Health

Summary

Ms C complained that the practice unreasonably removed her from the patient list. Ms C had had concerns about the treatment which she had received from the practice previously but these had been dealt with under the complaints procedure. Ms C was surprised to subsequently receive a letter from the NHS practitioners services advising her of the decision taken by the health board to remove her from the practice patient list due to a breakdown in the professional relationship. Ms C then learned that the instruction to remove her came from the practice and that she had not been given an explanation as to how the practice had come to their decision.

We took into account the contractual regulations and relevant guidance regarding the removal of patients from the practice list. This sets out that, other than in cases involving violence or aggression, a patient whose behaviour is giving cause for concern should be given a written warning informing them that they will be removed from the practice list if they do not alter their behaviour. The warning should last for 12 months. While the practice did have concerns about Ms C's actions, and did discuss the issue with the health board, staff did not formally bring them to Ms C's attention in line with the regulations and guidance and therefore she was unaware of the practice's concerns. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for unreasonably removing her from the practice list. 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 be aware of and comply with the guidance and regulations where there are concerns about patient behaviour.

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 provided to his late relative (Mr A) at Dr Gray's Hospital. Mr A was admitted to hospital following a referral from his GP with raised body temperature/fever, an irregular heart rate and a high National Early Warning Score (NEWS - an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration). Mr A's condition deteriorated over a few days and he was transferred to the high dependency unit where he died a short time later. Mr C complained that the board failed to provide a reasonable standard of both clinical care and nursing care to Mr A. He also complained that the board failed to respond to his complaint in a reasonable way.

We took independent advice from a consultant in acute medicine and a nurse. Regarding Mr A's clinical care, we found that there was poor documentation by medical staff and a lack of concern to Mr A's deterioration and failure to improve. We noted that the severity of Mr A's illness may have been underestimated. Therefore, we upheld this aspect of Mr C's complaint. However, we noted that the board had identified failings and had taken steps to address these.

In relation to Mr A's nursing care, we found that there were no shortcomings in personal care of pain assessment and monitoring or blood sugar monitoring. However, we noted that nursing care in relation to fluid balance fell below a reasonable standard and that there were omissions in the recording of NEWS scores. Therefore, we found that the board failed to provide a reasonable standard of nursing care and upheld Mr C's complaint.

Finally, Mr C complained that he did not receive a response to his complaint from the board until approximately five months after he submitted it. We found that the board did not keep Mr C informed of their progress and that there was an unreasonable delay in responding to his complaint. We upheld this aspect of Mr C's complaint. However, we noted that the board acknowledged that there was an unreasonable delay and apologised to Mr C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for failing to provide a reasonable standard of clinical and nursing care and treatment to Mr A.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:

• Deteriorating patients should have their vital signs checked and the appropriate guidance followed when NEWS scores escalate.
• Fluid balance charts should be completed and used appropriately by nursing staff.
• When a complaint response takes longer than 20 days and/or amended timescales for completion are not met, the complainant should be kept updated on progress.

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 complained about the care and treatment given to her late father (Mr A) by the practice. Specifically that, during the three years prior to a diagnosis of a very rare form of cancer, there were failures to take action on his symptoms, not all tests that were due were carried out, and there were delays in making required referrals. Mrs C believed that this led to a delay in Mr A's diagnosis and affected his outcome.

We took independent advice from a GP. We found that Mr A had a history of dizziness and cardiology problems and he had a pacemaker. It was only after he had persistently raised white blood cells that a referral was made for him to attend hospital but, while the referral was agreed it was not sent for a number of months. Blood tests confirmed his white blood cell count and he was referred to haematology (medicine of the blodo) for further testing where his count was shown to be reduced. Nevertheless, we found that it would have been reasonable for the practice to have arranged repeat tests a few weeks later to ensure that his results had returned to a normal range, and this did not happen. An earlier diagnosis could perhaps have been made, but we could not conclude that an earlier diagnosis would have changed Mr A's outcome. Because of the the delay in making the referral and the failure to repeat tests, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for not arranging further follow-up tests and for the delay in the referral.

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

• In circumstances like this, follow-up blood tests should be arranged. GPs within the practice should ensure they are familiar with the condition Mr A had.
• Referrals should be sent 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

Mrs C complained about the care and treatment given to her late father (Mr A) after his GP referred him to the board for neurology treatment. Mr A had his first neurology appointment and the following month was diagnosed with a rare type of cancer. He was told that he would require no treatment. However, three months later he attended the emergency department at Forth Valley Royal Hospital with chest and abdominal pain and was admitted to the hospital. Mrs C complained about Mr A's care and treatment by both nursing and clinical staff, and about the lack of information she and her family were given. Mr A died some weeks later, and Mrs C said that the family had been unaware of the seriousness of Mr A's illness and its prognosis and, as such, they were shocked and unprepared for his death.

