Health

Summary

Mr C complained on behalf of his wife (Mrs A) that the ambulance service unreasonably failed to dispatch an ambulance following an emergency call and that they did not handle his complaint reasonably.

Mrs A had been diagnosed with a tumour at the rear of her brain and was waiting for an operation. Mr C said that Mrs A was told to call the emergency services if she experienced certain symptoms. When Mrs A subsequently experienced these symptoms, Mr C called the emergency services and spoke to a call handler who referred Mrs A to NHS 24. Mr C was unhappy that the ambulance service failed to dispatch an ambulance following the emergency call.

We took independent advice from a consultant in emergency medicine. We found that the information reported during the emergency call did not confirm that Mrs A had an immediately life-threatening condition, which would have required the dispatch of an ambulance as an emergency. The adviser noted that the decision to refer the call to NHS 24 in order to get a more detailed assessment of the situation by a clinically trained person was reasonable. We found that the decisions taken by the ambulance service were reasonable and therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, we found that the ambulance service had performed a detailed audit of the emergency call and that the member of staff involved had appropriately reflected on the call. We were satisfied that the complaint investigation carried out was reasonable and that the response to Mr C addressed the points he had raised. We did not uphold this aspect of Mr C's complaint.

Summary

Mr C underwent nasal surgery at St Johns Hospital and subsequently had ongoing issues with nasal obstruction, facial pain, breathing issues and sinus infections. Mr C complained that he was not warned of the recognised risks associated with the procedure and that the surgery itself was not performed to a reasonable standard. Mr C also complained that the board did not handle his complaint reasonably.

We took independent advice from an ear, nose and throat consultant. We found that appropriate information was provided to Mr C regarding the recognised risks of the surgery. We also considered that the nasal surgery was performed to a reasonable standard. We did not uphold these aspects of Mr C's complaint. However, we noted that there was a delay in removing Mr C's nasal splints (temporary splints which are used to stabilise the nose after surgery) and made a recommendation in light of this.

In relation to complaints handling, we found that there was a delay in issuing a response to Mr C and that there was insufficient detail about the surgery included in the letter. We considered that the board did not handle Mr C's complaint reasonably and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of advice about nasal splints following the surgery, and the failings in complaints handling. The apology should meet the standards set out in the SPSO guidelines on 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

Ms C complained to us about the care and treatment her mother (Mrs A) had received after she was admitted to St John's Hospital with bipolar disorder (a mental health condition marked by alternating periods of elation and depression).

Ms C complained about a number of issues in relation to the nursing care provided to Mrs A. We took independent advice from a mental health nurse. We found that it had been unreasonable for nursing staff to allow Mrs A off the ward without an escort. Although Mrs A came to no harm, her safety and wellbeing were placed at undue risk as a result of this. We also found that, despite it being known that Mrs A had medication compliance issues, there was no evidence in the records of a coherent care plan designed to promote her compliance with oral medication. Neither her care needs nor her nursing care had been effectively planned or kept under review. Care plans in the records were dated four weeks after Mrs A had been admitted to hospital and we found that the manner in which the documentation had been used and completed was ineffective and unreasonable. In view of these failings, we upheld Ms C's complaint about the nursing care provided to Mrs A.

Ms C also complained about a number of aspects of the psychiatric and medical treatment Mrs A received in the hospital. We took independent advice on these issues from a psychiatric consultant. We found that there had been a delay in actioning Mrs A's electrocardiograph (ECG - a test that records the electrical activity of the heart) results and that the consultant psychiatrist had failed to make themselves aware of these results. We also found that it was unreasonable that specialist cardiology advice was not sought and that anti-psychotic drugs were prescribed to Mrs A without attention being paid to the cardiac risks or guidance being given to staff that she should be closely monitored after taking these. In addition, Mrs A received two anti-psychotic drugs at the same time, when the intention had been for staff to give Mrs A either one or the other. We also received advice that an alert should be put on Mrs A's records regarding one of the anti-psychotic drugs. We further found that the frequency of consultant review over a period of ten days had been unreasonable as adequate staff cover was not in place. Whilst it had not been unreasonable to start the application process for a compulsory treatment order for Mrs A, it was unreasonable that this had been done without a medical examination being carried out. We also found that staff failed to give Mrs A vitamin replacements that had been agreed. In view of these failings, we upheld Ms C's complaint about the psychiatric and medical treatment provided to Mrs A.

Finally, Ms C complained that the board had failed to provide a reasonable response to her complaint. We found that the board's response to her had not been reasonable, particularly that they had not informed Ms C of the outcome of their investigation into her complaints about staff behaviour. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide nursing care and psychiatric and medical treatment to Mrs A, and for failing to provide a reasonable response to Ms C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Consider putting an alert on Mrs A's records that she should not be prescribed one of the anti-psychotic medications in future.
• Inform both Ms C and us of the outcome of their investigation into Ms C's complaints about staff behaviour in relation to Mrs A's case.

