Health

Summary

Mrs C complained that the practice had failed to provide appropriate care and treatment to her husband (Mr A) when he reported mobility problems following a fall where he was hit by a car door. Mr A had a history of ankylosing spondylitis (a type of arthritis in the spine). Following the fall, a nurse practitioner made a home visit and, after speaking to a GP, a diagnosis of a dead leg syndrome was made. Mr A continued to deteriorate and a further call was made to the practice the following day. Mr A was then admitted to hospital where he was diagnosed as having two unstable fractured vertebrae (bones in the spinal column).

We took independent advice from a GP adviser and from a nursing adviser. We found that, based on the symptoms first reported by Mr A, there was no indication of a serious illness and that he did not require a hospital admission that first day. We found that it was appropriate that it was only when his condition deteriorated and he reported some numbness that it was deemed necessary to contact the hospital specialists and arrange for Mr A to be admitted to hospital. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment his daughter (Mrs A) received at Royal Cornhill Hospital. In particular, he complained that the board had failed to carry out appropriate risk assessments for Mrs A.

We took independent advice from a consultant psychiatrist. We found that Mrs  A had been been provided with reasonable care and treatment and that regular risk assessments were carried out. We also noted that Mrs A had been appropriately assessed on her return to the ward after absconding from the hospital. However, we were concerned that, when Mrs A first went missing from the hospital, the board did not follow their missing persons policy. We found that there was a delay in the board contacting the police and that their missing persons policy did not specify a time period within which to initiate the actions to be followed when an in-patient goes missing from care. We were also concerned that the nursing records did not state when the first ward check was carried out after Mrs A went missing, and that there was no record of the actions taken by the board between the first check and a later check at 21:30. Therefore, we upheld this complaint.

Mr C also complained that Mrs A had not been provided with appropriate medication. We found that the board's approach to medication treatment was appropriate and reasonable and in line with relevant guidelines. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for failing to follow the missing persons policy. 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 times of ward checks should be documented.
• When an in-patient goes missing from care, the missing persons policy should be followed in relation to police contact.
• There should be clear guidance in place in relation to the timescales for taking action when an in-patient goes missing from 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

Mr C complained about the care and treatment provided to his mother (Miss A) during two admissions to the mental health unit at Forth Valley Royal Hospital. In relation to Miss A's first admission, Mr C had concerns about the monitoring and treatment of blood pressure and the treatment provided to Miss A by a psychiatrist. In relation to her second admission, Mr C had concerns about medical care, nursing care and issues around communication. Mr C also complained about the gap in community psychiatric care in the period between the two admissions.

We took independent advice from a nurse and a consultant psychiatrist. We found that there were failings by nursing staff in the monitoring of Miss A's blood pressure and upheld this aspect of Mr C's complaint. However, we noted that the board had acknowledged this failing and had introduced a new system for recording observations. Overall, we found that the medical treatment provided to Miss A during her admission was reasonable and did not uphold these complaints. However, we noted that one letter sent to Mr C contained unhelpful language and we made a recommendation in light of this.

In relation to the gap in community psychiatric care in the period between the two admissions, we found that the board had not followed the clinical management plan in place once Miss A's psychiatrist left the community mental health team. Therefore, we upheld this aspect of Mr C's complaint. We did note, however, that the board had apologised for this failing and had put a new appointment system in place to address this issue.

In relation to Miss A's second admission, neither adviser identified any failings in medical care, nursing care or communication. Therefore, we did not uphold these aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A and Mr C for the failure to appropriately monitor Miss  A's blood pressure and the content and tone of the letter sent to Mr C. 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:

• Blood pressure monitoring should be carried out in line with the instructions by the medical team.

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's husband (Mr A) underwent minor surgery at Victoria Hospital. He was discharged the same day, but died of a blood clot in the lungs two weeks after his surgery. Mrs C complained that the aftercare provided to Mr A was unreasonable. Specifically, she was concerned that Mr A should have been kept in overnight after the surgery, and she felt that when he came home from hospital he was not breathing properly.

