Health

Summary

C complained about the care and treatment that they received during their labour and delivery of their baby (A). In particular, C complained that the standard of care and treatment they received had been unsafe, that there had been a lack of communication in relation to their requested position during labour, the use of forceps and the provision of pain relief. C also complained that they had been unable to give their informed consent for the use of forceps.

The board, when responding to C’s complaint, accepted that some aspects of C’s care did not meet the standard that they would expect in terms of communication and C’s requested positioning throughout the labour and delivery of A. As a result of C’s complaint, the board had shared the complaint with the midwifery staff responsible for C’s care. The board asked them to reflect on C’s experience and consider ways of improving care for the purpose of providing person centred care. The board also accepted that they had failed to arrange C's postnatal review clinical appointment. The board said they had taken action to review and amend the process for appointing consultant led postnatal follow-up. The board indicated that, while the event had not been recorded as an adverse incident and a Datix (an incident/risk management reporting system to collect and manage data on adverse events) had not been submitted, a review had been carried out and action had been taken as a result of that review.

We took independent advice from a consultant obstetrician (a doctor who specialises in care during pregnancy, labour and after birth). We found that during C’s labour there were significant periods of loss of contact (LOC) during the recording of the foetal heart rate. However, we also found that, while labour would have been complicated by the LOC there was no evidence that C or A were put at risk. We also found that the actions of staff during this period were reasonable and proportionate to the needs of C and the clinical circumstances which occurred at the time. We found that safe care and delivery had been provided to C. However, we also found that there had been a material change in C’s birth plan and that there had been a failure to communicate these changes with C.

The board accepted that there was no documentation in the medical records of a discussion with C in line with Royal College of Obstetricians and Gynaecologists guidance on obtaining verbal consent on assisted vaginal births. We found that obtaining consent is an important aspect when providing care and treatment to a patient, and completing the appropriate documentation is a professional standard. The event should have been recorded as an adverse incident and a Datix should have been submitted. We upheld the complaint and provided feedback to the board in relation to the use of the adverse event process and the submission of a Datix.

Recommendations

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

• Patients should receive clear explanations and appropriate information where there are changes to their birth plan. Where discussions have taken place with a patient, this should be documented.
• Staff should be aware of the relevant Royal College of Obstetricians and Gynaecologists (RCOG) guidance on documenting consent.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate and address all aspects of the complaint.

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

C complained about the care and treatment provided to their spouse (A). C said that the board’s actions or inactions caused unnecessary suffering and stress to A and their family through misdiagnosis of A’s condition, poor administration of treatment, and failure to provide care in a proper manner whilst following health and safety guidelines.

We took independent advice from a consultant radiologist, consultant in emergency medicine and a consultant oncologist.

We found that, overall, the board provided reasonable care and treatment to A, there were no avoidable delays in A’s diagnosis, and the care and treatment prior and after their diagnosis was reasonable, with the exception of a case of poor documentation on a particular admission and poor communication in relation to A’s diagnosis. We did not uphold the complaint.

Summary

C complained about the care and treatment they received from the board in relation to an incident of extravasation (the leakage into surrounding tissue of medication administered intravenously) of chemotherapy into their arm. C told us that following the incident, their arm became painful and swollen and that they were left with loss of function in their hand and arm, despite being referred to the board's orthopaedic, plastic surgery and physiotherapy departments for further treatment. C considered that the aftercare they had received had been unreasonable and that there had been a lack of diagnosis in relation to the injury to their arm. C also complained about the attitude of nursing staff after the incident, which they felt lacked compassion.

The board told us that extravasation is a known risk of chemotherapy treatment but that once the extravasation was noticed, chemotherapy treatment was stopped immediately and that attempts were made to aspirate the fluid from C's arm. The board also noted that C was reviewed by an on-call plastic surgeon, all in accordance with their extravasation policy. The board acknowledged that, while C was subsequently seen by specialist in orthopaedics and physiotherapy, their recovery appeared to be slower than would normally be expected and that the long term implications were unclear.

