Health

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 Mrs A's complaint to the board was originally made on her behalf by an MSP.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.

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.