Health

Summary

Miss C complained about care and treatment provided to her late mother (Mrs A) at Queen Elizabeth University Hospital. Miss C complained that both the nursing and medical care and treatment provided to Mrs A were unreasonable.

We took independent nursing advice. We found that, whilst a number of aspects of nursing care and treatment were reasonable, there was a failure by staff to discuss continence issues with Mrs A. We also found that nursing staff failed to complete fluid balance documentation fully and accurately, and failed to appropriately complete pressure ulcer risk assessments. We also found that there were issues with infection prevention and control. We upheld Miss C's complaint about the nursing care and treatment provided to Mrs A.

We also took independent advice from a consultant physician. We found that some aspects of medical care and treatment provided to Mrs A had been reasonable, however we determined that the frequency of dosing of morphine (a pain relief medication) was unreasonable and failed to take into account Mrs A's kidney function. We also found that there was a failure to document Mrs A's adverse reaction to tramadol (a pain relief medication) appropriately. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to provide a reasonable standard of nursing and medical care and treatment to Mrs A. The apology should meet the standards set out in the SPSO guidance on apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• When a patient has continence issues, these should be discussed with them and their continence should be assessed. They should be assisted to manage any issues in a way that protects and promotes dignity, in line with the Nursing and Midwifery Code.
• Fluid balance charts should be fully completed when required.
• Pressure ulcer risk assessments should be completed when required.
• Infection prevention and control guidance, such as the Healthcare Improvement Scotland standards for Healthcare Associated Infections, and the National Institute for Health and Care Excellence quality statement on Vascular Access Devices, should be followed.
• Kidney function should be considered when prescribing morphine.
• If a patient suffers a reaction to medication, this should be documented.

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, who works for an advocacy agency, complained on behalf of her client (Ms A). Ms C complained that Ms A did not receive a reasonable standard of psychiatric care and treatment when she was admitted to the Royal Alexandra Hospital. Ms A had been unwell and when she was admitted to hospital a psychiatrist diagnosed her as suffering from anorexia nervosa (an eating disorder) and implemented a care plan. Ms C said that Ms A did not agree to all aspects of the care plan, which she felt was very restrictive and intrusive, and that the communication with her and her family about the severity of her condition and treatment decisions was unreasonable.

We took independent advice from a psychiatry adviser. We found that, while there were no failings in relation to the psychiatric assessment and treatment provided to Ms A, the board had failed to evidence that Ms A had fully consented to her treatment, and that there were failings surrounding the extent to which she was informed of the details of her proposed care plan. We were also concerned that such a restrictive and intrusive care plan was implemented when Ms A disagreed with it, and that it was not subject to mental health legislation which would have afforded protection to Ms A. As a result, we found that Ms A was likely to have experienced distress which may have a long-term impact on her future relationships with mental health professionals. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to evidence consent to treatment. 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:

• Care plans (in particular intrusive or restrictive care plans) should be fully explained to patients and relevant consent procedures should be followed and clearly documented.
• Professionals taking decisions about detention under the Mental Health Act should be mindful of de facto detention (where a patient feels under pressure to agree to admission to hospital or to remain in hospital, often because they feel threatened by the possibility of detention, and are, therefore, not giving valid consent to their stay in hospital) and should document their reasoning for their decisions (including consideration of the mental health legislation) clearly.

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 had been on a waiting list for a knee operation for a number of months and, despite the board telling him that he would undergo the operation within 12 weeks, it took approximately five months after Mr C was first put on the waiting list for him to have the operation. Mr C said this was contrary to the treatment time guarantee (12 weeks) and did not take into account his clinical need. Mr C had told the board he was willing to travel to any hospital in the UK to undergo the operation. Mr C said that, as a result of the board's failings, his physical and mental health had deteriorated. Mr C complained to us that the board failed to provide him with a knee operation within a reasonable time and that they failed to respond to his complaint in a reasonable way.

We took independent advice from an orthopaedic adviser. We found that the board's failure to meet the treatment time guarantee or consider other healthcare providers meant that Mr C suffered pain and discomfort for number of months, with implications for his emotional health as a result. We also found it unreasonable that, at times, Mr C had to take the initiative to find out what was happening once the 12 weeks treatment time guarantee period had passed. We were not satisfied from the evidence available that the board had reasonably had regard to the legislation concerning the treatment time guarantee, and we upheld the complaint.

In relation to complaints handling, we found that the board had wrongly told Mr C that it was not NHS policy to offer surgery outwith the health board area when the guidance around the treatment time guarantee is clear that one of the things health boards must do when the guarantee is breached is consider alternative providers within and outwith Scotland and the NHS. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide treatment within a reasonable time. 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:

• Identify any training needs to ensure staff fully understand the legislation and guidance around the treatment time guarantee, and its application.

