Health

Summary

Mrs C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the communication with Mrs B's husband (Mr A). Mr A suffered some stroke like symptoms and his GP referred him to the hospital for a scan to check if he had had a stroke or transient ischaemic attack (TIA or 'mini-stroke'). A doctor discussed the results of the scan with Mr A in an appointment at the TIA clinic, about two weeks after his initial symptoms. It was recorded that Mr A was at risk of a further stroke, and the doctor recommended that he take medication to reduce this. Mr A suffered a further stroke some months after this, and later died. Mrs B said that Mr A never told her about the results of the scan, and she queried whether he had fully understood this, given he was suffering from confusion. Mrs B felt it was unreasonable for the doctor to share this information with Mr A at an appointment he attended alone, and not with her.

We took independent advice from a consultant in general medicine and medicine for the elderly. We found that Mr A's confusion was temporary and that there was nothing in the records to suggest he was not able to understand the information given or that he needed support during the appointment. We did not uphold Mrs C's complaint. We noted that the board had said that they had learned from the complaint and that they were changing the appointment letters for this clinic to suggest that patients may wish to bring someone with them.

Summary

Ms C complained that the board unreasonably failed to identify her hip fracture. Following a referral to Ninewells hospital, Ms C was reviewed by a consultant orthopaedic and trauma surgeon who considered that she had strained a ligament in her knee. She was then referred for physiotherapy for mobilisation and rehabilitation. Ms C was reviewed over the following months and developed progressively worsening pain. A subsequent x-ray identified a hip fracture.

We took independent advice from a consultant orthopaedic surgeon and a physiotherapist. Ms C noted that no x-ray was performed at the consultation with the surgeon. The board said that an appropriate examination was carried out, and that this examination gave no indication that an x-ray was required. The orthopaedic surgeon adviser said that the examination was not recorded in sufficient detail in Ms C's medical record, and that it provided inadequate evidence that a hip fracture was excluded.

Ms C also raised concern about the subsequent physiotherapy appointments. The physiotherapist adviser considered that, throughout the physiotherapy sessions, there were indications that the initial diagnosis of ligament strain of the knee may have been incorrect. We found that there was a failure to re-evaluate the situation in light of Ms C's increasing pain and deteriorating mobility. We considered that this contributed to the delay in identifying the hip fracture. Finally, we found that there was failings in recording of assessments and pain scores during these appointments. However, we noted that the board had acknowledged this failing and had taken steps to address this.

Overall, we found that the board unreasonably failed to identify Ms C's hip fracture and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for unreasonably failing to identify her hip fracture and for the failings in record-keeping.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:

• Staff should carry out full and appropriate examinations and assessments, and record these in contemporary 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 complained about the care and treatment his late father (Mr A) received at Perth Royal Infirmary (hospital 1). Mr A was suffering from a chest infection and was also experiencing periods of delirium. Mr A was discharged from hospital 1 to a community hospital (hospital 2) in another health board area, but they refused to admit him due to his condition and he was transferred by ambulance to another hospital (hospital 3). Mr A was later admitted to hospital 2, where he died a short time later. Mr C complained that the decision to discharge Mr A from hospital 1 was unreasonable and that there was an unreasonable delay in replacing his hearing aids which were lost during his admission.

Mr C raised concerns that hospital 1 had treated Mr A for a chest infection, and hospital 2 also identified a chest infection. Mr C therefore considered that Mr A was discharged from hospital 1 with an unresolved infection and he questioned whether this was appropriate. We took independent medical advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that Mr A's observations were stable leading up to his discharge from hospital 1. We did not consider that there was any evidence to suggest Mr A was not fit for discharge. We noted that Mr A quickly developed a further infection but we did not consider that this was identifiable, or could reasonably have been predicted, at the time of discharge. Therefore, we did not uphold this aspect of Mr C's complaint. However, the adviser noted that there was no evidence of medical staff having formally assessed Mr A's delirium using a recognised screening tool and we therefore, made a recommendation regarding this.