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

• Relevant staff should be fully aware of their responsibilities in relation to the application of Nurses Holding Power under the Mental Health Act.
• Template documentation introduced to ensure the quality of record-keeping should be completed in full and as intended in order that nursing care, including medication compliance, is effectively planned, documented and kept under systematic review.
• Robust systems should be in place to ensure the results of medical investigations are accessed, recorded, considered and actioned in good time.
• Prescribing clinicians should be aware of the accepted prescribing guidance, especially with regard to the use of higher risk medications (such as some anti-psychotics) in vulnerable patient groups (such as the elderly) and there should be adequate processes in place for the physical monitoring of patients when such medications are administered.
• There should be adeqaute arrangements in place to cover medical staff's leave to ensure that all reasonable requests by patients and carers for consultant review are met.
• Staff prescribing medication should ensure that they provide appropriate guidance on when and how the medication is to be given.
• All staff taking decisions under the Mental Health Act should have due regard to the principles of the Act, as they are required to do, and adequate records should be made of these decisions and the rationale for reaching them.
• Patients should be given vitamin replacements where this has been previously agreed and there is no clinical reason not to give it.

In relation to complaints handling, we recommended:

• Complaints should be investigated appropriately.

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 the board. She complained that, when she suffered a slipped disc in her back, she was not given appropriate neurosurgical treatment during two periods of care. Ms C also complained that she was later not provided with reasonable treatment by the department for infectious diseases, cardiology, or rheumatology.

We took advice from a neurosurgeon, a consultant in infectious diseases, a cardiologist and a rheumatologist. We found that, whilst overall the neurosurgical care given to Ms C was reasonable, there was a failure to properly document an appointment; that there was no evidence that the likely outcome of surgery was discussed with Ms C; and that there was a delay in follow-up after Ms C underwent surgery. We upheld this aspect of Ms C's complaint.

We found that the care and treatment provided by the department for infectious diseases, cardiology, and rheumatology was of a reasonable standard and 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 the documentation of the neurosurgical appointment falling short of the standard expected; for the lack of evidence that that the likely outcome of surgery was discussed with Ms C as part of the consent process; and for the unreasonable delay between surgery and Ms C's follow-up appointment. 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:

• Documentation of appointments should be in line with General Medical Council guidance. The likely outcome of surgery should be discussed and documented as part of the consent process. Follow-up after surgery should be 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

Mr C complained on behalf of his late wife (Mrs A) that the practice failed to provide a reasonable standard of care and treatment. Mrs A attended the practice with pain in her right chest wall which was thought to be related to an injury. The practice noticed a small lump over her clavicle (collar bone) and requested an x-ray, which showed no significant abnormality. Mrs A attended the practice again with worsening shoulder pain and was referred to orthopaedics (the branch of medicine involving the musculoskeletal system). Mrs A was later diagnosed with bone and liver cancer. Mr C complained that the practice failed to note Mrs A's history of breast cancer on the x-ray request form and that they had not chased up the orthopaedic referral.

We took independent advice from a general practitioner. We found that there was no indication for the practice to consider cancer as a possible diagnosis. The practice had been investigating Mrs A's shoulder pain and lump as an injury and we considered that the practice's diagnosis was reasonable. We did not uphold Mr C's complaint. However, we identified failings in the way the practice handled his complaint and made recommendations in light of this.

Recommendations

In relation to complaints handling, we recommended:

• The practice should ensure that they have adopted the model complaints handling procedure and all staff should be aware of this. The model complaints handling procedure and guidance can be found here: http://www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

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 on behalf of his late wife (Mrs A) about the treatment she received at Monklands Hospital. Mrs A attended her GP with pain in her right chest wall and was referred to hospital for an x-ray which found no significant abnormalities. Mrs A later attended her GP with worsening shoulder pain and her GP sent an urgent referral to the orthopaedics department (the branch of medicine concerned with the musculoskeletal system). This referral was downgraded by the board from urgent to routine. Mrs A was later diagnosed with bone and liver cancer. Mr C complained that the board unreasonably failed to check the x-ray for signs of cancer and that they unreasonably downgraded the urgent referral to routine.

We took independent advice from a consultant radiologist. We found that Mrs A had been referred for an x-ray due to an injury and that an x-ray is not the correct test to reliably pick up on a tumour. We also noted that the x-ray had showed a subtle change in bony texture of the clavicle (collar bone). As Mrs A had been referred for an x-ray due to an injury and the abnormality was so subtle, it would have been unreasonable to expect a radiologist to pick this up. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to the referral downgrade, we took independent advice from a consultant physician. We found that the orthopaedic referral letter did not suggest any need for the appointment to be urgent, no mention of cancer and no indication that the problem was considered to be anything other than shoulder pain that had not responded to physiotherapy. Therefore, we did not uphold this aspect of Mr C's complaint.

