Health

Summary

Miss C complained on behalf of her late mother (Mrs A) that the practice unreasonably admitted Mrs A to hospital when it was her wish to remain at home. Mrs A had terminal cancer and was being cared for at home. A GP from the practice visited her at home and was concerned about the ability to meet her care needs there. Therefore, the GP arranged for Mrs A to be admitted to hospital where she died two days later. Miss C was concerned that this was against Mrs A's wishes as she had wanted to remain at home.

We took independent advice from a GP. The adviser considered that the initial decision to have Mrs A admitted to hospital was reasonable. However, by the time that the ambulance crew had arrived, she had lost consciousness. We found that, at that point, the GP should have consulted the family about having Mrs A admitted to hospital. We considered that Mrs A should have been allowed to remain at home if that was what her family wanted. Therefore, we upheld Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not clarifying and acting in line with her family's wishes about Mrs A's admission to hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

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

• When someone is in the final days of their life, there should be shared decision making with them and with their family, as appropriate, about their 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

Miss C complained to us on behalf of her late mother (Mrs A). Mrs A was admitted to Victoria Hospital with stomach pain, which was thought to have been gallstones (small stones that form in the gallbladder). Mrs A was later diagnosed with cancer. Miss C complained that there was an unreasonable delay in diagnosing Mrs A's cancer.

We took independent advice from a consultant surgeon and a consultant radiologist. We found that the board carried out appropriate investigations into Mrs A's condition. However, we found that the board's interpretation of a scan was not reasonable as the scan results raised the possibility that Mrs A had liver cancer or a liver infection and that further investigations should have been recommended as a result of this. We found that there was an unreasonable delay in giving Mrs A an appointment to discuss those scan results and we noted that the board had identified this failing. We considered that the failings in the interpretation of Mrs A's scan led to an unreasonable delay in diagnosing her cancer. Therefore, we upheld this aspect of Miss C's complaint.

Miss C also complained about an unreasonable delay in proceeding with surgery on Mrs A's gallbladder. We found that it was appropriate that the board tried to treat her without surgery first. We, therefore, did not uphold this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in diagnosing Mrs A's cancer. 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:

• As far as possible, scan findings should be accurately reported.

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 board failed to process an autism spectrum disorder (ASD) assessment for her child (child A). Mrs C said there were a range of administrative errors in the process, which led to significant delays. Mrs C also said that the board unreasonably tried to transfer child A's care to a different health board, based on child A attending a new school outwith the board area.

The board upheld Mrs C's complaint and apologised for some administrative errors in the process. They acknowledged that they were responsible for the assessment (rather than the other health board) and that their current wait times for assessment were unacceptable. The board said that they were introducing a new assessment pathway to improve this, including a new central point of contact for processing referrals. Mrs C remained dissatisfied and brought her complaint to us.

We took independent paediatric and nursing advice. We found that the board failed to process child A's referral in line with their own guidance, including failing to follow-up the paperwork sent to Mrs C. The board also failed to arrange a planned follow-up appointment with a paediatrician. We also found that it was unreasonable that the board tried to transfer child A outwith the board area, as staff should have been aware that they were responsible for all children resident in the board area, regardless of schooling. We upheld Mrs C's complaint.

While the board had acknowledged some failings, we found that their response to Mrs C did not give a clear and full apology for all the failings we identified. We considered that the action taken by the board to improve waiting times and communication was appropriate. However, we were concerned that, in 2014, we made similar findings about a delay in an ASD assessment (case 201401014) and, while the board took action following that case to reduce waiting times, these appeared to have extended again significantly. The board said that they had implemented a new pathway for ASD assessments, and we asked to see evidence of this and other actions the board is taking to reduce waiting times. We also made a number of recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C's family for the unreasonable delay in the ASD assessment, their error in attempting to refer child A outwith the board area, the administrative failings in their handling of the assessment pathway, and the failure to provide a follow-up paediatric review. 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:

• Information about patients within the board's area of responsibility should be easily accessible to all staff.
• Requests for consent to ASD assessment should be followed up, in line with the relevant guidance, when there is no response.
• Planned follow-up reviews should take place. If this is subsequently considered not necessary, clear explanations should be provided to the patient.

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 clinical and nursing care and treatment she received when she was admitted to Victoria Hospital. In particular, that there was an unreasonable delay in surgery being carried out to remove her ovaries and an unreasonable delay in arranging surgery for the repair of an incisional hernia (a type of hernia caused by an incompletely-healed surgical wound). Mrs C also complained that the nursing care and treatment of her wound following surgery was unreasonable.

We took independent advice from a consultant in obstetrics and gynaecology (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts), a consultant general surgeon and a nursing adviser.

In relation to the clinical care and treatment provided to Mrs C, we found that the delay in carrying out surgery to remove Mrs C's ovaries was not unreasonable. However, we were concerned that some of Mrs C's medical records were missing. We did not uphold this aspect of Mrs C's complaint but made a recommendation about the missing medical records.

