the support provided to Mrs  C once her CPN was absent. Prior to discharge, Mrs C had been without support for around four months, despite her care plan stipulating that she would be seen every two weeks. The adviser noted that the care plan should have been updated to reflect the CPN's absence but this did not happen. They also confirmed that, while Mrs C was aware that a diagnosis of BPD was being considered, no formal diagnosis had been given. However, they noted that Mrs C had now been referred back to the board for the specific purpose of reaching a clear diagnosis.

Overall we found that the decision to discharge Mrs C was reasonable. However, the manner that this was handled and communicated to Mrs C was not in line with the agreed care plan or relevant guidance. Therefore, we upheld both of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to appropriately handle her discharge and failing to clearly communicate her change of diagnosis. 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:

• The board should have an ICP to guide care provision for patients with BPD.
• Care plans should be reviewed and appropriately amended when a member of staff is absent from work long-term to ensure consistency of care.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr  A) at Ninewells Hospital. Mr A was resident in a care home and had Alzheimer's disease. He was referred to the emergency department by his GP as he was suffering from hip pain and could not bear weight. The GP asked that staff at the hospital rule out bony injury as a cause of Mr A's symptoms. X-rays were carried out and Mr A was discharged back to the care home after staff found no significant changes from previous x-rays. Four days later, an emergency referral was made for Mr A and he was admitted to hospital. Subsequent tests showed that Mr A had an abscess (a painful swelling caused by a build-up of pus) in his hip. It was determined that he was not suitable for surgery and Mr A was referred to the palliative (end of life) care team. Mr A died in hospital a few days later. Mrs C complained that Mr A's care in the emergency department was unreasonable and that there had been confusion over his palliative care referral. She also complained about how the board handled her complaint.

We took independent advice from an acute care consultant and from an emergency medicine consultant. The advice highlighted that Mr A's pain and inability to straighten his leg should have prompted further action by the staff who saw him in the emergency department. However, there was no indication that earlier treatment would have changed the outcome for Mr A. We also found that national guidance from the Scottish Intercollegiate Guidelines Network (SIGN) in SIGN 111 recommended tests that could have identified Mr A's infection earlier and that the care he received fell short of what he required as a patient with dementia. Therefore, we found that the care and treatment Mr A received was unreasonable and upheld this aspect of Mrs C's complaint.

In relation to communication around palliative care arrangements, we found that the board had identified failings and had apologised to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint but made no recommendations as we considered that this had been adequately dealt with by the board.

Finally, we found that Mrs C had not been kept properly updated during the complaints process, which exceeded the 20 working day timescale set out in the board's complaints handling procedure. 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 decision to discharge Mr A without further investigation of the cause of his hip pain and for the failings in the handling of her complaint. 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:

• Emergency department staff should take appropriate account of patients' cognitive impairments given that these make them more vulnerable to healthcare associated harm.
• SIGN 111 should be followed for patients with suspected hip fracture.

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

Miss C complained about the medical treatment her late mother (Ms A) received at Ninewells Hospital before her death. Ms A had been admitted to hospital on three occasions with exacerbation of chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed). It was then diagnosed that she had heart failure and Ms A died a week after her final admission. Miss C considered that there had been a delay in making a diagnosis of heart failure, as staff wrongly assumed that Ms A had COPD and delayed in carrying out the tests that showed she had heart failure.

We took independent advice from a consultant in acute medicine and from a consultant radiologist. We found that the investigations carried out in the hospital had been reasonable and appropriate and that it was reasonable that staff initially considered Ms A had COPD. We noted that it can be difficult to distinguish between heart and lung disease, especially when both are present together, and that there had not been an unreasonable delay in making a diagnosis. We did not uphold this aspect of Miss C's complaint.

Miss C also complained that staff had failed to adequately communicate with her and Ms A. The board had accepted that there were failings in relation to communication and we upheld this aspect of Miss C's complaint. We found that the main impact of this was that Miss C was not prepared for Ms A's sudden death. However, we were satisfied that the board had apologised for and addressed these failings whilst they were dealing with Miss C's complaint and we did not make any recommendations in relation to this matter.