Health

Summary

Mrs C complained about the care and treatment she received at Wishaw General Hospitial in relation to her fertility treatment. In particular, Mrs C stated that she had been misinformed that the medication she was taking would not affect her fertility.

We took independent advice from a consultant obstetrician and gynaecologist (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts). We found that the correct investigations in relation to Mrs C fertility problems had been performed in a timely manner. We also noted that it was explained to Mrs  C at an early stage about the contributory factors to the fertility problems she was experiencing and the treatment which would be required. We found that there was no evidence that Mrs C had been misinformed about the cause of her fertility problem and that she had been kept advised of the results of the various investigations carried out as they proceeded. Therefore, we did not uphold the complaint.

Mrs C also complained that the board had failed to adequately address her complaint. We found that the board had handled the complaint in line with their complaint process and had offered the opportunity to meet with senior staff to address any outstanding questions. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received while she was a patient in Wishaw General Hospital. Mr C was concerned about both the medical and nursing care Mrs A received, and about the way that the board handled his complaint.

In regards to Mrs A's medical treatment, Mr C questioned the length of time a central line (a tube placed by needle into a large, central vein of the body to administer drugs or take blood samples) was in place. Mr C also complained that there was an unreasonable delay by medical staff in reviewing blood test results, and subsequently in Mrs A receiving antibiotics. Mr C believed that, because of poor treatment, Mrs A was denied the opportunity of starting chemotherapy treatment.

We took independent advice from a consultant general surgeon with experience in oncology (cancer treatment) We found that, following Mrs A's admission surgery and further investigations being carried out, it was confirmed that she had extensive, incurable cancer and all further treatment was to be palliative (end of life care). We considered that the length of time Mrs A's central line was in place and the actions of medical staff in prioritising the alleviation of Mrs A's severe pain was reasonable. However, we found that there was a significant delay of several hours in reviewing Mrs A's blood test results and starting appropriate antibiotics. While we found that it was unlikely that the delay in starting antibiotics significantly changed Mrs A's outcome, given her underlying condition and poor prognosis, the delay was unacceptable. Therefore, we upheld this aspect of Mr  C's complaint. The board had already acknowledged that there was an unacceptable delay, due to a breakdown in communication involving both junior and senior doctors, and had noted that this has been addressed with staff.

In relation to Mrs A's nursing care, Mr C was concerned over elements of record- keeping and the frequency and recording of some of Mrs A's observations by nursing staff. We took independent advice from a nurse. We found that certain aspects of Mrs A's nursing care were good however, both advisers noted failings in the quality of the completion of some of Mrs A's records and in the frequency of her observations. Therefore, we upheld this aspect of Mr C's complaint. The board had already acknowledged that these issues were unacceptable and noted that they had apologised and taken action.

Finally, Mr C was dissatisfied with the board's response to the concerns he and his family raised about Mrs A's care and treatment. In relation to a meeting which was held to discuss Mr C's concerns, we identified certain aspects that we found to be unreasonable. For this reason, we considered that the board had not responded reasonably to Mr C's complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failings identified including a breakdown in communication causing a significant delay in reviewing Mrs  A's blood test results and starting appropriate antibiotics failings by nursing staff in record keeping; and a failure to respond to concerns raised by Mr C and his family following a meeting. 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:

• Current practices and processes and the working relationship between junior and senior doctors should be improved to minimise the risk of a future similar event occurring. Ensure that the importance of effective handover is emphasised as part of a junior doctor's induction. Ensure appropriate timescales are in place for requesting, performing and documenting results, and actions taken, for investigations such as blood tests.
• Nursing observations should be carried out in line with the board's Medical  Early Warning flowchart and the scoring system should be accurately applied. Nursing care charts and care bundles should be completed accurately and in line with the Nursing and Midwifery Council's guidance on record-keeping. The board should reissue relevant staff with their central line care policy and provide appropriate education to staff to support this. Also, senior nurses should routinely audit compliance with the central line maintenance bundle.

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 that the care and treatment she received at Raigmore Hospital, in relation to problems with her gallbladder, was unreasonable. She said that on several occasions she attended an out-of-hours GP and the emergency department but her symptoms were not investigated and as a result, when she was diagnosed with cholecystitis (inflammation of the gallbladder), the surgery was complicated and her recovery was difficult.

We took independent advice from a GP, a consultant in emergency medicine, and a surgeon. We found that the care and treatment provided to Mrs C was of a reasonable standard and there was no indication of gallbladder problems at her attendances prior to the diagnosis of cholecystitis. We did not uphold Mrs C's complaint.