We took independent advice from an oncologist and a nurse. We found that the board's response to the extravasation incident, both immediately and in the months that followed, was in keeping with their extravasation policy and established good practice. However, on review of the available documentation, there was no evidence to show that nursing staff had completed the necessary hourly checks of C's peripheral vascular cannula (through which the chemotherapy was administered) or that the extravasation incident had been discovered as a result of monitoring by nursing staff. This was unreasonable and contrary to professional nursing standards in relation to record-keeping. For this specific reason, we upheld C's complaint. However, there was no evidence within C's clinical records to confirm that the attitude of nursing staff had been poor.

We also found failings in the board's handling of C's complaint and made recommendations under our powers to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the complaint handling failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All relevant staff should be trained in and be aware of the relevant guidance in relation to PVC insertion, monitoring, maintenance and removal; and the completion of the relevant PVC monitoring documentation (this should include reference to the NMC Code Section 10). There should be a reliable method of ensuring that a PVC chart/aide memoire/policy/guideline is included in each patient's record as required. Relevant documentation should where appropriate be marked “N/A” if the sections are not required, so it is apparent that they have not just been missed.

In relation to complaints handling, we recommended:

• The board should comply with their complaint handling guidance when investigating and 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

C complained about the practice's care and treatment of their parent (A) who died as a result of sepsis several days after being admitted to hospital. According to the death certificate, one of the underlying causes of A's death from sepsis was an infected grade four sacral ulcer (an injury that breaks down the skin and underlying tissue, grade 4 is the most severe type) that had been there for several months.

C complained that in the period preceding admission to hospital, GPs from the practice never assessed A's sacral ulcer, despite C's requests for them to do so. C complained about a house visit consultation carried out by a GP (GP1) when the family suspected A may have sepsis. They complained about GP1's decision to prescribe oral antibiotics even though A was known to have swallowing problems. C also complained about the GP's refusal to assess the ulcer visually and their decision not to arrange admission to hospital. C also complained about a telephone consultation a few days later, in which a GP (GP 2) declined to carry out a house visit and arranged admission to hospital on a non-urgent basis.

We took independent advice from a GP. We accepted GP1's clinical assessment that oral antibiotics were appropriate. However, we were critical of GP1's failure to record observations during the house visit, noting that in the absence of these records it was not possible to establish the basis on which GP1 concluded A did not have sepsis. We found it unreasonable that GP2 declined to carry out a house visit or arrange urgent admission to hospital, even though this may not have changed the ultimate outcome for A. We found there were omissions in the records in relation to anticipatory care/palliative care planning. There was also a lack of recorded discussions with A's family. Taking all of this into account we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family in writing for each of the failings identified in our investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• GPs should take and record observations where appropriate. GPs should review a grade 4 ulcer if requested to do so, with District Nursing support as required. GPs should carefully consider house visit requests where concerns about sepsis are raised. GPs should ensure record-keeping meets a reasonable standard. Where appropriate, anticipatory care plans/palliative care plans should be in place, documented and discussed with relevant parties. GPs should ensure patient records contain summaries of discussions with key family members and other health care staff.

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

C complained that their spouse (A) was not properly assessed by Scottish Ambulance Service (SAS) paramedics and should have been conveyed to hospital, as they had a high temperature, was struggling to breathe, had a fever, a cough and a NEWS2 score of 5 (the system used to identify acutely ill patients). C felt paramedics dismissed A's high temperature due to the temperature in the room and that A should have been given oxygen. C also complained about SAS's handling of their complaint. SAS considered the assessment by paramedics was reasonable.

We took independent clinical advice from a paramedic. We found that while it was reasonable that paramedics did not administer oxygen, the paramedics did not follow the advice provided in the SAS Clinical Guidance for COVID-19 v5.0 guidelines, as A met the criteria for a referral to the Covid Hub and this was not considered by paramedics. We found paramedics did not appear to have considered or acted on warning signs for sepsis and there was no documented rationale for the decision to downgrade the NEWS2 score. We also found that the initial investigation and complaint response was lacking in detail and explanation.

