Health

Summary

Mr C complained to us about the psychiatric care and treatment his daughter (Miss A) had received from board staff. Miss A was subject to compulsory measures in a care home under mental health care legislation.

Mr C complained that the board had failed to consider the family's requests for Miss A to be moved to a different care home. We took independent advice from a consultant psychiatrist. We found that the board had acted reasonably in relation to the family's requests for Miss A to be moved. We found that the issue was discussed with the family and that attempts were made to identify and understand Miss A's views on the subject. We also found that the board had made reasonable efforts to listen to and respect the family's views. We did not uphold this aspect of the complaint.

Mr C also complained that the board had failed to provide Miss A with adequate psychiatric care while she was in the care home. He considered that this led to her admission to a psychiatric hospital. We found that there were no significant failings in the psychiatric care provided to Miss A in the care home. Her care plan had been reasonable and she had received adequate psychiatric care and supervision during the relevant period. Additional attempts to monitor or supervise Miss A would not have changed the outcome and board staff had acted reasonably in relation to this. Although we did not uphold this aspect of Mr C's complaint, we found that Miss A's records about her care plan were not of an adequate standard and we made a recommendation in relation to this.

Recommendations

Sector: health

Subject: clinical treatment / diagnosis

Decision: not upheld, recommendations

• Summary
• Mr C complained to us about the psychiatric care and treatment his daughter (Miss A) had received from board staff. Miss A was subject to compulsory measures in a care home under mental health care legislation.
• Mr C complained that the board had failed to consider the family's requests for Miss A to be moved to a different care home. We took independent advice from a consultant psychiatrist. We found that the board had acted reasonably in relation to the family's requests for Miss A to be moved. We found that the issue was discussed with the family and that attempts were made to identify and understand Miss A's views on the subject. We also found that the board had made reasonable efforts to listen to and respect the family's views. We did not uphold this aspect of the complaint.
• Mr C also complained that the board had failed to provide Miss A with adequate psychiatric care while she was in the care home. He considered that this led to her admission to a psychiatric hospital. We found that there were no significant failings in the psychiatric care provided to Miss A in the care home. Her care plan had been reasonable and she had received adequate psychiatric care and supervision during the relevant period. Additional attempts to monitor or supervise Miss A would not have changed the outcome and board staff had acted reasonably in relation to this. Although we did not uphold this aspect of Mr C's complaint, we found that Miss A's records about her care plan were not of an adequate standard and we made a recommendation in relation to this.
• Recommendations [1]

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

• Care plans in care programme approach documentation should be clear and the objectives should be focussed and specific, with responsible persons or agencies identified. There should also be a clear discussion of the outcomes of each objective recorded at each crae programme approach review. Where the board is working with another care provider, there should be a clear record of the discussion around care plan objectives allocated to such care providers and the attempts to meet these objectives.

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 to us that the practice had failed to provide appropriate care and treatment to her when she reported symptoms of altered bowel habit. When she was referred to hospital cancer specialists after a period of some months it was established that she had bowel cancer. Ms C belived that the practice should have referred her to the hospital cancer specialists earlier and that the diagnosis would have been reached sooner.

We took independent advice from a GP adviser and concluded that there were no delays in the practice making a referral for a specialist hospital opinion. Ms C had attended the practice on a number of occasions with a number of physical and psychological symptoms and initially it was felt that a referral to a respiratory clinician was appropriate. However, when Ms C continued to report different symptoms it was then appropriate for a referral to be made to the hospital cancer specialists. We found this to be reasonable and we did not uphold the complaint.

Summary

Mr C complained about the care and treatment his late mother (Mrs A) received at Queen Elizabeth University Hospital. Mrs A suffered from kidney failure. Mr C complained that her high blood pressure was not properly managed and that the care and treatment provided to her during three hospital admissions was not of a reasonable standard.

We took independent advice from a consultant nephrologist (a consultant who specialises in the kidneys). We found that Mrs A's blood pressure was managed appropriately, and that the care and treatment provided to her when she was an in-patient was reasonable. We did not uphold these aspects of Mr C's complaint.

Mr C also complained that a nurse did not provide him with an appropriate level of information when notifying him of his mother's admission to hospital. Based on the evidence available, we found that the level of information provided to Mr C was appropriate. We did not uphold this aspect of Mr C's complaint.

Summary

Ms C complained that the practice failed to provide a reasonable standard of medical care and treatment to her late father (Mr A). Mr A attended appointments at the practice over a period of two months. Mr A was initially referred to hospital by the practice to be assessed for deep-vein thrombosis (DVT, a blood clot that develops within a deep vein in the body) and was prescribed medication. The results of the ultrasound scan taken at the hospital did not indicate DVT and the medication was stopped, however, Mr A's condition deteriorated. He attended two more appointments at the practice but died of a pulmonary embolism (a blocked blood vessel in the lungs) a few days after his final appointment. Ms C said that the practice had failed to see that Mr A's symptoms indicated DVT and believed that his death could have been prevented. Ms C also complained that the practice failed to respond to her complaint in a reasonable way.