Summary

Miss C complained about the length of time which she was going to have to wait for an appointment at an orthopaedic clinic (a clinic for conditions involving the musculoskeletal system). Following a car accident a number of years ago Miss  C had seen a number of health professionals. She also took numerous forms of medication but remained in severe pain. Her GP referred her to the orthopaedic clinic and the referral was marked as routine. After six months Miss  C had not received an appointment date. Her GP made a further referral to orthopaedics, and was told that the current waiting time was 48 weeks. Miss  C complained that, despite two referrals from her GP, her case was not being treated as urgent by the board.

We took independent advice from an adviser in orthopaedic medicine. We found that, although the board had not managed to arrange the orthopaedic appointment within the treatment time guarantee, they had apologised for the delay and had explained what action they were taking in an effort to reduce waiting times. We found that the board had correctly classified both of the GP referral letters as routine rather than urgent based on the information provided by the GP. We did not uphold the complaint.

Summary

Mrs C complained about the treatment she received at the Queen Elizabeth University Hospital following a hysterectomy (surgical removal of the uterus). The morning following the surgery Mrs C received a blood thinning injection and when she was discharged later that afternoon she was given an information leaflet on exercises to undertake at home. Just over a week following the discharge, Mrs  C developed breathing difficulties and a high temperature and attended hospital where it was found she had suffered a pulmonary embolism (a blockage of an artery in the lungs) and required further blood thinning injections. Mrs C felt that she was not given sufficient blood thinning injections following the surgery and that she had been discharged home too early.

We took independent advice from a medical adviser and found that, following her surgery, Mrs C's observations were found to be normal and that she was able to eat and drink and was mobile. We also found that she had been fitted with TED  stockings (stockings that help to prevent blood clots) and had received a blood thinning injection within a reasonable timeframe following the surgery. We concluded that it was appropriate to have discharged her from hospital and that there was no clinical indication that she would then go on to develop a pulmonary embolus. We did not uphold Mrs C's complaints.

Summary

Mrs C attended the emergency department of Glasgow Royal Infirmary twice with severe abdominal pain. On both occasions, Mrs C was told she had stomach flu and was discharged home. Mrs C's GP decided to refer her to the hospital's surgical department, as she was still in severe pain. She was then found to have a hernia (a condition where an internal part of the bodypushes through a weakness in the muscle or surrounding tissue wall) in her stomach and a small bowel obstruction.

Mrs C complained that the board failed to give her appropriate care and treatment during her two attendances to the emergency department. Specifically, Mrs C complained that she was misdiagnosed with stomach flu and was not given appropriate pain relief.

We took independent advice from a consultant in emergency medicine and from a nurse. We found that all appropriate investigations were carried out into Mrs  C's condition on both occassions. On the basis of those investigations, we considered that it was reasonable that Mrs C was diagnosed with stomach flu. However, we found that Mrs C's pain level was not appropriately assessed or recorded and that there was an unreasonable delay in giving her pain relief medication. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to appropriately assess and record her level of pain, and for the delay in giving her pain relief medication. 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:

• Pain levels should be assessed and recorded appropriately. Timely and appropriate pain relief should then be provided to patients, and staff should check with patients whether they require pain relief medication.

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 that the practice failed to carry out appropriate checks for allergies before prescribing penicillin. Mrs C was visited by a GP at home and prescribed an antibiotic containing penicillin which she is allergic to. Mrs C did not suffer any ill-effects as she read the information on the packet and therefore did not take the medication. The practice said that the GP asked Mrs C if she was allergic to penicillin before prescribing, which Mrs C denies. They also noted that doctors do not have sight of patients' medical records when on house calls but that the GP looked at the patient's medical summary before the appointment.

We took independent advice from a GP. They considered that it was reasonable for the surgery to check a patient's records before leaving the practice and to ask the patient if they were allergic to any medications. We found that Mrs C's penicillin allergy was noted on the medical summary the GP said that they had referred to. We considered that if the GP had checked this first they ought to have been alert to prescribing penicillin in a patient with allergies. Although the practice acted reasonably in checking the medical records before the home visit, we considered the allergy should have been picked up then. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to take sufficient steps to establish that she was allergic to penicillin, and prescribing her an antibiotic that contained penicillin. 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 GPs should be reminded of the importance of carefully checking records before house calls (or if that is not possible, checking for allergies by phoning the surgery), in addition to asking patients about allergies, before prescribing penicillin.

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 care and treatment her late mother (Mrs A) received while she was a patient at Inverclyde Royal Hospital. Mrs A was taken to hospital after she was unable to return to bed, finding her legs were too weak. She spent time in the emergency department before being transferred to two different wards. Mrs A died shortly after. Miss C complained about the standard of both clinical and nursing treatment Mrs A received, that the board failed to communicate adequately with her and that they did not respond to her complaint reasonably.