As such, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology.

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

• Patients presenting symptoms should be appropriately assessed, taking into account relevant SAS guidance. The presence of warning flags for sepsis, including NEWS2 scoring, should be appropriately assessed and acted on taking into account relevant guidance. If a decision is made not to act on warning flags or NEWS2 scoring in accordance with relevant guidance the reasoning for this should be recorded in the clinical documentation.

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

C complained about the care and treatment their grandparent (A) received when they were admitted to hospital. A was acutely unwell with a poor prognosis and was treated in the COVID-19 ward for a number of days. A's condition improved and they were discharged home. C complained that A did not have capacity to consent to treatment and that treatment to address A's confusion made their symptoms worse. C believed that clinicians failed to clearly communicate the treatment plan for A, that it was unreasonable for clinicians to focus on end of life treatment and that staff failed to meet A's basic needs.

In response to the complaint, the board explained that A was admitted with possible aspiration pneumonia and COVID-19. They said A was treated for COVID-19 and with antibiotics and that the care and treatment in this regard together with the assessment of A's capacity, was appropriate. Nursing staff gave A regular oral hygiene, but due to high flow oxygen therapy this was difficult. Appropriate assessment and treatment was undertaken with respect to A's skin.

We took independent advice from a consultant geriatrician (specialist in care and treatment of the elderly) and a nurse. We found that whilst many aspects of A's care were reasonable and of a standard expected, there was a significant failure with respect to the assessment of A's delirium. We also found that there were significant failures with respect to the level of personal care provided to A. Therefore, we upheld C's complaints relating to medical and nursing care and treatment.

In relation to communication with C and their family, we found that the records documented an appropriate level of communication with respect to decisions made about A's care. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to handle their complaint reasonably. We found that there was discrepancies and apparent inaccurate information contained in the board's response. Therefore it was reasonable to conclude that the board failed to carry out a reasonable investigation and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failure to handle and respond to the complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and A for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Staff to be compliant with HIS (2020) Prevention and Management Standards. All staff assessing pressure ulcer risk fully understand the risks and are able to put in place measures and equipment to minimise risk. Staff completing care rounding able to identify that patients at risk of pressure damage must have their position changed and not nursed in the same position for 24 hours.
• Relevant staff are familiar with the adult with incapacity process and the importance of delirium screening tools with patients where delirium is observed and evident.
• Staff responsible for undertaking oral care are trained and competent in assessing oral hygiene requirements, carrying out oral hygiene and accurately documenting this in the records.
• To ensure a person centred approach to assessment of continence and appropriate prescribing of continence management products.

In relation to complaints handling, we recommended:

• Complaints handling staff to be familiar with the complaints handling procedure. Clinical staff to be aware of the significance and importance of a thorough consideration of clinical records and reflecting on these in an open and transparent manner when offering responses to specific aspects of complaint.

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

C complained about the care and treatment provided to their late partner (A) who was admitted to hospital with hallucinations and delirium. C complained that hospital staff labelled A an alcoholic and that this negatively impacted the treatment that they received. A was treated for a suspected urinary tract infection (UTI) but died in hospital. C was critical of several aspects of the treatment A received, including concerns about their nutritional intake, the medication they were given and the staff's response to the rapid deterioration of A's condition.

In their response, the board apologised that C had been given the impression that staff felt the only cause of A's delirium was alcohol excess. The board explained A's clinical presentation and the reasoning for treating them for suspected UTI and alcohol withdrawal. The board explained A's condition rapidly deteriorated in hospital and resulted in a cardiac arrest. The board's position was that the care provided was reasonable.

We took independent advice from a consultant in respiratory and general medicine. We found that a reasonable working diagnosis of a possible infection was determined and the treatment plan was appropriate. We considered that the care and treatment provided was reasonable. Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the board's out of hours (OOH) service. A was experiencing worsening symptoms of disorientation, fatigue and abdominal pain. C telephoned NHS 24 and received a call back from an OOH GP who arranged for an ambulance to attend A's home. Paramedics examined A and called the OOH service who agreed that an OOH GP would carry out a home visit to A. Paramedics left the house and the OOH GP attended shortly afterwards. Upon examination, A was found to have a mild fever and fast heart rate, with all other observations recorded as normal. The OOH GP prescribed antibiotics. A died a few days later.