We took independent advice from a GP. We found that the medical care and treatment was of a reasonable standard based on the evidence provided and the information available to the practice at the time in question. We also noted that the practice fully addressed the issues raised and took account of the clinical evidence available when responding to Ms C's complaint. Therefore, we did not uphold Ms C's complaints.

Summary

Mr C complained that the prison healthcare centre's decision to stop his suboxone medication (medication used to treat opium addictions) was unreasonable. A prison nurse reported that Mr C appeared to act suspiciously when they were administering his suboxone medication. They did not consider that Mr C gave them an adequate opportunity to confirm that the medication had been taken correctly. His medication was subsequently stopped and he was later given methadone as an alternative opiate replacement therapy. Mr C disputed the nurse's allegation that he did not comply and brought his complaint to us.

We took independent advice from a GP. We found that Mr C's suboxone was stopped as prison healthcare staff felt that he had not complied with the instructions set out in the contracts. Mr C had signed two contracts in relation to medication and one of these declared that he understood he would be taken off suboxone if caught or suspected of concealing medication. Healthcare staff suspected that he was concealing medication and they were, therefore, entitled to act on that suspicion if they felt that there was a risk of clinical harm to Mr C and/or the good order within the prison. The adviser raised no concerns about the decision taken to stop Mr C's suboxone and we considered that this decision was reasonable in light of Mr C's suspected non-compliance. Therefore, we did not uphold this complaint.

Summary

Mr C, who works for an advocacy and support agency, complained on behalf of his client (Ms A) about the care and treatment she received at Royal Alexandria Hospital. Specifically, the complaint was about a procedure in which Ms A was given a femoral line (a tube placed by needle into a large vein near the groin) for pain relief. Mr C complained that Ms A was not given any warning or explanation before the procedure. Mr C also complained that it was not carried out properly, as Ms A found it extremely painful.

We took independent advice from a consultant in acute medicine. We found that Ms A should have been given alternative pain relief while medical staff prepared to insert the femoral line. We noted that Ms A's consent for the procedure was not properly obtained and/or documented. Finally, we found that the board had a checklist for carrying out this type of procedure but as it was not used, it was unclear if the procedure was carried out appropriately. Therefore, we considered that the board failed to provide Ms A with reasonable care and treatment and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for not giving her appropriate pain relief, for failing to obtain and/or document her consent appropriately, and for failing to document the procedure reasonably. 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:

• Adequate pain relief should be given to all patients.
• Information given verbally to a patient about a procedure should be documented (including the rationale for the procedure, any alternatives, the risks involved and what the procedure will entail), along with the outcome of the consent discussion.
• Femoral lines should be inserted using the appropriate technique, equipment and anaesthetic, which can be ensured by using the central line checklist.

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 mother (Mrs A) who was admitted to Glasgow Royal Infirmary's Acute Assessment Unit (AAU). Mr C complained that there was a delay in providing a bed for his mother. Mrs A's complaint to the board was originally made on her behalf by an MSP. Mr C also complained that the board's handling of this complaint was unreasonable.

We took independent advice from a consultant in acute medicine and from a nurse. We found that the care and treatment provided to Mrs A was reasonable. We noted that there is often a wait for a bed to become available in a hospital ward, so that a patient can be transferred to an appropriate ward from a unit such as the AAU. However, we found that it took six hours for Mrs A to be moved from a trolley to a bed in the AAU. Given Mrs A's age and several health problems, we considered that this delay was unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the board's complaints handling, Mr C said that there were errors in their response to the complaint that the MSP had made. We found that there was an error in Mrs A's name, however, this was the name used by the MSP when making the complaint. We noted that the board could have confirmed Mrs A's name with the MSP's office and used the correct name in their response. However, we found that, other than the error in Mrs A's name, the board's response to the complaint was reasonable and appropriate. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

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

• The board should consider whether the current prioritisation in the hospital's AAU for moving elderly patients with additional diseases from a trolley to a bed is appropriate, taking account of the relevant guidance.

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 by Southern General Hospital and Victoria Infirmary in relation to a diagnosis of follicular lymphoma (a type of blood cancer). Ms C had two appointments with extended scope physiotherapy practitioners (ESPs) within the orthopaedics department regarding pain in her shoulder which later developed a lump. She complained that the ESPs did not carry out reasonable assessments which resulted in a delay in her being diagnosed with lymphoma. Ms C also complained that after her diagnosis of lymphoma, there was a failure on the part of the haematologists (doctors who specialise in medicine of the blood) to investigate her reports of back pain appropriately, and that this turned out to be due to another lymphoma mass pressing on her spine. Finally, Ms C complained that the board failed to communicate reasonably with her regarding her condition.

We took independent advice from an ESP and from a consultant haematologist. We found that the ESPs failed to take a full history and assess for 'red flag' symptoms (symptoms which may be indicative of a serious illness such as cancer) when seeing Ms C. We also found that when Ms C was unable to tolerate a scan which had been arranged, no further attempts were made by the ESP to investigate the lump on Ms C's shoulder. We found that this resulted in a delay of around four months in Ms C being diagnosed with follicular lymphoma and we upheld this aspect of Ms C's complaint.

