Health

Summary

Mr C, who is an MSP, complained on behalf of his constituent (Mr A). He said that the board had failed to provide Mr A with reasonable care and treatment in relation to blisters, fluid, diabetes, constipation and ventilation whilst he was in Hairmyres Hospital. Mr C also complained that that the day after Mr A was discharged, he was admitted to another hospital with renal failure.

We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that Mr A did not develop renal failure as a result of the treatment he had received in hospital. He had chronic kidney disease and this was a longstanding problem that was worsening. Based on his blood tests on admission and discharge as well as what was documented in the notes, we found that it had been likely that he would end up on dialysis (a form of treatment that replicates many of the kidney's functions). That said, Mr A did not seem to be fully aware of this and we brought this to the board's attention.

We also found that the care and treatment Mr A received in relation to blisters and fluid management was reasonable and that there was no evidence in the records to indicate that he was ignored by staff when he informed them of developments regarding his health. In their response to Mr A's complaint, the board had apologised that he was given sugar with his drinks and had stated that they had asked the hostess to review her protocol in relation to this. They had also apologised that one of Mr A's laxatives was not prescribed, although we found that Mr A had received other laxatives and that his constipation had been alleviated. In addition, the board had apologised that he found the temperature in the ward uncomfortable.

On balance, we did not consider that the overall care and treatment provided to Mr A in the hospital had been unreasonable, particularly in relation to the most severe areas such as renal failure. We accepted there were some areas of care that the board acknowledged fell short of expectation, particularly in how some aspects of his care were communicated, but we considered that the board's response to these was reasonable and the steps they took to address the issues were what we would have asked them to do to prevent recurrence. On balance, we did not uphold Mr C's complaints.

Summary

Ms C complained on behalf of her daughter (Miss A) about the care and treatment she received from her psychiatrist. Miss A has a diagnosis of bipolar affective disorder (a mental health condition marked by alternating periods of elation and depression) and received care and treatment from the board's Child and Adolescent Mental Health Services for a number of years. Miss A was later transferred to general adult services under the care of a consultant psychiatrist, who met with Ms C and Miss A on three separate occasions. Ms C complained that the treatment Miss A received during this period was unreasonable. Ms C's concerns related in particular to treatment decisions, management plans, communication and attitude.

We took independent advice from a psychiatrist. We found that the consultant acted reasonably in relation to treatment decisions and management, and that, while there was evidence that one of the consultations was challenging for all concerned, there was no evidence that communication was of an unreasonable standard. Therefore, we did not uphold this complaint. However, we made recommendations to the board in regards to record-keeping and the transition from adolescent to adult services.

Recommendations

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

• The board should ensure that adequate records are made of important meetings and filed in patients' medical records.
• The board should improve communication by providing more information about frequency of reviews and expectations, and consider scheduling more frequent reviews to help patients adjust to adult services in similar cases.

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, an advocacy worker, complained on behalf of her client (Mr B) regarding the care and treatment of his late father (Mr A). During an admission to Hairmyres Hospital, Mr A was assessed and deemed not to meet the criteria for hospital-based complex clinical care (HBCCC), as it was considered that his needs could be met in a nursing home. He was transferred to Stonehouse Hospital for interim care while awaiting completion of a community care assessment. Before a transfer to a nursing home could be arranged, Mr A died. Mrs C complained that the decision to transfer Mr A to another hospital was unreasonable as he was not well enough and that the hospital was not equipped to meet his needs. Mrs C also complained that the decision that Mr A was fit to be discharged to a care home was unreasonable. Finally, Mrs C felt that communication with Mr B surrounding the transfer and fitness for discharge decisions was poor.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the hospital was equipped to meet Mr A's need and that the need for acute hospital care was not indicated. In particular, we noted that the medical input into Mr A's care following the transfer was reasonable. Therefore, we did not uphold this aspect of Mrs C's complaint.

In regards to the decision to discharge Mr A to a care home, we found that a second opinion was arranged by the board. This was followed by a formal appeal of the decision, both of which maintained that the criteria for HBCCC was not met. We found that this decision was reasonable. We did not consider that Mr A's subsequent deterioration and death suggested that there had been a requirement for HBCCC. Therefore, we did not uphold this aspect of Mrs C's complaint.

Finally, we found that there was appropriate communication with Mr B in advance of Mr A's transfer between hospitals. We noted that the initial communication following the transfer was good, with medical staff having met with Mr B to explain the HBCCC criteria and their views on why Mr A did not meet this. However, while the outcome of Mr B's subsequent appeal was verbally communicated to him within a reasonable timescale, he had to request formal written confirmation of this and there was an unreasonable delay in this being provided. We considered that the board need to clarify their process for formally communicating the outcome of HBCCC appeals. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

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

• The board's HBCCC appeals process should make clear how decisions will be formally communicated to appellants, including the timescale for doing so.