With regard to arranging surgery for the repair of an incision hernia, we found that the board failed to meet the legal treatment guarantee time, which states that health boards should take all reasonable steps to ensure that patients receive in-patient and day case treatment within 12 weeks of treatment being agreed. We also found that there was no evidence that Mrs C was advised of her options given the failure to meet this guarantee. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care and treatment provided to Mrs C's wound, we found that there was no evidence of failings in care and that the treatment she received was reasonable. Therefore, we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unreasonable delay in arranging surgery for the repair of an incisional hernia. 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:

• Records should be kept in accordance with the Scottish Government Records Management: NHS Code of Practice (Scotland).
• The board should inform patients as soon as possible of any inability to meet treatment targets and provide them with information about the options available to them in the circumstances.

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 he received at University Hospital Crosshouse following a referral made by his GP. He was suffering from chest pain and was seen by a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) at the hospital. Mr C complained that the examination he received was poor and that the consultant failed to take into account all the information provided by his GP. At a later appointment, Mr C underwent an echocardiogram (echo - a heart scan that uses sound waves to create images) and was fitted with a Holter monitor (a device that measures and records the heart's activity). Mr C considered that the results were not properly reported and no follow-up appointment was made. He complained to the board who confirmed that there had been errors in the consultant's note taking but that they did not impact upon his care. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant cardiologist. We found that some records contained inaccuracies and that there had been no reference made to Mr C's chest pain which was the reason for his attendance. We also found that no investigations were made at his initial referral and the adviser noted that they would have expected an electrocardiogram (ECG - a test that records the electrical activity of the heart) to be carried out. We found that the subsequent echo was reported as normal although there were some abnormalities. We considered that the board failed to provide reasonable care and treatment and upheld Mr C's complaint. However, we noted that although some information was not recorded correctly, this would not have affected Mr C's treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide a reasonable level of cardiology care and treatment. 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 cardiology department should consider whether all new cardiology patients should have an ECG on arrival and consider whether or not provision should be made to arrange other tests prior to, or very soon after, consultation.
• In their clinical records, the named consultant in cardiology should consider and offer opinion about their patients' presenting 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 about the care and treatment she received during out-patient consultations at University Hospital Crosshouse. Mrs C initially attended a consultation in the renal medicine department (department of medicine relating to the kidneys) and it was felt that her test results showed that she had sub-clinical hypothyroidism (a condition where thyroid stimulating hormone level is higher than normal). Mrs C was prescribed a small dose of medication to treat this. Mrs C subsequently attended a consultation in a different department. This department did not agree that Mrs C had sub-clinical hypothyroidism and recommended that the medication should be stopped. A review appointment was arranged for three months' time. Mrs C was unhappy with this decision and undertook to self-source a supply of thyroid medication. She attended a further consultation in the renal medicine department approximately a year later. At this time, Mrs C was advised to discontinue taking her self-sourced thyroid medication as it was considered that it was causing suppression of her thyroid stimulating hormone. Mrs C disagreed with the board's findings and explained that she felt better taking the thyroid medication, which she reported had also improved her kidney function. She complained to us that the board were not providing her with the medication she felt she needed. Mrs C also complained that she was unreasonably advised to stop taking her self-sourced thyroid medication.

We took indepdendent advice from a consultant physician. We found that the test results over a number of years did not show evidence of sub-clinical hypothyroidism. For this reason, we considered it was reasonable for the board to discontinue the medication and to advise Mrs C of the risks of continued use. In relation to Mrs C's consultation in the renal medicine department a year later, we found that it was reasonable for the board to recommend that Mrs C stop taking the medication. We did not uphold Mrs C's complaints.

Summary

Mr C complained about the care and treatment his late father (Mr A) received at the Royal Alexandra Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing and treating Mr A's metastatic melanoma (skin cancer that has spread). Mr C also complained about a failure to communicate clearly from the outset to Mr A that he was suspected to have cancer.

We took independent advice from a plastic surgeon. We found that appropriate investigations were carried out into Mr A's condition. However, we found that Mr A's treatment plan should have been discussed by the multi-disciplinary team when there were concerning findings from his full body scan. We also found that it would have been appropriate for Mr A to have been offered a scan. We upheld this aspect of the complaint.

We found that discussions with Mr A about his condition were not recorded. The board acknowledged failings in their record-keeping and outlined steps that they had taken to address this. We upheld the complaint and we have asked the board to provide evidence of the action that they said they have taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in referring Mr A to the regional multi-disciplinary team to discuss his treatment plan; for not offering a scan and for the failure to properly document discussions with Mr A in which he was told he might have cancer.

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

• High risk cases of melanoma should be discussed by the regional multi-disciplinary team before surgical treatment is carried out.

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 aspects of the physiotherapy care provided to her child (child A), who has complex care needs.