We found that the assessments and examinations by haematologists when Ms C was reporting back pain after her diagnosis of lymphoma were reasonable. However, there was a failure to make suitable arrangements to enable her to undergo a scan and this resulted in a delay in identifying the lymphoma masses pressing on Ms C's spine. Therefore, we considered that the care and treatment Ms C received following her diagnosis of lymphoma was unreasonable. We upheld this aspect of Ms C's complaint.

In relation to the boards communication with Ms C, we found that the clinic letters regarding her treatment were only sent to her GP. We considered that it would have been beneficial for these letters to be sent to Ms C as well in order for her to have a better understanding of her care and treatment. We also noted that it would have been beneficial for Ms C to have an identifiable key worker who could act as her first point of contact. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for unreasonably delaying in diagnosing her with follicular lymphoma; failing to provide her with reasonable care and treatment after she was diagnosed with lymphoma; and failing to communicate reasonably with her regarding her condition. 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:

• A full history, including assessment of red flag symptoms, should be taken by ESPs; and painful lumps or swellings should be scanned.
• When a patient is unable to, or finds it difficult to tolerate scanning, discussion should take place between departments and with the patient in order to make suitable arrangements for them to undergo necessary scanning.
• Haematology patients should be copied into clinic letters to their GPs.
• Haematology patients should have an identifiable key worker (either a named consultant or clinical nurse specialist) who serves as their first point of contact.

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 that staff at Queen Elizabeth University Hospital failed to provide her late mother (Mrs A) with appropriate medical treatment in view of her presenting symptoms. Miss C raised a number of concerns about Mrs A's treatment following her arrival at hospital, when she was thought to have new onset confusion due to a possible urinary tract infection or a stroke. Mrs A died six days later.

We took independent medical advice from a consultant in emergency medicine and a consultant neurosurgeon. We found that the emergency department staff failed to consider Mrs A's current medication during their assessment of her and failed to record her Glasgow coma score (detailing the level of consciousness in a patient), pupil response and blood sugar level. They also failed to record their decision and actions following receipt of Mrs A's blood clotting test and did not carry out a scan as part of the emergency department's assessment and evaluation of Mrs A. We found that there was a delay in the administration of Mrs A's Beriplex (a drug to help blood clot) and in a second scan being carried out. We also noted that there were discrepancies between the findings of the board's internal report on Miss C's complaint and the board's response to Miss C, resulting in her not receiving adequate explanations of what happened in Mrs A's case. Therefore, we upheld Miss C's complaint. However, we noted that the outcome in Mrs A's case was unavoidable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and her family for failing to carry out an appropriate assessment of Mrs A; failing to note relevant decisions and actions; the delay in administering Beriplex; the delay in carrying out scans; and failing to provide Miss C with an adequate response to her 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:

• In cases such as this, patient's existing medications should be considered in the emergency department; doctors in the emergency department should record key decisions/actions; an assessment and record should be made of patient's Glasgow coma score, pupil response and blood sufar level; and consideration given to carrying out a scan as part of the emergency department's assessment and evaluation of the patient.
• Medications should be administered in a timely manner.
• Patient deterioration should be appropriately recognised in circumstances such as this, and scans carried out 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

Ms C, an advocacy and support worker, complained on behalf of her client (Mrs B) regarding the care and treatment of her late husband (Mr A). Mr A was referred to the respiratory team at Inverclyde Royal Hospital with a worsening cough, and lung cancer was suspected. However, the diagnosis was not formally confirmed until a number of months later. Mr A was then informed that his condition was terminal and that he only had a few weeks left to live.

Ms C complained about the delay in diagnosing Mr A's cancer. Mr A was diagnosed with an empyema (a collection of pus between the lungs and inner chest wall) in the interim period and the board indicated that treating this became the priority. They said that delays caused by Mr A's impaired health meant that biopsies could not be carried out sooner.

We took independent medical advice from a respiratory consultant. We found that it was reasonable for the medical team to have focussed on the management of the empyema. It was noted that Mr A's case was discussed with the lung cancer multidisciplinary team on a regular basis. We considered that the cancer diagnosis was not unreasonably delayed and therefore, we did not uphold this part of Ms C's complaint. However, we found that there was a delay in commencing Mr A on antibiotics when an infection was identified following a bronchoscopy (a procedure that examines the inside of the lungs and airway). While we did not consider that this contributed to the delay in diagnosing the cancer, we made a recommendation in relation to this.

Ms C also complained that there was a lack of communication with Mrs B and Mr A by the medical team. We found that the medical records documented reasonable efforts by staff to communicate with both Mrs B and Mr A. However, the board reflected that their communication fell short of what they would expect. In particular, they acknowledged that sickness absence of key staff directly impacted on the level of support Mr A received. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for the unreasonable delay in commencing Mr A on antibiotic medication for the infection identified following the bronchoscopy procedure. 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:

• When test results identify the need for antibiotic treatment, medical staff should ensure that this is commenced within a reasonable timeframe.

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.