Health

Summary

C spent time in hospital for their mental health. C complained about how the board had managed their prescriptions and about the lack of treatment for their physical symptoms of migraines and hand/arm injuries.

We took independent advice from a consultant psychiatrist adviser. We found that C’s perspective was recorded in contemporaneous notes, that they had requested a change of medication and that their doctor agreed to the trial of an alternative. C’s consent was regularly sought and this was good practice. The evidence suggested that C’s reports of physical symptoms were also properly investigated and that C was offered appropriate pain relief for their migraines. As such, we did not uphold the complaints.

Summary

C complained about the care and treatment provided to their late parent (A). A underwent surgery to treat hypertension (high blood pressure). A few days later, A’s condition deteriorated with the cause thought to be sepsis (a life-threatening reaction to an infection). A’s condition worsened further and they were transferred to the High Dependency Unit (HDU). A died later that day.

C complained that there had been a failure to administer antibiotics that A had required and that there had been unreasonable delays in transferring A to the HDU, which resulted in A being left in a state of distress. C also complained about the conclusions that the board had reached about A’s care following a Significant Clinical Investigation (SCI).

The board stated that A had been monitored every 30 minutes and that there had been no delay in providing antibiotics to A. The board accepted that there had been a failure in communication between nursing and porter staff which had led to a delay in A being transferred to HDU. However, the board considered that this would not have resulted in a different outcome although it was acknowledged that this would have reduced A’s family’s distress.

We took independent clinical advice from an acute medicine and nursing adviser. We found that there were a number of failings in the care provided to A following the initial deterioration in their condition. This included failure to initiate tests to identify sepsis, failure to commence intravenous fluids (medical technique that administers fluids, medications and nutrients directly into a person's vein) and failure to perform necessary blood tests, as had been outlined by A’s consultant. There was also no evidence that A had received antibiotics nor had been monitored with the frequency stated by the board. We also found that nursing staff failed to escalate a further deterioration in A’s deterioration and that there had been an unreasonable delay of around two hours in transferring A to HDU. In addition, we found that several aspects of the nursing records fell below the professional standards required by the Nursing and Midwifery Council and that the board’s SCI had failed to identify areas of learning arising from this case. For these reasons, we upheld this complaint.

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 available at www.spso.org.uk/information-leaflets.

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

• Significant Clinical Incident reports should:
• (i) be reflective and learning processes that consider events against relevant standards and guidelines,
• (ii) ensure failings are identified and any appropriate learning and practice improvements are made and,
• (iii) be in line with Learning from adverse events through reporting and review - A national framework for Scotland: December 2019 (healthcareimprovementscotland.org)
• Treatment plans should be comprehensive and document the working diagnosis. Patients should receive the treatment plan recorded in the medical records following consultant review unless there is a change of plan. If this happens this should be clearly recorded.
• Where the cause of a patient’s deterioration is suspected to be due to sepsis, the sepsis bundle should be initiated.
• Patients should be assessed, in accordance with the NEWS guidance relative to the patient's NEWS score. Where there is deviation from this, this should be recorded. In addition, patients who are assessed to have a NEWS score of five or greater should be escalated urgently for further assessment in line with NEWS guidance. NEWS scoring documentation should be fully completed and recorded.
• For patients where there is the presence of red flags indicating an ECG, this should be acted on without delay.
• Where blood tests are requested in order to investigate a deterioration in patient's condition they should be processed and reviewed as soon as possible. Patients should receive the appropriate blood tests to adequately assess the cause of deterioration and any tests that have been specifically requested by clinicians.
• Where a deteriorating patient requires to be transferred from the ward for more intensive treatment, the transfer should take place as soon as possible and without undue delay. A record should also be made showing which member of staff has requested the transfer, the time at which the transfer was requested and to whom the request was made.
• Nursing records should be documented in real time, as far as it is reasonably practicable to do so. They should also include a clear timeline of events, the actions taken by nursing staff (including in what order) and details of all communication with relatives and other healthcare professionals.

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 actions taken by Borders NHS board in relation to diagnosing their child (A) with attention-deficit hyperactivity disorder (ADHD, a condition that affects people's behaviour, including restlessness and impulsiveness). C said that A’s initial referral was rejected and when an assessment did take place it failed to diagnose A’s ADHD. Requests for second opinions were then refused. C said that A was diagnosed with ADHD but not until some years after the initial referral and this was an unreasonable length of time.

We took independent advice from a consultant child and adolescent psychiatrist. We found that while the initial refusal of the referral and first assessment were reasonable, the decision to refuse the request for a second opinion and further assessment was not. This led to an unreasonable delay in diagnosing A with ADHD. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings 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:

• Where a request for a second opinion is made and the initial assessment demonstrated some indicators of a developmental disorder e.g. ADHD, then a second opinion should be carried out, particularly for developmental disorders where changes may have occurred in the intervening time period.