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, who is an advocacy and support worker, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's wife (Mrs A) during her admission to the Royal Alexandra Hospital. Mrs A suffered two falls while in the hospital. Ms C complained that the standard of nursing care and treatment provided to Mrs A was unreasonable. We took independent advice from a nursing adviser. We found that, in general, the nursing care was reasonable and the action taken by nursing staff to assess and protect Mrs A against the risk of falls was reasonable. However, the advice we also received was that Mrs A should have been referred to the falls team earlier than she was and that one of the two falls had not been recorded on the computer system which is used to record clinical incidents, such as falls. This computer system is an important mechanism to record incidents so that learning and improvement can take place. On balance, we upheld Ms C's complaint about the nursing care and treatment provided to Mrs A.

Ms C also complained that the medical care and treatment provided to Mrs A was unreasonable. We took independent advice from a consultant in general medicine. We found that, in general, the medical care and treatment was reasonable. However, we also found that the assessment carried out after the first fall was inadequate and that there was no evidence in the medical records that a medical review had taken place after the second fall. In addition, we found that the communication by medical staff was poor and that they had not fully explained the prognosis for Mrs A and their concerns about her recovery. Given the failings identified we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for failing to adequately review Mrs A after her falls, and for failing to adequately explain her prognosis to her family. 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 should receive a full medical assessment following a fall.

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 that the practice delayed in referring his late father (Mr A) for appropriate specialist investigation of his iron deficient anaemia (a condition where the blood lacks an adequate amount of healthy red blood cells). Mr C considered that an urgent colonoscopy should have been arranged, in line with cancer referral guidelines. He also raised concerns about the chosen referral pathway once a referral was eventually made, as the referral was to a vascular surgeon rather than directly for colonoscopy. Mr A was subsequently diagnosed with colorectal cancer which was not amenable to treatment and he later died. In responding to Mr C's concerns, the practice said they did not deem an earlier referral appropriate at the time in light of Mr A's other complex medical conditions.

We took independent medical advice from a GP, who advised that there were no current complex medical conditions which could have explained the significant deterioration in Mr A's red blood count. As such, they advised that cancer referral guidelines should have been followed and Mr A should have been appropriately assessed and referred for urgent investigation. We found no evidence of an appropriate examination having occurred and a referral was not made until almost nine months after iron deficient anaemia was diagnosed. We found that the referral should have been sent to a gastroenterologist or surgical doctor, rather than a vascular surgeon. In addition, the adviser highlighted that Mr A was prescribed an inappropriate dosage of iron supplements and he was not adequately monitored to assess his response to these. We concluded that there was an unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficient anaemia, and an unreasonable delay in arranging appropriate specialist investigation. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable failure to appropriately assess, treat and monitor Mr A's iron deficiency anaemia; and the unreasonable delay in arranging appropriate specialist investigation. 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:

• The GP involved in Mr A's care should refer themself to NHS Grampian's clinical support group for review of their knowledge and practice in relation to clinical assessment, prescribing and referral guidelines.

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 that his request for orthodontic treatment was unreasonably refused by the board. Following contact from our office, the board repeated their offer to provide Mr C with a further referral to an orthodontic consultant to assess suitability for treatment. As a result of this further action by the board, we determined that it would not be appropriate to take forward Mr C’s case at this time when he was still undergoing assessments.

Summary

Mrs C complained about the care and treatment given to her late father-in-law (Mr A) after he was admitted to a GP led unit for rehabilitation after a fall. She said that he was not properly supported or cared for which caused him to fall again and break his hip, and that there was a delay in transferring him to hospital for an operation. As well as these concerns, Mrs C also complained about communication with the family and that Mr A's wife (Mrs B)'s views were not taken into account when Mr A's discharge was being considered.

We took independent advice from a GP and from a registered nurse. We found that, while Mr A's medical care was reasonable, including his care when he fell, there were gaps in his nursing notes which were unacceptable and represented a failure in the care provided. For this reason, the first of Mrs C's complaints was upheld. The board said that they had taken steps to ensure improvement in record-keeping, and we asked them to provide us with evidence of this. We did not make any further recommendations in connection with this.

Regarding Mrs C's complaint about communication, we found that Mr A lacked capacity and could not make decisions about his own care. We found that there was no power of attorney in place to do this on his behalf. However, we noted that there were detailed discussions with the family about Mr A's discharge and that Mrs B's views on this were taken into account. We did not uphold this aspect of Mrs C's complaint.

Summary

Mrs C complained on behalf of her husband (Mr A) about the care and treatment he received from the board at Dumfries and Galloway Royal Infirmary. Mrs C complained that there was an unreasonable delay in diagnosing that Mr A was suffering from renal cancer, that there was an unreasonable delay in providing him with treatment and that staff had failed to communicate appropriately with Mr A and his family about his diagnosis and treatment.