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 she received at Wishaw General Hospital. Her concerns included that the consultant failed to initially list her for a colonoscopy (examination of the bowel with a camera on a flexible tube) as intended, and she was subsequently listed for a gastroscopy (examination of the gullet and stomach with thin, flexible telescope) in error. Ms C said that this error was not identified until the day of the procedure, despite her having called up in advance to query it. She said that the consultant did not contact her at any stage with an explanation of her results or treatment plan. Ms C also said that the consultant discharged her from their care as a result of her having submitted a complaint to the board. Although Ms C was later advised that they would arrange for one of their colleagues to see her instead, she heard nothing further.

We took independent advice from a consultant gastroenterologist (a doctor who specialises in the digestive system). We found that the board failed to list Ms C for a colonoscopy and later listed her for a gastroscopy in error. We also found that this error was not identified until the day of the procedure. We noted that a letter from the consultant to Ms C, requesting a stool sample, failed to explain the reasoning behind the request and inform Ms C of the findings and of a further management plan.

We also found that the consultant unreasonably discharged Ms C from their care and failed to ensure safe transfer of the necessary information on her case to a colleague, in line with the correct guidelines. We considered that the board then failed to take appropriate action when this was raised with them. Therefore, we found that the care and treatment Ms C received was unreasonable and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for sending a letter requesting a stool sample that contained inadequate information; unreasonably discharging her from their care; and failing to ensure safe transfer of the necessary information on her case to a colleague.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 be accurately listed for endoscopic procedures and the steps for this process documented. Phone contact by patients about listed procedures should be documented, tracked, and where appropriate, acted on.
• Essential patient information on care and treatment should be provided to the patient. Patients should be discharged from care in line with the correct guidelines. Patients should have the safe transfer of the necessary information on their case to another consultant.

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 and Miss B complained to us about the care and treatment their uncle (Mr A) had received from the board. Mr A had been admitted to Monklands Hospital with shortness of breath. He was discharged from hospital three weeks later. Miss C and Miss B complained that it had been unreasonable to discharge Mr A at that time because of his immobility and a lack of adequate discharge arrangements.

We took independent advice from a consultant in acute medicine. We found that Mr A had been medically fit for discharge, although there were some concerns about how he would manage. Although we found that, ideally, there should have been additional support in place for Mr A when he was discharged, we did not consider that the discharge arrangements the board put in place were unreasonable. On balance, we did not uphold this aspect of the complaint.

Miss C and Miss B also complained about the care and treatment Mr A received from both medical and nursing staff at his home when his condition deteriorated. We found that the care and treatment provided to Mr A, including treatment for an infection, had been reasonable. We did not uphold this aspect of the complaint.

Mr A was subsequently readmitted to hospital and died there two days later. Miss C and Miss B complained to us about the standard of care and treatment provided to Mr A in hospital before his death. We found that there had been a short delay in communicating Mr A's deterioration to his family and that the timing in relation to asking the family to complete a document about his interests and preferences at the time he was deteriorating was inappropriate and insensitive. However, we found that the care and treatment provided to Mr A had been reasonable and appropriate. It was also reasonable that he was not transferred to the intensive care unit. In view of this, we did not uphold this aspect of the complaint.

Summary

Mrs C, who works for an advocacy and support agency, complained about the care and treatment that her client (Mrs B)'s adult son (Mr A) received from the board's mental health services. Mrs B and Mr A had been told that Mr A had an assumed borderline personality disorder and that, as part of his treatment, he would attend a specified cognitive behaviour therapy programme. However, the decision was taken that Mr A should attend another course which caused Mr A and his family great distress and they felt that the staff had not diagnosed his condition appropriately. Subsequently, Mr A was reassessed by a consultant psychiatrist as having an Emotionally Unstable Personality Disorder (EUPD) and was placed on the original specified cognitive behaviour therapy programme. The family felt that there was an undue delay in the diagnosis of EUPD.

We took independent advice from two mental health advisers and found that Mr A had been seen by a number of clinicians in mental health over an extended period of three years. We found that, although Mr A had displayed some traits of EUPD, no formal structured assessments had been completed which would have led to an earlier diagnosis of EUPD. We found that this was contrary to national and local guidance. The assessments which were carried out during the period lacked detail and consistency. They concentrated on current symptoms, rather than someone taking on collective responsibility and arriving at a diagnosis of EUPD by carrying out a structured assessment using recognised tools. We also found that there was a failure by the board in arranging for Mr A to receive a second medical opinion which had been requested by one of the consultant psychiatrists. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B and his family for the unreasonable delay in reaching a diagnosis of EUPD and for not arranging a second medical opinion. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should familiarise them themselves with relevant guidance for personality disorders.
• Staff should ensure that requests for a second medical opinion are actioned.