We took independent advice from a surgeon. We found that a risk assessment tool had not been filled in. If it had been, it would have shown that Mr A had a number of risk factors for blood clots. This in turn should have led to the consideration of the use of a variety of preventative measures including Flowtron  boots (boots to prevent blod clotting), TED stockings (stockings used to try and prevent blood clots) and heparin (a medication which reduces the ability of the blood to clot), though we noted that these measures may not have changed the eventual outcome. Inconsistencies in the documentation meant that it was unclear if Flowtron boots or TED stockings had been used to prevent venous thrombo-embolism (VTE, or blood clots in the veins), however it was clear that heparin was not considered. We found that it was reasonable not to keep Mr A in hospital overnight, and did not consider that this would have changed the outcome. We found that there were likely to be other reasons for Mr A's breathlessness after the surgery, and did not consider that the blood clot would have been present so soon after surgery.

On balance, we considered that the aftercare provided to Mr A was unreasonable and we upheld Mrs C's complaint.

The board said that this complaint had alerted them to inconsistencies in practices, and confirmed that they were undertaking a review with a view to standardising and ensuring guidelines were followed. We asked for evidence of this and we also made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the poor record-keeping, and for failing to consider the use of heparin after Mr A's surgery. 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:

• Staff should ensure that patients' documentation is completed at every stage of their admission. The General Surgery VTE/Risk Assessment Tool should be completed for all patients.
• Staff in the day surgery unit should be clear about the board's policy for dealing with the presence of risk factors for VTE in day case surgery. (While  the board are reviewing this matter, interim measures should be in place to ensure that appropriate steps are being taken when risk factors are present).

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 time taken to refer her to a specialist in a different board area for her urology issues (urology is the area of medicine relating to the kidneys, bladder and urinary tract). She said she asked for this referral repeatedly, but that it took a number of months for the board to refer her. She also complained that the board did not send on some test results to her new consultant, so she was required to repeat these privately at her own cost.

In response to Miss C's complaint, the board said that referrals to another health board are not available on demand. They said that the consultant who reviewed Miss C's case and made the referral felt that it was appropriate to refer her on for more specialist advice at that time. The board acknowledged that they did not include a copy of the test results with the original referral, and they apologised for this. They said they had sent on the test results about two months later.

We took independent advice from a consultant urologist. We found that Miss C's condition was first investigated by gynaecology (the area of medicine that deals with the health of the female reproductive systems and the breasts) and, while Miss C did request a referral to the specialist during this time, she then agreed to continue with additional tests. Miss C then advised the gynaecology service that she was now seeing a private gynaecologist, and she was appropriately discharged from their care. About six months after this first urology appointment, Miss C was reviewed by urology, and there is no evidence in the medical records that she requested a referral to the specialist before this review. We considered that this time-frame was reasonable, and there was insufficient evidence to conclude that the board had failed to respond to her request for a referral. We did not uphold this aspect of Miss C's complaint.

In relation to the test results, we found there was evidence that the board did send these on two months after the referral (although it appeared they were never received by the specialist). We found the delay was unreasonable, but noted that the board had already apologised for this. We found that it was likely the specialist would have asked Miss C to repeat these tests in any case, so we did not recommend that the board refund this cost. We did not uphold this aspect of Miss C's complaint.

Summary

Mr C's late mother (Mrs A) was receiving palliative care (end of life care) for advanced pancreatic cancer at home in a sheltered housing complex. Mr C contacted the out-of-hours service a number of times over a weekend, as he was concerned about the amount of pain that Mrs A was in. On the Sunday evening, Mrs A was admitted to hospital and transferred to a hospice the following day, where she died several days after. Mr C complained that the board failed to provide a reasonable standard of medical care and treatment and that they failed to respond to his complaint in a reasonable way.

We took independent advice from a specialist in general practice medicine. We found that the medical care and treatment provided to Mrs A was of a reasonable standard and that she was admitted to hospital within a reasonable time. In relation to complaints handling, we found that the board had fully addressed the issues raised and took account of the evidence available at the time. We did not uphold Mr C's complaints.