Mrs C complained that the physiotherapy provided to child A did not reflect their needs. We took independent advice from a physiotherapist. We found that, for the most part, child A received appropriate physiotherapy for their condition. Although we found some gaps in the record-keeping, we concluded that, on the whole, the care and treatment provided to child A was reasonable. We did not uphold this aspect of the complaint.

Mrs C also raised concern that the board failed to provide appropriate physiotherapy input to child A following administration of a treatment at a hospital in another health board's area. We found that the board had appropriately liaised with the other health board, and that child A received an increase in physiotherapy following the treatment. We found this to be reasonable and we did not uphold this aspect of the complaint.

Lastly, Mrs C complained that the board had not communicated with her reasonably about a change in physiotherapy service provided to child A and that child A would no longer be working with a physiotherapy assistant. We found that the board had arranged an event to update families about changes in the physiotherapy service. However, we found that, in the period prior to this, there was no evidence to suggest that Mrs C was informed that child A would no longer be working with the physiotherapy assistant. The advice we received also noted that there was no evidence that a reduction in the frequency of physiotherapy input was discussed with Mrs C. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and child A for the lack of documented reasons for the change in frequency of physiotherapy input; the lack of communication in relation to this; and failure to inform Mrs C that child A would no longer be working with the physiotherapy assistant. 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:

• Physiotherapy staff should explain decisions and ensure children, young people and families fully understand them and their implications, especially if the final decision is not what they hoped for. Staff should also document decisions and the communication of these in the records.

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 suffers from post-traumatic stress disorder and has a longstanding difficulty leaving his house as a consequence. Mr C complained that the practice unreasonably decided that he was not housebound. Mr C's psychiatrist wrote to the practice noting their view that his longstanding mental health difficulties effectively rendered him housebound. The practice had previously refused a request from Mr C for a home visit on the basis that he had managed to attend the surgery in the preceding months. Mr C contacted the practice to ask them to clarify their position in light of his psychiatrist's letter, and they maintained that he is not housebound.

We took independent advice from a GP, who considered that the practice's home visit policy was overly rigid in that it appeared to require a purely physical inability to travel and did not give due regard to Mr C's mental disability. Therefore, we upheld this complaint.

Mr C also complained that the practice failed to disclose relevant information to his psychiatrist when discussing his situation over the phone. This pre-dated the psychiatrist's letter and the psychiatrist appeared to agree with the practice at that time that Mr C was not housebound. Mr C considered that the conclusions drawn by his psychiatrist would have been altered if the long standing nature of his condition and its symptoms had been discussed. However, we noted that the psychiatrist was already aware of Mr C's long term symptoms and medical history from previous assessments by them. The purpose of the call was to find out if there were any current issues that they needed to be aware of. We found that it was reasonable for the practice not to refer to more details of Mr C's past medical history during the phone call. Therefore, we did not uphold this complaint.

In addition, Mr C complained that the practice did not advise him of his right to approach us on completion of their complaints process. The practice complaints policy and NHS complaints handling procedure states that complainants must be notified of their right to approach our office at the end of their internal complaints procedure. Therefore, we upheld this complaint. However, we noted that the practice accepted this failing and they proposed changes to the way they do things to prevent this happening again, therefore we did not make any further recommendations in relation to this.

Recommendations

What we asked the organisation to do in this case:

• The practice should apologise to Mr C for the fact that their policy on home visits did not give appropriate weight to the nature of his mental health disability. 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 practice should review their home visit policy and ensure that it has due regard to mental health as well as physical health disability, as defined by the Equalities Act 2010.

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 complained that the dentist failed to provide her with a reasonable standard of dental care and treatment. Ms C attended the dentist over a number of months, concerned about a number of issues. Ms C had experienced pain in one of her teeth which she subsequently discovered had a crack in it. She said that the dentist failed to investigate this appropriately. As a result, Ms C said an adjoining tooth was extracted, and she was unreasonably prescribed three courses of antibiotics before the cracked tooth was extracted. Ms C also had to receive root canal treatment on another tooth which had an infection Ms C said that as a result of the failings, she was in pain for months and needed to get veneers or implants to close the gap at the front of her mouth because she could not eat or smile.

We took independent advice from two dentists. We found that there were significant failings around record-keeping, the prescription of antibiotics, and the management of two teeth. We also found that the dentist was not in a position to appropriately monitor any potential decay progression, which was unreasonable. However, we did not find that the extractions were unnecessary. On balance, we found that the care and treatment Ms C received was unreasonable and therefore. we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to follow relevant guidelines and standards. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Records should meet the relevant standards and the dentist should become fully aware of and comply with the requirements of these standards.
• Ensure that the approach to patient care is in line with professional guidance (including key skills in primary dental care and management of acute dental problems) and complies with the new guidance due in 2018 in relation to x-rays (Ionising Radiation (Medical Exposure) Regulations).

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.