In relation to complaints handling, we recommended:

• Responses to complaints should be clear and accurate.

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 on behalf of their sibling (A) about the care and treatment that they received during a hospital admission. A had a cannula (a thin tube inserted into a vein or body cavity to administer medication, drain off fluid, or insert a surgical instrument) fitted which then became infected and caused them to develop sepsis (an infection of the blood stream). C complained that A had requested the cannula be removed sooner and that this was declined. C also complained that A had advised staff that they felt unwell and that this was not taken seriously, and also that their medication had not been properly managed.

We took independent advice from a consultant in acute internal medicine. We found evidence in the medical records that A declined to have the cannula removed. There is no other documentary evidence from the time about A either refusing, or requesting, to have the cannula removed. We found that the care and treatment provided was reasonable.

We also found that A's medication had been properly managed and that they did not note any failings in the communication with A and their family. We did not uphold this complaint.

Summary

C complained about the care and treatment that their child (A) received from the board. A had an autistic spectrum disorder (ASD) diagnosis and a history of treatment through the board's Child and Adolescent Mental Health Service (CAMHS). A was placed on an urgent waiting list for further assessment and treatment. A was assessed and was assigned medication and individual therapeutic work. Following a number of appointments, A was discharged from the individual appointments, was seeking support in the community and was supported with accommodation.

C reported concerns about A's behaviour, including an incident where they set a mattress on fire. A subsequently attended another appointment thereafter.

C complained that professionals failed to respond adequately to an escalation in A's behaviour which should have prompted an urgent appointment. C also complained that a later appointment did not result in a reassessment of A and the support that they required. In response to the complaint, the board said that there was no evidence of any new psychiatric symptoms that required urgent assessment, and that the later appointment was appropriate with a plan for A agreed at the time.

We took independent advice from a mental health services specialist. We found that appropriate assessments were completed following C's reports of concerns about A's behaviour. We found that the decision not to carry out an urgent psychological review was reasonable and that the records showed a thorough and detailed assessment was carried out at the later appointment. We found that the conclusions reached were reasonable. As such, we did not uphold the complaints.

Summary

C complained about the care and treatment provided to their partner (A). A had been suffering from an extended period of constipation which the District Nursing Team had attempted to treat at home. A's GP referred them to hospital for further treatment. A died following a fall in hospital.

C raised a number of concerns about the GP's assessment of A's condition and the decision to refer them to hospital. C said that the GP should have visited A at home, should have considered alternative treatments at home, and that the GP made assumptions about A's wishes and condition. C believed that there were no grounds for admitting A to hospital and that the GP's actions led directly to A's death.

We took independent advice from a general practitioner adviser. We found that the care and treatment provided to A was of a reasonable standard. It was not a requirement for the GP to visit A at home prior to referring them for admission. The admission had been discussed with C, and the decision to refer A for hospital admission was a reasonable clinical judgement for the GP to make in the circumstances. The GP's referral had acknowledged C and A's wishes for resuscitation to be attempted and the advice did not consider that there was an unreasonable focus on this in the admission.

We found that the care and treatment provided to A was reasonable and that the practice had acted appropriately when considering and responding to C's concerns. We did not uphold C's complaints.

Summary

C complained on behalf of their deceased grandparent (A) about care and treatment provided by the board during an admission to hospital following a fall and broken hip. C complained that A received poor nursing care, poor rehabilitation support, had not received enough nutrition and fluids, and had developed necrotic (dead) tissue on the back of their heels. C also complained that communication with the family and the incident management response had been unreasonable.

We took independent advice from a nursing adviser. We found that pain relief, personal care and rehabilitation support had been appropriate. However, we found that there was no evidence that assistance was provided with eating and drinking, and that fluid and nutrition charts had been poorly completed. We also found that the pressure sores on A's heels were poorly managed, that there were significant gaps in repositioning and that effective preventative measures were not appropriately implemented.

We found that information given to the family was insufficient and incorrect. We also found that the incident management response was unreasonable, as the necrotic heels were not deemed to be serious avoidable harm and therefore no serious adverse event review or duty of candour was undertaken. We therefore upheld C complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not offering sufficient support with eating and drinking and for not preventing and treating the pressure ulcers on A's heels appropriately. 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 for not recognising the seriousness of the incident and the avoidable harm caused. 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 for providing incorrect and incomplete information about their grandparent's condition. 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:

• Nursing staff are aware and correctly implement HIS Pressure Ulcer Prevention Standards 2020 (including introducing 2 hourly repositioning, therapeutic mattress and skin protection at the point that skin becomes red). Nursing staff know how to correctly diagnose and grade pressure ulcer damage (including “ungradeable”), correctly follow CPR for feet guidelines (such that they make timely referral to a Tissue viability specialist) and develop person centred treatment plan for the pressure ulcer. Nursing staff provide relevant handover information and relevant equipment such as therapeutic mattress and boots when moving a patient between wards.
• Nursing staff should ensure that fluid balance and MUST charts are completed to a reasonable standard. The board should also be reassured that they have appropriate processes in place to monitor performance in this area.
• That a duty of candour review is considered in the light of the SPSO findings.