We took independent advice from a consultant urologist who said that there was a severe failure to follow-up on a radiologist's report of a scan. The radiologist had suspected that an area of abnormality which showed in Mr A's kidney was renal cancer and had made a recommendation that the scan should be discussed at a urology multi-disciplinary team meeting (MDT). The radiologist's recommendation to discuss this at MDT was not actioned. There was also a failure to mention the scan finding in any of the correspondence on Mr A's discharge from the hospital. As a result, the suspected renal cancer was neglected until the same renal mass was found, by chance, a number of months later when Mr A had a scan to investigate a problem that was unrelated to his renal cancer. While it appeared that Mr A's tumour had not progressed when found, we found that the delay was unacceptable and that the diagnosis, management and treatment of his renal cancer was well below an expected standard. We upheld Mrs C's complaints about delays in diagnosis and treatment.

We also took independent advice from the consultant urologist, as well as a nursing adviser, about how staff communicated with Mr A and his family about his diagnosis and treatment. We did not find any reference in Mr A's medical records of medical staff having a discussion with him about his cancer diagnosis and treatment. We found that the actions taken by nursing staff had fallen short of the standard expected and needed for Mr A and his family at the time. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mr A for:
• an unreasonable delay in diagnosing that Mr A was suffering from renal cancer;
• an unreasonable delay in providing treatment to Mr A; and
• a failure in communication.
• 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:

• A system should be in place to ensure that unexpected findings of scans are appropriately reported and acted upon in a timely manner.
• It should be ensured that radiology are summarising any significant incidental findings at the end of a scan report, as per the requirements of a previous audit, and that these findings are brought to the attention of relevant staff in a timely manner.
• Staff should be aware of the importance of communication with patients and their families. Newly appointed staff should be supported and mentored in this regard and provided with appropriate training.

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 about the care and treatment provided to her mother (Mrs A) at her GP practice. Miss C was concerned that the practice were not addressing Mrs A's health problems or taking into account her fear of medical situations. Miss C had power of attorney for Mrs A and complained that the practice provided Mrs A with unreasonable treatment and that they were not keeping her informed of Mrs A's health care.

We took independent advice from a GP. We found that the practice had completed a full assessment of Mrs A and a full advanced care plan was done. Mrs A was seen on a house call, as requested, and appropriate treatment was provided. There had also been communication between the practice and other professionals regarding Mrs A's healthcare. We considered that the practice provided Mrs A with appropriate care and treatment, and therefore, did not uphold this aspect of Miss C's complaint.

In relation to Miss C's complaint about the practice failing to keep her informed, we found that at the time of Miss C's complaint, the practice held a letter confirming that Mrs A did have capacity. A subsequent assessment confirmed she lacked capacity, but the practice had not been aware of that at the time of the complaint, nor had they been aware of the power of attorney. We found that the practice acted appropriately in maintaining Mrs A's confidentiality until such time as it was brought to their attention that she no longer had capacity and Miss C had power of attorney. We did not uphold this aspect of Miss C's complaint.

Summary

Mrs C complained about the clinical and nursing care and treatment provided to her late husband (Mr A) when he was admitted to the University Hospital Ayr. We took independent advice from a consultant in emergency medicine, a consultant in acute medicine and a nursing adviser.

In relation to the clinical care and treatment provided to Mr A, having considered the available evidence and the advice provided to us we found that, overall, the medical care and treatment Mr A received was reasonable. The advice we received from the consultant in acute medicine was that Mr A's death was not preventable by the time he was admitted to hospital. We did not uphold the complaint. However, whilst the advice we received from the consultant in acute medicine was that cardiac monitoring would not have saved Mr A's life, they considered that the board should have a clear policy regarding which patients require cardiac monitoring. We made a recommendation regarding this.

Regarding the nursing care provided to Mr A, we found that there were gaps in the assessment and monitoring of Mr A and that the board wrongly focussed on anxiety being the cause of Mr A's shortness of breath. We also found that the guidance on using the Modified Early Warning Score (the monitoring of vital signs such as respiratory rate which helps alert clinicians to patients with potential for clinical deterioration or with established critical illness) was not followed, in that Mr A's Modified Early Warning Score was not repeated in line with guidance and there were gaps in the recording of his vital signs which was unreasonable. We further found that Mr A's Modified Early Warning Score should have been repeated on transfer to a new care area. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide a reasonable standard of nursing care and treatment to 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:

• There should be clear a policy regarding which patients require cardiac monitoring shared between the emergency department, the critical care unit and the acute medical unit.
• A Modified Early Warning Score should be checked within the recommended time frames. In line with good practice, a Modified Early Warning Score should be checked and documented when a patient is transferred to a new care area.
• When a patient or relative raises concerns about breathlessness, a Modified Early Warning Score should be rechecked and documented.
• Relevant staff should be aware of the importance of Modified Early Warning Score in anticipating deterioration in a patient.

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.