In relation to the hearing aids, the board apologised to Mr C for the loss of these. In responding to our enquiries, they offered a fuller explanation of the steps followed in replacing them. We found that the timescale described for replacing the hearing aids was typical for such a process. Therefore, we did not uphold this aspect of Mr C's complaint, but we were critical of the level of explanation offered to Mr C when responding to his complaint. We provided some feedback to the board in this regard.

Recommendations

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

• Medical staff should formally assess patients' delirium using a recommended screening tool, such as those recommended by Healthcare Improvement Scotland.

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 that his father (Mr A) received at Perth Royal Infirmary following a fall. Mr C was concerned that a fracture was not identified until Mr A had been in hospital for eight days. Whilst in hospital, Mr A also suffered a period of delirium. Mr C complained about communication issues and the way that Mr A had been transferred between wards at the hospital. Finally, Mr C also considered that the board had not handled his complaint reasonably.

We took independent advice from an emergency department consultant, an acute care consultant and a nursing adviser. We found that there was no documentation of an examination of Mr A's neck in the emergency department. As the x-rays that were taken had been difficult to interpret, further action should have been taken to rule out fracture, or clear reasons should have been recorded for not doing this. We considered that there were opportunities to diagnose the fracture at an earlier stage. In regards to Mr A's delirium, we found that the care he received was reasonable, although there was some areas where practice could be improved.

In relation to communication issues and transfers within the hospital, we found that nursing notes indicated that Mr A was in pain but that this information did not appear to have been shared with medical staff. We also found that Mr C had not been kept properly updated regarding Mr A's moves within the hospital. We noted that Mr A's moves had been reasonable however, on one occasion, he was transferred during a meal which was inappropriate.

In relation to complaints handling, we found that the board had not addressed Mr C's concerns about the delay in diagnosing Mr A's fracture in their response and that Mr C was not kept appropriately updated during the complaints process.

We upheld all of Mr C's complaints. However, we noted that the board identified some failings in their consideration of this case and had apologised for these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in diagnosing the fracture; for not fully addressing his concerns; and for not keeping him updated during the complaint process. 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:

• Medical staff should keep comprehensive medical records.
• Where x-rays are inadequate, consideration should be given to further imaging or discussion with the on call radiologist. If this is not considered necessary, the rationale should be clearly documented in the medical records.
• There should be a mechanism in place for nursing staff to make medical staff aware of issues with continuing pain. Consideration should be given to unitary records and reviewing how nursing/medical staff communicate during formal handovers.
• Consider the adoption of Health Improvement Scotland's 'Think Delirium' as a means to try to reduce delirium in hospital and manage it appropriately, particularly liaising with relatives.

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, who works for an advocacy and support agency, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's wife (Mrs A) at Gilbert Bain Hospital. Mrs A had pancreatic cancer and when she was admitted to hospital she could not eat. She was later assessed for palliative surgery (surgery which provides relief, but not a cure) at a different hospital, and was ultimately unable to have this surgery. Mr B felt that the reason his wife could not undergo the surgery was because she was not given adequate nutritional support (the giving of nutrients, either intravenously (directly into a vein) or by drip feeding through a tube placed in the digestive system) at Gilbert Bain Hospital.

We took independent advice from a consultant physician. We found that it was reasonable not to give Mrs A nutritional support until a decision was made to assess her for palliative surgery at the second hospital. Therefore, we did not uphold the complaint. However, we found that there were discussions between the two hospitals that were not recorded, so we made a recommendation to address this.

Recommendations

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

• Medical staff should maintain records of verbal conversations with staff at other hospitals in the medical 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

Ms C complained about the care and treatment provided to her late partner (Mr A) by the ambulance service. She felt that the service should have taken Mr A to hospital when they attended him and he was unwell with diarrhoea, because several days later Mr A was diagnosed with a perforated duodenal ulcer (when the lining of the stomach splits due to a sore).

