Health

Summary

Mr C complained about the follow-up care and treament he received at Dumfries and Galloway Royal Infirmary. Mr C underwent surgery for prostate cancer in another NHS board area but follow-up care was to take place within his own area. Mr C complained to the board about the way they handled his follow-up care as there were a number of delays. The board decided to undertake a Significant Adverse Event Review (SAER) as a result. Mr C was provided with a draft copy of the SAER at a meeting, however, the response to his complaint was not supplied until a number of months later with a copy of the finalised SAER report. Mr C complained to us that the board had unreasonably failed to provide him with appropriate follow-up care and treatment. He was also concered that the board had not followed their SAER policy appropriately and that there had been unreasonable failings in the way they handled his complaint.

We took independent advice from a consultant urologist. We found that there was a lack of appropriate follow-up care for Mr C and that poor communication between staff caring for him in different board areas had contributed to the issues with his follow-up. We upheld this aspect of Mr C's complaint but noted that the board had acknowledged and apologised for this failing.

In relation to the SAER, we found that it was reasonable in its findings. However, it took far longer to complete than Mr C had been advised, and we found a lack of evidence that the board had kept him updated on their progress. We upheld this aspect of Mr C's complaint.

In relation to Mr C's complaints handling concerns, we found that there had been significant delays in the investigation process and that the board had acknowledged and apologised for this. We also noted that the SAER was a separate process from the investigation of Mr C's complaints and we considered that it would have been helpful had the board's complaint response more clearly addressed the specific concerns he had raised in his original letter of complaint.

Recommendations

What we asked the organisation to do in this case:

• Review Mr C's follow-up care plan to ensure that he receives the appropriate standard going forward.

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

• There should be systems in place to facilitate communication between staff where more than one NHS board is involved in caring for a 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

Ms C complained about the treatment she received from her dentist, particularly in relation to the fitting of a crown which fractured multiple times and required repairs, and areas of untreated decay.

We took independent advice from a dental adviser. We found that the treatment Ms C received from the dentist was unreasonable and we therefore upheld the complaint. The repair carried out to the crown was unreasonable, as was the failure to investigate the cause of the fracture. There were failings in the dentist's record-keeping, and we found that Ms C was incorrectly charged for the repair. There were also failings around the untreated decay, though the dentist had already acknowledged and reflected on this.

We noted that the dentist had already apologised for some failings. They had also already taken steps to improve their practice and ensure these issues did not arise again, including carrying out an audit on clinical record-keeping, and undertaking some further training. We asked for evidence of these actions and we also made some further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the shortcomings in treatment and record-keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Refund Ms C the money charged for the crown repair.
• Consider reimbursing Ms C for the cost of the crown itself, since it broke twice soon after being fitted and had to be replaced.

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, who works for an independent advocacy service, complained that there was unreasonable delay in providing the required care and treatment to her client  (Miss A) when Miss A was admitted to Crosshouse Hospital after her Percutaneous Endoscopic Jejunostomy tube (PEJ tube - a feeding tube that is put inside an outer tube which goes into the stomach. The inside tube goes into the small intestine) became blocked. Mrs C also complained that the board's handling of her complaint was unreasonable.

We took independent advice from a gastroenterologist (a doctor who specialises in the digestive system). We found that the board's staff referred Miss A for an initial review, specialist review, arranged investigations and arranged for a replacement PEJ tube in a reasonable time. In view of this, we did not uphold Mrs C's complaint regarding the time taken to treat Miss A. However, we identified that there was no nutrition team involvement in Miss A's care, and that a nutrition assessment was not carried out. We were critical of this and made a recommendation to the board to address this matter.

Regarding complaints handling, we found that there was a lack of clarity as to how the board were investigating the issues raised by Mrs C. In addition, we found that the board did not adhere to the timescale required, nor did they appropriately update Mrs C on their progress. We, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to clarify how the complaint would be handled and for not keeping her reasonably informed about the progress of the 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:

• The involvement of a nutrition team should be considered where stopping of nutrition due to a blocked feeding tube is the reason for admission, and the patient cannot be easily assessed with regards to nutrition status. Nutritional assessment of such patients should be documented.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints procedure.

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 husband (Mr A) by the practice. Mr A attended the practice feeling unwell, having had a history of heart problems. In the following weeks Mr A was admitted to hospital where he was diagnosed with a condition in his heart. Mr A suffered an injury in the brain as a result of a bleed, and his short term memory has been impacted by this. Mrs C considered that if the heart condition had been diagnosed earlier, then Mr A's eventual outcome may have been different.

We took independent advice from a GP adviser. We found that the symptoms described and noted were not indicative of a particular illness. We also found that the classic symptoms of Mr A's condition were not seen until the day Mr A was admitted to hospital. We found that the GP took reasonable steps to establish the reason for Mr A being unwell and carried out appropriate tests. We also considered that the GP made an appropriate referral to a cardiologist (a  doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels). The referral to the cardiologist was not sent as a matter of urgency. The GP surgery acknowledged this error and took steps to ensure that this did not happen again. We found that, even if the referral had been sent urgently, this would not have had an impact on the outcome. We did not uphold the complaint.