We took independent advice from a GP. We found that it was an appropriate course of action to request a paramedic assessment upon receiving C's initial call to the OOH service. We also found that given the observations of the paramedics and the OOH GP, it was appropriate to treat and manage A at home and to take into consideration that A's own GP practice would be open some four hours later. Therefore, we did not uphold C's complaint but did provide feedback to the board in relation to the GP's record-keeping.

Summary

C's late parent (A) was referred by their GP to the board's ear, nose and throat (ENT) department on urgent suspicion of cancer. A's referral was originally vetted and agreed as urgent. In response to the COVID-19 pandemic, significant operational changes were made by the board resulting in A's referral being re-vetted and downgraded to routine the following month. Due to worsening of their symptoms, A contacted the board and it was agreed that A required further investigation by barium swallow (a test to look at the outline of any part of the digestive system). However, as an aerosol generating procedure, these procedures had been suspended by the board and A did not undergo the test until six month's after their initial GP referral. Following the barium swallow and further investigations, A was diagnosed with oesophageal cancer.

C complained that the care and treatment provided by the board to A had been unreasonable, noting the delays in investigating A's primary symptom of dysphagia (interference with the swallowing mechanism). C also considered A's age had negatively impacted the decision-making in respect of the investigations and treatment options they were offered, and they advised that A had not known until a month after their barium swallow that cancer had even been considered as the likely cause of their symptoms.

We took independent advice from a consultant ENT surgeon. We found that the referral to ENT should not have been downgraded to routine when it was re-vetted given A's symptom of dysphagia. On being seen at the ENT clinic, it was reasonable to refer A for a barium swallow at this stage but only if it had been done urgently. In A's case, the time between the request being made and their appointment was four months, which we considered was unreasonable in light of oesophageal cancer being recorded as a possible differential diagnosis on the referral form. We did not find that A's age had negatively affected the treatment options available to them. On the matter of when A became aware of their diagnosis or knowing that they were being investigated for cancer, we could not find any evidence to reasonably determine what was known or understood by A about the cause of their symptoms at the time. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in investigating and treating A's symptoms. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Evidence that the findings of this investigation have been fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding vetting processes.
• Patients referred with urgent suspicion of cancer symptoms should be appropriately assessed, taking into account 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

C complained that the board failed to adequately investigate and/or treat their late spouse (A)'s condition by failing to follow up their appointment at a gynaecological clinic.

A experienced abdominal pain and heavy menstrual bleeding. A's GP referred them to a gynaecology clinic. A attended the clinic and was referred for a scan. A was then discharged back into the care of their GP. A year later, A's GP referred them to gynaecology under a suspicion of cancer. A was subsequently diagnosed with endometrial cancer (a type of cancer that begins in the uterus). A was given various cancer treatments but later died.

C complained to the board about A's care and treatment. The board acknowledged that A's care was not to the standard it should have been. They accepted that the gynaecology clinic had failed to follow local treatment guidance in A's case. They apologised for this. C remained unhappy and asked us to investigate. C was concerned that the board had failed to adequately explain events.

We took independent advice from a gynaecologist. We found that the board had failed to follow their local clinical guidance in A's case. We welcomed the board's acknowledgement of this failing and their apology. However, given the significance of the failings identified we made additional recommendations for action by the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow the relevant clinical guidelines in A's case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Where local guidance varies from national guidance there should be appropriate review to ensure the variation has been adequately documented and controlled and diagnostic criteria and terminology is clear and appropriate. In undertaking the review we would encourage the board to consider our comments on the simplification of the local guidance and structure of its flowchart.
• Patients with heavy menstrual bleeding should receive appropriate care and treatment in line with the relevant clinical 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.