Summary

Miss C had long standing problems with her ears and had a number of operations to deal with this. More recently she began to experience nocturnal seizures (seizures which occur during sleep) which she thought were related to the problems she already had. Miss C complained about the care and treatment she received and that it took too long to get a diagnosis for the seizures. She felt that she had not been listened to and had unreasonably been referred to the psychology service because of stress. The board, however, took the view that her symptoms were unrelated to her existing condition and that her care and treatment had been reasonable.

We took independent advice from consultants in neurology and ENT (ear, nose and throat). We found that the mix of the two conditions from which Miss C suffered required time and effort to investigate and to prove that they were unconnected. We found that the care she received from the ENT and neurology departments was thorough in order to exclude the possibility that Miss C's ear problems were the cause of possible brain disease. We were satisfied that she had been reasonably and appropriately treated. However, we also found that there was a delay of six months between the time her GP referred her and when she received her first out-patient appointment. Once her treatment started, we found that Miss C also had to wait too long for her scans. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in receiving an out-patient appointment and the delay in scans being carried out. 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 should receive clinical appointments and scans/tests in a timely manner.

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 treatment which his late brother (Mr A) received when he attended the accident and emergency department at Dumfries and Galloway Royal Infirmary. Mr C had received a phone call from Mr A early one morning saying that he had difficulty breathing. An ambulance was called and took Mr A to the hospital. Later that morning Mr C received a further call from Mr A saying that he was being discharged from the hospital and asking Mr C to pick him up. Mr C ensured that Mr A was settled in his house. However, Mr C later learned that Mr A had died. The cause of death was heart failure and Mr C felt that more care should have been taken at the hospital and that perhaps Mr A should have been admitted for further tests.

We took independent advice from a consultant in emergency medicine. We found that the staff at the accident and emergency department had carried out an appropriate examination of Mr A at the time, which included a history of heart problems. They had taken a chest x-ray, electrocardiogram (ECG - a test to check the heart's rhythm) and blood tests. Although there were subtle signs of heart failure from the results, we concluded that it was reasonable for the staff to diagnose that Mr A was suffering from a chest infection rather than heart failure. It was also reasonable that Mr A was prescribed antibiotics and discharged home. We did not uphold the complaint.

Summary

Mrs C complained about the management of her husband's (Mr A) insulin after he was admitted to Dumfries and Galloway Royal Infirmary for treatment of a stroke. Mr A has a history of diabetes mellitus (a condition that occurs when the body cannot produce sufficient insulin to absorb blood sugar) for which he administers insulin.

In responding to the complaint, the board acknowledged and apologised for a delay in Mr A receiving insulin one evening. The board considered that, during Mr A's admission, staff had followed the correct procedures but more checks of his blood sugar and ketone levels would have allowed staff to act earlier. The board set out a number of measures that they said they had taken regarding staff training and improvements as a result of Mr A's experience.

We took independent advice from a consultant physician specialised in diabetes mellitus. We found that management of the insulin was below the expected standard, given the possibility that diabetic ketoacidosis (DKA, a serious complication of diabetes that occurs when the body produces high levels of ketones) could have been prevented by earlier recognition, more frequent monitoring and more aggressive insulin administration. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff did not specifically inform her or Mr A that he had developed DKA and urosepsis (a secondary infection that develops in the urinary tract). Mrs C said they had only been aware that Mr A had low blood sugar levels. We found that when Mr A developed DKA and urosepsis, there was no record of this having been explained to either of them at the time. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failings in communication. 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:

• Staff should be aware that early recognition of the warning signs and prompt restorative action should prevent DKA from developing.

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 was due to have surgery on her leg at Dumfries and Galloway Royal Hospital but this was cancelled shortly before the scheduled time. Miss C complained that the board did not carry out her surgery and that the reasons for this were not properly explained to her. While the board apologised for the confusion surrounding the decision to cancel Miss C's surgery, they felt that the decision was appropriate as it was a major operation with significant risks and she had shown some recent improvement. Miss C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant vascular surgeon. We found that it was reasonable for the operation not to have been performed, but we considered that the decision-making process surrounding this could have been clearer. We found that the entries made at the time in Miss C's medical records indicated that the reasons for not going ahead with the surgery had been explained to her. We did not uphold Miss C's complaints but provided feedback to the board regarding their decision-making process for surgery in complex cases.