We took independent advice from a consultant physician and a nurse. In relation to Mrs A's clinical and nursing care, we found that certain aspects of her care in the emergency department had been reasonable. However, we also indentified a number of failings including a failure to recognise and investigate whether Mrs  A, given her presenting symptoms, may have had a stroke or sepsis (a blood infection). We also noted there was a delay in administering intravenous fluids and rechecking her National Early Warning Score (NEWS - an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration).

While in the first ward, we found that staff had difficulties interpretating an x-ray of Mrs A's and that there was no written plan as to what to do about clarifying this. We also noted that the board failed to consider whether Mrs A had suffered a subdural haematoma (where blood collects between the skull and the surface of the brain) or possible sepsis. We also noted a failure to ensure that she had received appropriate fluids, monitor her urine output, issues with record-keeping, and a failure to anticipate, recognise and address that she was deteriorating and to plan for this in line with national recommendations. There were also multiple attempts to catheterise Mrs A and no account appeared to have been taken of the distress and discomfort this may have caused her.

When Mrs A was transferred to another ward, we found that there was a failure of continuity of handover between the medical teams caring for Mrs A. It also appeared that although Mrs A was having active treatment with intravenous fluids and regular NEWS, at the same there was a failure to act on her elevated NEWS, recognise that she was dying and manage her end of life care appropriately. Overall, we found that both the clinical and nursing care provided to Mrs A was unreasonable and we upheld these aspects of Miss C's complaint.

In relation to communication, Miss C said that staff failed to inform her or consult with her about Mrs A's care and treatment during her admission, despite the fact that she held welfare power of attorney. We found that an Adults With Incapacity form had not been completed and that Miss C had not been consulted about the plan to insert a catheter. We considered that there appeared to have been a lack of evidence of Miss C having being proactively and regularly updated and a failure to try to understand her needs, expectations and concerns about Mrs A. We also noted that that Mrs A's deterioration did not appear to have been communicated effectively with Miss C. Therefore, we upheld this aspect of her complaint.

In relation to how her complaint was handled, Miss C said that she had not been informed that a significant clinical investigation (SCI) was carried out by the board until she received a copy of the report by the Procurator Fiscal (a legal officer who performs the duties of public prosecutor and coroner). We considered that the board had kept Miss C appropriately updated on the investigation into her complaint, however, the delay was unreasonable. We also noted that she was unaware that the SCI was being carried out and we considered that the board should not have left it to the Procurator Fiscal's office to have made her aware of the SCI report. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to provide Mrs A with reasonable medical and nursing care and for the failure to reasonably communicate with her about Mrs A's care and treatment. 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:

• Where patients present with fluctuating conscious level and reduced power in their limb(s), consideration should be given to whether they have had a stroke or a subdural haematoma and to carrying out a CT brain scan. When patients transfer from the emergency department to an acute medical ward there should be an appropriate re-examination of the patient including their case history.
• Where patients who present meet the SIRS (systematic inflammatory response syndrome), criteria consideration should be given to whether they may have sepsis and appropriate investigations carried out.
• Where patients present with deterioration and fluid overload, consideration should be given to performing a renal ultrasound to look for any obstruction in the urinary tract.
• Where there are difficulties by staff in interpreting an x-ray, consideration should be given to obtaining a formal report from the radiologist or asking for it to be reviewed by a more senior member of staff.
• There should be in place a structured response to patient deterioration where it is clear that the patient is failing to improve or continues to deteriorate as recommended by national guidance.
• Consideration should be given to seeking a more expert practitioner to assist with catheterisation after repeated attempts.
• Where a patient's prescribed rate of fluid is changed, this should be entered on their fluid prescription sheet.
• An Adults with Incapacity form should be completed for patients who lack capacity and discussed with the person who has power of attorney wherever possible.

In relation to complaints handling, we recommended:

• Wherever possible, complaints should be investigated and responded to in line with the board's complaints handling procedure. Where a SCI review is to be carried out, staff should ensure that the patient and/or their family is clearly informed of the action that is being taken.

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

Ms C, an advocacy worker, complained on behalf of her client (Mr B) about the care and treatment provided to his late father (Mr A) at Queen Elizabeth University Hospital. Mr A had dementia and was admitted to hospital by ambulance after becoming unwell at home. It was suspected that he had urinary retention (inanbility to empty the bladder) and a urinary tract infection. Mr A was treated with antibiotics and fitted with a catheter (a thin tube used to drain and collect urine form the bladder). While in the hospital, Mr A suffered a fall and also developed pressure ulcers. After surgery to fix a bone broken during a fall, Mr  A's condition worsened and he developed pneumonia (an infection of the lungs). Mr  A's condition continued to deteriorate and he later died. Ms C made several complaints about the treatment that was provided for Mr A's urinary tract infection, catheter care, prevention of falls and pressure ulcer care.