We took independent advice from consultants in emergency medicine and haematology (medicine of the blood) and from a registered nurse. We found that Mr A's emergency treatment had been reasonable and appropriate and that he was assessed and managed properly. Afterwards, when Mr A was admitted to the ward, the approach to his illness was watchful waiting. We found that his death could not have been anticipated. For these reasons we did not uphold the complaints about the care and treatment given to Mr A by clinical staff.

We did find that there had been some failures in his nursing care and that there were gaps and inconsistencies in his medical notes, and so we upheld Mrs C's complaint about nursing care. However, we noted that the board had already apologised and taken action with regards to these failings, and therefore we made no further recommendations in this regard.

While Mrs C was unhappy about the level of information given to her family, we were satisfied that they had been kept informed of Mr A's deteriorating condition, but that his imminent death could not have been foretold. On balance, we did not uphold this part of the complaint.

Summary

Miss C underwent cataract surgery at Falkirk Community Hospital and, during this operation, she suffered a leak of the fluid in her eye and her eye was stitched following surgery. A few years later, Miss C suffered a detached retina and underwent surgery for this. Following the surgery, Miss C's vision deteriorated significantly, and she subsequently had to have further surgery. Miss C was concerned that the stitching of her eye following her first surgery may have contributed to the detached retina, and she said that staff had commented at the time that they did not have the correct equipment on hand (but went ahead anyway). Miss C was also concerned that she had high pressure in her eye following the second surgery, and required to be readmitted a couple of days later. She felt that she should have been kept in hospital for longer for observation and queried whether this had impacted on the poor outcome of the surgery.

In response to Miss C's complaint, the board explained that the first surgery was complicated by zonule dehiscence (the breaking of the structures that hold the lens in place, which can cause fluid within the eye to come forward). The board said that this may have contributed to Miss C's subsequent detached retina, but that it was unlikely since the detached retina occurred a long time after the surgery.

We took independent advice from a consultant ophthalmologist (a doctor who deals with diseases and injuries to the eye). We found that Miss C suffered a recognised complication during her first surgery, which was appropriately managed, and that the decision to stitch her eye was reasonable. We also found no evidence that staff did not have the correct equipment for stitching the eye and, therefore, we did not uphold Miss C's complaint. However, we noted that there was no record of any discussion with Miss C to explain the complication that had occurred. Therefore, we made a recommendation to the board regarding this.

In relation to Miss C's second surgery, we found that the decision to discharge Miss C for follow-up in a few days was reasonable. Although Miss C had high pressure in her eye, this was not so high as to require continued admission and observation. We found that Miss C's poor vision was affected by the known risks of surgery rather than an outcome of her aftercare. Therefore, we did not uphold this complaint. However, we noted that when Miss C returned to hospital a few days later, staff did not measure her eye pressure and did not record why this was not done. We made a recommendation to the board regarding this.

Recommendations

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

• Where a complication has occurred in surgery, staff should inform the patient of this and clearly record this discussion.
• Where staff do not follow the standard practice, the reasons for this should be recorded.

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's child, (child A), was born with a cleft palate (an opening or split in the roof of the mouth that occurs when the tissue doesn't fuse together during development in the womb) which led to difficulties in breathing and feeding. After treatment at one hospital, child A was transferred to Forth Valley Royal Hospital. They were discharged 11 days later, however, Mr C had to return child A to Forth Valley Royal Hospital that night because they had been struggling to breathe since their discharge. Child A was admitted and within a few days they were referred to another hospital. Mr C complained that child A should not have been discharged from Forth Valley Royal Hospital given their medical condition at the time. Mr C also complained that the board failed to address his complaint in a reasonable way.

We took independent advice from a paediatrician. We found that the decision to discharge child A was reasonable given his medical condition at the time. There were no medical concerns noted in the days prior to their discharge and we considered that the board's actions were appropriate. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, we found that the board fully addressed Mr C's concerns. However, we found that there was an unreasonable delay in arranging a meeting and that there had been a lack of communication with Mr C regarding this. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to deal with his complaint in a reasonable way. 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:

• Meetings with complainants should be arranged within a reasonable time; complaint files should record any delays; and complainants should be told within a reasonable time of any alterations to the arrangements.

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 complained to us that the practice had failed to appropriately monitor her for any side effects of taking nitrofurantoin medication (antibiotic to treat urinary tract infections) for a number of years. She subsequently went on to develop pulmonary fibrosis (lung disease) and liver disease and she felt that these conditions were a direct result of the practice's failure to monitor her medication.

We took independent advice from a GP adviser and concluded that the practice had failed to appropriately monitor Mrs C's liver function and respiratory status over a number of years. The British National Formulary, which is the gold standard reference and guidance regarding medicines, has over the years highlighted advice and more recently issued safety alerts that patients on long term nitrofurantoin medication should be regularly monitored for liver function and respiratory function, although it does not state the frequency. In addition, Mrs C was exhibiting symptoms which are recognised complications of nitrofurantoin medication. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to monitor her medication.The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-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

Mr C complained about the practice regarding the handling and communication of decisions to reduce or remove three medications he was prescribed for chronic pain. The practice had taken steps to reduce these medications, as they considered a continued consumption of a high dosage of opiate medication was placing Mr C at risk of further health problems and addiction. However, Mr C was concerned that his pain was no longer being suitably managed and also that he was not adequately involved in the decision making process.