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 GPs at the practice. Ms C complained that GPs incorrectly diagnosed a viral illness, and that they should have recommended hospital admission at an earlier point.

We took independent advice from a GP. We found that, on the two occasions that GPs from the practice attended Mr A, they assessed and examined him reasonably and that, based on this, the diagnosis of viral illness was reasonable as there was no evidence of any more serious cause of Mr A's illness. We did not uphold this complaint.

Summary

Ms C complained about the care and treatment provided to her late partner (Mr A) by an out-of-hours GP and at Belford Hospital. She complained that the GP did not reasonably assess Mr A and that, when he was later admitted to hospital, there was a delay in diagnosis which resulted in no treatment options being available for his perforated duodenal ulcer (when the lining of the stomach splits due to a sore).

We took independent advice from a GP and a consultant physician. We found that the care and treatment provided to Mr A by the GP was of a reasonable standard and that his symptoms were most fitting with a diagnosis of viral illness at this time. We also found that, whilst there was some delay in diagnosing Mr A when he was admitted to hospital (which the board had acknowledged), this did not have any impact on Mr A's outcome as, due to his other illnesses, surgery would not have been an option for him. We did not uphold this complaint.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms A). Over the past twenty years Ms A has suffered from balance issues and problems with her eyes. Over a period of years, Ms A attended the ophthalmology (eye) and neurology (brain and nervous system) departments of Raigmore Hospital. Her symptoms were assessed and investigated and she was referred for a second opinion, but no causes were found for her symptoms. The ophthalmology department decided not to arrange further appointments for her and it was suggested that she attend the rehabilitation clinic. Ms A considered that clinicians had given up on her and that she had been disbelieved. Ms C complained to us that the decision to discharge Ms A to the rehabilitation clinic was unreasonable, as she had not yet been diagnosed.

We took independent advice from consultants in ophthalmology and neurology. We found that all of Ms A's care and treatment had been reasonable and appropriate but that, despite this, Ms A's symptoms remained. It was acknowledged that this was very challenging for her, however we considered that the absence of a diagnosis or abnormal test findings did not mean that she had been disbelieved. Furthermore, we found that it was sensible and reasonable to refer her to the rehabilitation clinic which was best placed to deal with her continuing condition. We did not uphold the complaint.

Summary

Ms C complained about maternity care and treatment she received at Raigmore Hospital in relation to her labour and birth. Ms C had previously had a caesarean section and had planned a vaginal delivery for this birth. Ms C went to the hospital as her waters had broken, however, she was not experiencing contractions. She was admitted and the following day, a drip was administered to augment her labour. Ms C's labour progressed with continuous monitoring of the baby's heart rate. When this dropped, the drip was stopped and Ms C had an emergency caesarean section to deliver her baby. During the operation, it was discovered that a scar from a previous caesarean section had ruptured. Ms C complained about the care she received as she considered that she was left too long without action after her waters had broken and that the drip had not been prescribed at a safe level, given her previous caesarean section. Ms C was also concerned about the board's handling of her complaint as there were delays and inaccuracies in the final response.

We tookindependent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the risks and benefits of vaginal delivery following caesarean section had been discussed during Ms C's pregnancy. We found that the care and treatment Ms C received was in line with local protocols and national guidance. We did not uphold this aspect of Ms C's complaint. However, we made a recommendation that the board consider recording that the Royal College of Obstetricians and Gynaecologists leaflet on birth options after previous caesarean section is provided to patients like Ms C.

Regarding complaints handling, we found that during the board's own consideration of the case, they apologised that there had been delays in Ms C's complaint reaching the appropriate team, although we were unable to determine the reason for the delay. We found the board's final response was open to misinterpretation in terms of the timeline and plan for Ms C's care. We also noted there was an inaccuracy in relation to the rate that Ms C's drip was administered at. We upheld Ms C's complaint about the way the board handled her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the inaccuracies in the final response to Ms C's complaint. 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:

• Consider ensuring (and documenting) that the Royal College of Obstetricians and Gynaecologists Patient Information Leaflet on Birth Options After Previous Caesarean Section has been provided to patients to confirm that the risks and benefits have been appropriately shared.
• The final response to complaints should be clear, accurate and easy to interpret.

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.