We took independent advice from a consultant in acute medicine, a consultant urologist and a nursing adviser. In relation to urinary tract infection treatment and catheter care, we found that Mr A had been started on antibiotics which was reasonable. However, a scan of his urinary tract and bladder had not been carried out ahead of catheterisation. We also found that the completion of catheterisation records was inadequate and that it had been difficult for staff to contact the on call urology team at some points. We noted that Mr A pulled on his catheter and that there had been difficulties in re-catheterising.

In relation to fall risk management and pressure ulcer care, we found that the care planning in the assessment of these risks was unreasonable. We upheld all of Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for the failings identified in the investigation of Mr A's urinary tract infection; his catheterisation; and in the assessment and management of his falls and pressure ulcer risk. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org/leaflets-and-guidance.

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

• Bladder scans should be considered and carried out where appropriate.
• Staff should be able, as far as possible, to obtain specialist urology advice/assistance when necessary.
• Accurate medical records should be maintained.
• Staff should respond appropriately in cases where patients try to pull out catheters and have the appropriate catheterisation skills.
• There should be sufficient support and guidance for nurses to carry out comprehensive, structured assessment and care planning. The patient should be re-assessed and their care plan updated as needed throughout the hospital stay. There should be evidence that the patient or their power of attorney informs the care plan and participates in its review.
• National guidance on the prevention and management of pressure ulcers and standards of care for older people in hospital should be implemented appropriately.
• Appropriate pressure relieving equipment should be identified and obtained timeously. There should be an escalation process where there are delays in equipment being available.

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). Mr A was admitted to hospital as an emergency with abdominal pain, and investigations were carried out over the next few days. Following a request by the family for medical review, Mr A was reviewed by a surgeon and a scan was carried out, which showed a bowel obstruction. Mr A had surgery the next day. Following this, Mr A was transferred to the high dependency unit (HDU) where he contracted a chest infection. He was then transferred to a ward, but his condition deteriorated and he developed sepsis. Mr A was transferred back to the HDU four days later, and then into intensive care. His condition deteriorated further, palliative care (end of life care) was started and Mr A later died.

Mrs C complained to the board about the care and treatment provided to Mr A. The board met with Mrs C about her complaints and carried out a significant clinical incident review. Mrs C was not satisfied with the outcome, or the way the board handled her complaint, and so she brought her complaints to us. She complained that the board did not provide reasonable medical treatment to Mr A, did not provide reasonable nursing care to Mr A, did not communicate reasonably with the family during Mr A's admission, and did not respond reasonably to her complaints.

We took independent advice from a consultant in general medicine, a nurse and a consultant radiologist (a doctor who uses medical imaging such as x-rays, ultrasounds and scans to diagnose and sometimes treat ilnesses). We found that there were delays in investigating and diagnosing Mr A's condition, and in identifying, responding to, and recording the deterioration following the surgery. We also found that there was no documentation of the reasons for transferring Mr C from the HDU, and poor documentation of a decision to commence using a ventilator. We found that, while aspects of the communication with the family were reasonable, on the whole the standard of communication fell below a reasonable standard, especially in light of the fact that the family held power of attorney. We upheld Mrs C's complaints about medical care and treatment, and about communication.

We did not find failings in the nursing care provided to Mr A, and so we did not uphold this aspect of the complaint.

We found that the board had failed to respond to many of the issues Mrs C had raised in her complaints, despite taking a significant amount of time to investigate. The board was also poorly prepared for the meeting they had with Mrs C about her complaints. We upheld Mrs C's complaint about the board's handling of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in medical care and communication, and for failing to respond to the points raised in her complaint.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:

• Patients should be reviewed regularly, with prompt consideration of the results of any investigations to inform diagnosis and treatment.
• Medical staff should clearly record the reasons for key decisions.
• Deterioration in patients should be identified and escalated to senior staff, with timely transfer to high-dependency care where appropriate.
• Welfare attorneys should be involved in decisions about care, and discussions should be clearly documented.

In relation to complaints handling, we recommended:

• The board should adequately prepare for complaint meetings by ensuring staff attending are aware of the specific complaint issues and are able to respond to the specific issues and discuss the timeframes covered by the complaint. They should also agree an agenda or format prior to the meeting, to ensure shared expectations.

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.