Summary

Mr C complained that the board unreasonably failed to provide him with appropriate care and treatment for his prostate cancer. He said that a consultant urologist (a doctor who specialises in medicine focusing on diseases of the urinary tract and the male reproductive organs) at Hairmyres Hospital advised him that his cancer was confined to his prostate, that it was T3 (had grown through the prostate capsule, outwith the prostate and was just outside the prostate) and that a laparoscopic radical prostatectomy (removal of the prostate via a small incision using robotic surgery) was an appropriate treatment. The consultant referred Mr C to a second consultant urologist at another board. Mr C said that when he was seen by the second consultant, he was told that the surgery proposed was not appropriate.

We took independent advice from a consultant urologist. We found that the first consultant referring Mr C for consideration of laparoscopic radical prostatectomy was appropriate and was in keeping with the West of Scotland Management Guidelines for prostate cancer. We found that, ideally, the first consultant should have pointed out that in their opinion Mr C's disease was suitable for radical prostatectomy, but that the final decision on suitability for surgery lay with the surgeon performing the surgery. The adviser explained that the main issue was one of a difference in clinical opinion between surgeons, and not a change in the extent of Mr C's cancer during the time between his appointments. On balance, we did not consider that the board unreasonably failed to provide Mr C with approprite care and treatment for his prostate cancer, and we did not uphold this aspect of the complaint.

Mr C also complained that the board unreasonably failed to arrange his referral for prostate surgery within a reasonable time and that they did not take the issue of the delay in arranging the referral appointment seriously. We found that the board had failed to respond to Mr C's phone calls about his referral and to take the issue of the delay seriously. We upheld this aspect of the complaint. We noted that the board had already apologised for this, and had taken steps to avoid this happening again in the future. We asked them to provide us with evidence of the action they had taken, however we made no further recommendations.

Summary

Mr C complained about treatment that he received at Raigmore Hospital when he was admitted via the emergency department. Mr C had undergone a vasectomy procedure (a procedure where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) over two weeks earlier and had developed painful swelling. Mr C complained that, after admission for assessment/investigation in the urology department, he was examined and then discharged with advice to manage his symptoms conservatively. Mr C later had to be admitted for a number of days for treatment of an abscess.

We took independent advice from a consultant urologist. We found that there were several factors in Mr C's presentation that meant that, on balance, a more proactive approach to his symptoms would have been appropriate. We upheld this aspect of his complaint.

Mr C also complained that the board's response to his complaint was inaccurate. We found that key dates in the response were incorrect. We noted that the board acknowledged this failing and advised that they had taken steps to address it going forwards. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to consider and/or document consideration of, a more proactive approach to Mr C's care and for the inaccuracies in the final response to Mr C's complaint. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org/leaflets-and-guidance.

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

• All relevant clinical factors should be taken into account and this should be apparent from the notes made in the contemporary clinical records.

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, a solicitor, complained on behalf of his client (Mr A) about the care and treatment he received at West Glasgow Ambulatory Care Hospital. Mr A was suffering from heart problems and was seen by a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) and it was decided that no further investigations were appropriate. Mr C said that although Mr A continued to experience heart and chest pain, the board failed to take his concerns seriously and refused unreasonably to offer him appropriate treatment.

We took independent advice from a consultant cardiologist. We found that it was appropriate for the board not to investigate Mr A further as doctors had assessed the risks and benefits of more investigations and concluded, based on a number of points, that he should not be offered more. It was also noted that further cardiac investigations carried risks and could result in complications. We found that it was appropriate for no further tests to be carried out unless there was a solid indication to do so. Therefore, we did not uphold Mr C's complaint.

Summary

Mr C complained that the board failed to arrange his appointment for prostate surgery following a referral from another board within a reasonable time. Mr C's concerns included that the board unreasonably failed to send the letter for his appointment with the consultant at New Victoria Hospital to his correct address and that it was nearly three months until he was seen at the hospital. He also said the board failed to acknowledge the impact of the delay in arranging his appointment on the treatment of his cancer, including that he was advised by the board that he could not have the proposed surgery.

We took independent advice on the case from a consultant urologist. We found that the delay in Mr C's appointment was not acceptable. The board explained that they had Mr C's old address in their patient management system and when they received his referral, they failed to update the address. The board apologised for this and said that staff had been reminded of the importance of checking patient details on receipt of referrals and carrying out updates where necessary. They said the member of staff involved had been made aware of the considerable impact the error had on Mr C and would be given additional training, following which their performance would be closely monitored. We asked the board to provide us with evidence of their remedial action.

We found that the board correctly stated that the delay in Mr C's appointment would have been unlikely to have accounted for Mr C's cancer moving from operable to inoperable. The adviser said they did not think that there was a change in the extent of Mr C's cancer between him being referred to the board and him being seen by the consultant at the board.

We upheld Mr C's complaint. We asked the board to provide us with evidence of the steps they have taken to stop these failings occuring again in the future, however we made no further recommendations.