We took independent advice from a consultant in emergency medicine who is involved in the training of paramedics and who works alongside them in the provision of pre-hospital care. We found that the ambulance service appropriately assessed Mr A and reasonably contacted an out-of-hours GP to further assess Mr A. We did not uphold this complaint.

Summary

Mrs C complained that her late husband (Mr A) had been taken to the wrong hospital by the ambulance service. Mrs C explained that, when Mr A became ill, she recognised signs of a stroke and called an ambulance. She said she thought that, according to the protocol in place at the time, Mr A should have been admitted to the Hyper Acute Stroke Unit at a particular hospital. He was taken to a different hospital and Mrs C felt that this had had an impact on the treatment he was given.

We took independent advice from a paramedic. We found that, on the basis of the information given by Mrs C in the emergency call, the ambulance crew should have suspected a stroke and on this basis should have taken Mr A to the stroke unit at the hospital where Mrs C thought he should have gone. We, therefore, upheld this complaint. We noted that the ambulance service had carried out stroke education since the events of this complaint; however we recommended that they carry out an audit to confirm that patients are being taken to the correct hospital. We also noted that the ambulance crew had failed to document a test they carried out, and we made a recommendation on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for unreasonably taking Mr A to the hospital they did, rather than the specialist stroke unit elsewhere.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:

• Tests carried out by ambulance crews when attending a patient should be documented.
• In similar situations, suspected stroke patients should routinely be taken to the Hyper Acute Stroke Unit, as opposed to the local emergency department in line with protocol.

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 provided by the ambulance service to her mother (Mrs A). Miss C raised concerns that the ambulance crew did not handle Mrs A's transfer to hospital appropriately. In particular, that she had been dropped in the vehicle and that she had bruising on her back. Miss C also complained that the ambulance services' investigation and response to her complaint were unreasonable.

We took independent advice from a registered nurse who is experienced in moving and handling issues. We found that based on the paramedic records, staff undertook the handling and transfer of Mrs A appropriately. Therefore, we did not uphold this aspect of Miss C's complaint.

In relation to complaints handling, we found that there was no evidence of factual inaccuracy in the complaints response from the ambulance service, and that they had apologised for the delay in providing the response. Therefore, we did not uphold this complaint.

Summary

Following an x-ray of her spine, Mrs C's GP made a referral for a DEXA scan (dual-energy x-ray absorptiometry scan - a scan which is used to measure bone density). This referral, and a further referral, were rejected by the board as Mrs C did not meet the criteria. Mrs C was unhappy with this decision and complained to the board. The board said that because DEXA uses ionising radiation and they were required to assess whether the radiation detriment was outweighed by the benefit of receiving the scan. The board said that the referral criteria require a patient to have a predicated fracture risk of 10%, and since Mrs C's calculated risk was lower than this she did not meet the referral criteria.

We took independent advice from a general medical adviser. We found that the board's referral criteria were based on appropriate national guidance, and we were satisfied that it was reasonable not to offer Mrs C a DEXA scan as she did not meet the criteria. We did not uphold the complaint.

Summary

Mr C, who is a solicitor, complained on behalf of his client (Mr A) about the treatment Mr A had received from the prison health centre. Mr A was assaulted and suffered a broken jaw. Some months after this, he started experiencing headaches. Mr A attended a number of GP consultations and his pain relief medication was adjusted at various points as a result. When Mr A suggested that the prescribed medication was not effective, he was referred to neurology (a branch of medicine that looks at the brain and nervous system) and had a scan. The results of this came back as normal and Mr A continued to be treated through adjustments to his pain relief medication. Mr C complained that the pain medication provided to Mr A was not reasonable or appropriate.

We took independent advice from a GP adviser. We were satisfied that Mr A had been treated in line with General Medical Council and World Health Organisation best practice guidelines. We found that the medication prescribed had been appropriate.

The board acknowledged that they did not pass on Mr A's scan results to him and apologised to him directly for this. They also outlined steps that they had taken to ensure this didn't happen again. We were satisfied that the fact that Mr A was not provided with his scan results had no impact on the treatment provided or medication prescribed. On balance, we did not uphold the complaint.