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 sibling (A) had not received appropriate care and treatment from their GP practice in relation to symptoms of an infection. C felt the on-call GP failed to arrange for A to be admitted to hospital and that the practice failed to see and examine A, who died the following day of sepsis (an infection of the blood stream).

C also complained that they were unable to access the practice, and that the practice failed to follow its emergency protocol. As such, C complained that the practice had failed to provide reasonable care and treatment to A. The practice considered the care and treatment provided to A had been reasonable.

We took independent advice from an experienced GP adviser. We found that it was reasonable for the on-call GP not to admit A to hospital as this was a decision for the Scottish Ambulance Service (SAS) to make and paramedics expressed no concerns. It was also reasonable for the practice to not examine A as they had already been assessed by the Out-of-Hours Service, the District Nurse and paramedics.

However, we fund that the practice failed to follow the emergency protocol and C and A were unable to access the practice. We also found that the practice's handling of C's complaint was unreasonable due to the quality of investigation carried out. Therefore, on balance, we upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow the emergency protocol when they attended in person to seek an appointment for A. 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:

• For SAER's to be carried out within prescribed timescales.
• Patient Problem Lists should be appropriately summarised with major diagnoses and events to be included.

In relation to complaints handling, we recommended:

• For administrative staff to be reminded of their duty of candour.
• For all complaints to be dealt with empathetically and sincere apologies provided.

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 made a complaint about the care and treatment provided to their late spouse (A) by the board. C was concerned that A had sepsis (an infection of the bloodstream) at the time of their discharge. C considered that A would not have died had they remained in hospital.

We took independent advice from a consultant in geriatric medicine (a doctor who specialises in treating older patients) and general medicine. We found that there was a failure to properly assess A's blood and urine test results prior to their discharge. Had this been done, there would have been a greater likelihood that infection could have been diagnosed and treated prior to A's discharge from hospital. Although A may still have died had they remained in hospital, this could have given A a better chance of surviving their illness.

We found that there were failures in communication with A's family. A's family should have been provided with 'safety netting' advice about repeating A's temperature or looking for other potential signs of infection once A had returned home. We also found that there were failings in the board's handling of C's complaint. The board's own complaint investigation did not include all relevant staff for comment, the response was brief and did not provide fully accurate information in relation to A's condition.

In light of the above, we found that the board failed to provide A with reasonable medical care and treatment. We upheld C's complaint.

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 available at www.spso.org.uk/information-leaflets.

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

• Patients whose test results are suggestive of an underlying infection should be fully and appropriately investigated, in line with recognised guidelines. When a patient is discharged, appropriate 'safety netting' advice about worsening condition should be provided.

In relation to complaints handling, we recommended:

• The board's complaints handling system and their investigation should ensure that relevant staff have the opportunity to comment, that complaint responses appropriately address the issues raised and are accurate and that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

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 to the board about several aspects of the care and treatment provided to their parent (A) during their time in hospital and also about the discharge planning on each occasion.

A was diagnosed with terminal cancer and was in hospital for treatment before being discharged home. A was later readmitted to hospital with illness. A was discharged home again and later died.

The board's position was that the discharge planning for A on each occasion was appropriate. There was discussions about what supports could be offered, and it was frequently documented that A's wish was to be at home. Discharge plans were discussed on a daily basis.

With respect to the care and treatment provided to A during the second admission, the board commented that A was being treated for a chest infection and apologised if C was not aware of A's chest infection. The board said that there was no indication to replace the nasogastric tube (tube used to deliver food or medicine to the stomach for people who have difficulty eating or swallowing).

We took independent advice from a consultant geriatrician (doctor who specialises in treating older patients) and from a registered nurse. We found that the care and treatment provided to A during their admission was reasonable. We also found that given A's condition and prognosis, the decision that A was suitable to be discharged was also reasonable. We did not uphold the complaint about care and treatment.

With respect to the planning made for A's discharge home, we found that the planning on each occasion was reasonable. On A's first discharge from hospital, appropriate assessments were carried out and discussions documented about supports which could be put in place for A's return home. It was documented that these were declined by A.

With respect to the second discharge, whilst there was no formal discharge plan, given A's prognosis and assessment that they were independent and requesting to go home, it was reasonable to discharge A.

Whilst we determined that the arrangements for A's discharge were reasonable, and did not uphold these complaints, we provided feedback to the board with respect to the absence of some records which we would have expected to see and/or be updated more regularly.