Summary

Mrs C complained about the care and treatment provided to her late father (Mr  A) at University Hospital Ayr. Mr A was elderly and had a visual impairment. Mrs C complained that nursing staff failed to take into account her father's visual impairment when communicating with him and that they failed to recognise he needed extra assistance when reaching for food and drinks. Mrs C also complained about the handling of the discharge process. She felt that the nursing staff did not give accurate information to the social work department about Mr A's mobility, which resulted in difficulties in managing his care at home. Mrs C also raised concerns about the board's handling of her complaint.

The board acknowledged their communication with Mrs C could have been better and that they should have consulted with her more regarding her father's discharge planning. The board also acknowledged that nursing staff communication with Mr A was not acceptable. Mrs C remained unhappy and brought her complaints to us.

We took independent nursing advice. We found that the nursing care provided to Mr A was below an acceptable standard and that the discharge planning could have been improved by holding a case conference. We upheld these two aspects of Mrs C's complaint. However, we found that the board did take adequate steps to ensure that Mr A received appropriate post-discharge care at home. We did not uphold this aspect of the complaint.

Regarding complaints handling, we found that the board did not handle Mrs C's complaint in line with their complaints handling procedure. We upheld this part of the complaint.

Recommendations

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

• Staff should be more aware of how to take into account and accommodate the individual needs of visually impaired patients and should ensure these needs are recorded appropriately in the records.
• The board should recognise the importance of personalised discharge planning, particularly when patients are elderly and frail and are already receiving complex care at home.

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 about the assessment of her father (Mr A)'s capacity by old age psychiatry staff who visited him at home and while he was an in-patient at University Hospital Crosshouse. She was also concerned that the assessment of the level of care Mr A required was unreasonable.

We took independent advice from a consultant in old age psychiatry. We found that Mr A's capacity had been assessed regularly and that the assessments themselves reached reasonable conclusions. Therefore, we did not uphold Ms  C's complaints. While we found that the assessment of Mr A's care requirements was appropriate, it was noted that Ms C and her family appeared to have received somewhat confusing information from social work staff regarding the level of care needed. We provided feedback to the board on this matter.

Summary

Mr C complained about the treatment he received from the prison health care service and from the hospital he attended. In particular, he was concerned about the treatment he received for both a hand injury and hip pain, withdrawal of medication and how his complaint was handled.

We took independent advice from a consultant orthopaedic surgeon and from a GP adviser. Mr C said that he had not received reasonable and appropriate treatment in relation to an injury to his hand. We found that the treatment Mr C had received when he attended the accident and emergency department about the injury had been reasonable. Mr C was also referred to an orthopaedic consultant in another board for a second opinion. However, we found that there had been an unacceptable delay in supplying Mr C with a physiotherapy exercise ball in relation to the injury. Therefore, we upheld this aspect of his complaint. We noted that the board had already apologised for this.

Mr C also complained that the board had failed to provide reasonable and appropriate treatment in relation to his hip pain. Whilst there had been a delay in informing Mr C of the result of a scan, this had been carried out by another board and it was their responsibility to act on this. We found that the treatment Mr C had received from the board for his hip pain had been appropriate. We did not uphold this aspect of his complaint.

Mr C complained that the board had withdrawn his medication after he was found to have too many tablets in his possession. We found that the prison health care service's actions in relation to this matter had been reasonable. We did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board had failed to deal with his complaints adequately. Mr C had made a large number of complaints, but we found that there had been a significant delay in responding to one of the complaints. Therefore, we upheld this aspect of his complaint.

Recommendations

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

• The board should ensure that physiotherapy equipment that has been approved for prisoners is provided within a reasonable timescale.

In relation to complaints handling, we recommended:

• Staff should be aware of the timescales for responding to complaints.

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 has type 1 diabetes and needed a consultant-led maternity unit for the delivery of her baby. The board (Board 1) have a service level agreement (SLA) with another health board (Board 2) for the provision of specialist care, which meant Ms C would deliver her baby there. Ms C asked Board 1 if she could instead deliver her baby at a hospital in a different board area (Board 3), where she would have access to greater support from her family. Board 1 refused this request as they did not consider there to be any clinical need for Ms C's care to be transferred to Board 3. Ms C complained that this decision was unreasonable and was taken without consideration of her individual needs.

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy, childbirth and the female reproductive system), who was critical that the initial decision was taken at senior midwife level with no apparent medical input. The board indicated that treatment outside the SLA can be approved when there are deemed to be compelling clinical grounds. We were of the view that they should, therefore, have a more robust process in place to fully assess individual medical needs. Medical input was later obtained, but only when Board 1 investigated the complaint. This showed that Ms C's consultant physician was becoming concerned that the stress from the situation was impacting on her health and diabetic control. We considered that these ongoing and developing medical reasons might reasonably have led Board 1 to reconsider their position.