We took independent advice from a GP adviser. We found that the clinical decision to reduce the medications was correct, and in line with relevant guidelines. We were also satisfied that the decision to remove the prescription for one of the medications was reasonably handled and communicated. For this reason, we did not uphold the complaint about this prescription. However, we considered that the practice had failed to appropriately discuss the decisions to reduce the dosage of the other two medications with Mr C in advance of the reduction. As such, we upheld these two complaints.

Although we upheld the complaints we found that, in response to Mr C's initial complaints, it was clear that the practice had accepted the failings in question, apologised for them, and taken steps to ensure these mistakes would not be repeated. As such, we did not make any recommendations.

Summary

Ms C complained to us about the care and treatment that her late father (Mr A) had received from the practice. Mr A had attended the practice as he was feeling some discomfort in his chest after exertion and increasing fatigue. He was referred to hospital urgently for a chest x-ray. The GP also increased the dose of Verapamil (a medication used for high blood pressure and angina) Mr A was receiving. Mr A had a scan of his heart at the hospital approximately ten days later This showed valve disease in Mr A's heart, which can lead to heart failure. An appointment was made for him to see a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) and the Verapamil was stopped and his medication changed. Mr A's condition deteriorated and he returned to the practice several days after the hospital appointment. He complained of chest pain radiating to his back and said that he was no better with the new heart medication. The GP thought that this might be caused by gastric irritation and increased his medication for stomach acid. Mr A died from heart failure the following morning.

Ms C complained about the practice's decision to increase her father's Verapamil. We took independent advice from a GP adviser. We found that Mr A had been referred to hospital because it was considered that he had worsening angina. The GP had consequently increased Mr A's Verapamil, which is a recognised and common treatment for angina. The GP could not have foreseen the echocardiogram result at that time and, therefore, could not have foreseen that increasing the Verapamil was not the best treatment. Mr A's valve disease had not been caused by Verapamil, but is a condition that deteriorates over many years. We did not uphold this aspect of Ms C's complaint.

Ms C also complained that the GP did not examine Mr A's chest at the appointment after his hospital visit. We found that the GP should have examined Mr A, as he was complaining of persistent chest pains and had no improvement with cardiac medication, despite recent cardiology confirmation that he had developed new heart failure. We upheld this aspect of Ms C's complaint, although we were unable to say if an examination by the GP would have changed the overall outcome for Mr A.

Finally, Ms C complained that the practice had delayed in processing a medication request for Mr A. The practice had accepted that there had been failings in relation to processing this request and had apologised to Ms A for this. We also, therefore, upheld this aspect of her complaint. We made no further recommendations regarding this, but we asked the practice for evidence of the action they said they had taken.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to carry out an examination of Mr A. 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 be aware of the symptoms, signs and management of unstable angina and should carry out and record an adequate clinical assessment in appropriate cases in line with General Medical Council 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 to us about the care and treatment her later father (Mr A) received from the cardiology department at Victoria Hospital. Mr A had been referred to the hospital by his GP because he was feeling some discomfort in his chest after exertion and increasing fatigue. When he attended the hospital, Mr A had a scan. This showed significant impairment of the pumping function in his heart.

A letter from the hospital to Mr A's GP also referred to a significant recent increase in the frequency of his chest pain and a corresponding reduction in the amount of effort required to bring on these pains, along with recent chest pain at night. These are characteristic features of unstable angina (a coronary condition which can be predictive of an impending heart attack.) The hospital changed Mr A's medication and made an appointment for him to see a consultant cardiologist the following week. However, Mr A continued to have chest pain and died six days later.

Ms C complained that the cardiology department should have admitted Mr A to hospital given the findings at the initial appointment. We took independent advice from a consultant cardiologist. We found that it had been reasonable not to admit Mr A to hospital and we did not uphold the complaint. However, we found that the cardiology department should have given Mr A and his GP more information about his condition and its management. We made recommendations to the board in relation to this.

Ms C also complained that a doctor discussed the decision not to resuscitate Mr A whilst he was in a very critical condition. We recognised that this would have been distressing for the family, but given the seriousness of Mr A's condition, it had been reasonable to discuss the issue of resuscitation. We did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mr A with adequate information about his diagnosis and guidance as to what to do if he deteriorated whilst awaiting review. 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 given a diagnosis of unstable angina or severe but stable angina should be clearly informed of the diagnosis and should have clear guidance about what to do if their condition deteriorates whilst awaiting review. This information should also be shared with their GP.

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.