We considered the reasonableness of Board 1's overall refusal, further to Ms C's complaint and their review of the position. We considered that Board 1 had not provided sufficient evidence that they took full account of all Ms C's relevant medical needs (which we noted had evolved with the passage of time). Ms C subsequently registered as a patient in Board 3 and delivered her baby there. We found that Board 1 had sent a letter to Board 3 regarding her diabetic care but her obstetric information did not appear to have been passed on despite the clearly noted requirement for a carefully planned delivery. Overall, we considered that the board unreasonably refused to request for Ms C's maternity care to be transferred to Board 3 and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to take full account of all her relevant clinical needs when refusing her request to deliver her baby in Board 3; and for failing to formally transfer all of Ms C's clinical information to the team when she decided to register as a patient there. 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 board should ensure that they have a robust process in place for considering future requests for out of area maternity referrals, ensuring that patients' clinical needs are fully considered at an appropriate level and in partnership with the patient.
• The board should ensure that all relevant clinical information is passed on to the appropriate hospital when they become aware that out of area maternity care is being delivered to one of their patients, especially where the need for a specialist care plan has been identified.

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 provided to her mother (Mrs A) by the practice. In particular, Mrs C complained that the practice unreasonably failed to re-start Mrs A's diuretic medication (medication that can help reduce fluid build-up in the body which occurs when the heart is not functioning properly) which had been stopped in hospital. Mrs C felt that this resulted in a deterioration of Mrs A's longstanding heart condition. Mrs C complained that the practice unreasonably failed to liaise with Mrs A's cardiologist in this regard. Mrs C also raised concerns about the decision to commence Mrs A on anti-depressant medication. Mrs A was subsequently reviewed by a consultant geriatrician (a doctor who specialises in the medicine of the elderly) who restarted the diuretic medication and stopped the anti-depressants.

We took independent medical advice from a GP. We found that there was no evidence that Mrs A's diuretic medication should have been restarted earlier, or that the practice missed any significant signs of deteriorating heart failure. We also took independent advice from a consultant geriatrician on the timescale for restarting this medication. They explained that restarting diuretic medication is difficult to balance as restarting too soon can worsen dehydration, but leaving it too late can worsen the heart condition. The adviser considered that Mrs A's diuretic was restarted within a reasonable timeframe. We also found that an earlier cardiology review was not indicated, and that there was not a failure by the practice to liaise with Mrs A's cardiologist. As such, we did not uphold these aspects of Mrs C's complaint.

In terms of the decision to prescribe anti-depressants, we found that Mrs A had indicated that she was feeling low and anxious and that, as such, the prescription was not unreasonable. We did not uphold this aspect of the complaint. However, the GP adviser said that the medical records kept by the practice were sparse in detail and were not consistent with the General Medical Council's Good Medical Practice (GMC GMP) guidance on record-keeping. We made a recommendation regarding this.

Mrs C also complained about the practice's handling of her complaint. The practice accepted that they did not respond to the complaint within the required timescale, and they explained that there were exceptional circumstances which contributed to this delay. We found this explanation reasonable, however, we considered that their eventual response to Mrs C's complaint lacked detail and thorough explanation. We upheld this aspect of Mrs C's complaint. We were satisfied with the remedial action already taken by the practice to address the identified complaints handling failings, however we noted that their website could provide more information about their complaints handling procedure, and so we made a recommendation in relation to this.

Recommendations

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

• Medical records should be consistent with GMC GMP guidance on record-keeping, and the practice should familiarise themselves with this guidance, available at: https://www.gmc-uk.org/guidance/good_medical_practice/record_work.asp.

In relation to complaints handling, we recommended:

• The practice should provide more information on their website about their complaints procedure.

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 on behalf of his wife (Mrs A) that the ambulance service unreasonably failed to dispatch an ambulance following an emergency call and that they did not handle his complaint reasonably.

Mrs A had been diagnosed with a tumour at the rear of her brain and was waiting for an operation. Mr C said that Mrs A was told to call the emergency services if she experienced certain symptoms. When Mrs A subsequently experienced these symptoms, Mr C called the emergency services and spoke to a call handler who referred Mrs A to NHS 24. Mr C was unhappy that the ambulance service failed to dispatch an ambulance following the emergency call.

We took independent advice from a consultant in emergency medicine. We found that the information reported during the emergency call did not confirm that Mrs A had an immediately life-threatening condition, which would have required the dispatch of an ambulance as an emergency. The adviser noted that the decision to refer the call to NHS 24 in order to get a more detailed assessment of the situation by a clinically trained person was reasonable. We found that the decisions taken by the ambulance service were reasonable and therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, we found that the ambulance service had performed a detailed audit of the emergency call and that the member of staff involved had appropriately reflected on the call. We were satisfied that the complaint investigation carried out was reasonable and that the response to Mr C addressed the points he had raised. We did not uphold this aspect of Mr C's complaint.