Health

Summary

Mrs C complained about the nursing care that her father (Mr A) received whilst he was an in-patient at the Western General Hospital. During his admission, Mr A developed a pressure ulcer and Mrs C was concerned that this was not maintained hygienically or to a reasonable standard. Additionally, Mrs C complained that her father's discharge home was unreasonably delayed by a member of nursing staff.

We took independent advice from a nursing adviser. We found that Mr A's risk of developing a pressure ulcer had not been accurately assessed and that pressure ulcer care had not been provided in line with relevant guidance. The advice we received highlighted a number of issues with record-keeping in relation to pressure ulcer care and also hygiene, including that a wound assessment chart was not completed for Mr A. We also found that a pressure relieving mattress was not ordered for Mr A until he had already developed a pressure ulcer. There was also no evidence that appropriate specialist input was sought with regards to Mr A's care. We upheld Mrs C's complaint about maintaining Mr A's hygiene and the pressure ulcer.

Regarding Mr A's discharge, the advice we received was that the delay of a few hours was reasonable as nursing staff were concerned that there may not have been anyone at home to be with Mr A when he arrived. We did identify communication issues around this, which were drawn to the board's attention, however, we found that the actions of nursing staff were reasonable and we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in pressure care. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Appropriate risk assessments for pressure ulcers should be carried out accurately and all pressure care should be provided in line with the board's Pressure Area Care Pathway (2015).
• Patients should be nursed on a surface suitable to manage their risk of developing pressure ulcers, in line with the board's Protocol for Ordering Therapeutic Mattresses (2013).
• Wound assessment charts should be completed for patients like Mr A and injuries should be treated appropriately, in line with the relevant guidance.
• Appropriate referrals should be made for patients when specialist input is required.
• Full and accurate nursing care records should be kept for patients.

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 provided to her late mother (Mrs A) by the practice. Mrs C complained that the practice failed to appropriately monitor and treat Mrs A's symptoms after she was diagnosed with a heart condition. Mrs A was referred to cardiology by the practice a number of years ago and was diagnosed with a heart condition known as mitral regurgitation (when blood back flows through a valve in the heart called the mitral valve). She was prescribed diuretic medication (also known as water tablets - tablets which can help reduce the fluid build up that can occur when the heart is not working normally). When Mrs A was reviewed by cardiology again two years later, the condition was noted to have resolved and the cardiology clinic advised that the diuretic medication could be reduced and stopped. In line with Mrs A's wishes, she continued to take the medication for a further three years before it was stopped when she was found to have low sodium levels. In the interim, Mrs A had also been given a steroid inhaler for suspected asthma. Mrs A suffered a heart attack and died less than two months after stopping the diuretic medication.

Mrs C complained that stopping the diuretic medication contibuted to her mother's death. She raised concerns that closer monitoring of Mrs A's known heart condition did not occur. She also raised concerns that the steriod inhaler prescribed for breathlessness may have masked the underlying problems with Mrs A's heart. In particular, Mrs C did not consider that Mrs A received the appropriate attention required to properly identify the cause of the symptoms she presented with in the final months of her life.

We took independent advice from a GP adviser. We found that the management of Mrs A's symptoms was reasonable. The adviser noted that the cause of the mitral regurgitation was never established and that, when it appeared to have resolved, no ongoing cardiology follow-up was arranged. Had heart valve disease, which is one of the possible causes of mitral regurgitation, been identified, the adviser confirmed that this would have been followed up by the cardiology clinic, and not by the practice. In light of the cardiology clinic's advice that the diuretic medication could be stopped, alongside the low sodium level later found in Mrs A, we were advised that it was reasonable for the practice to have stopped this medication. We were also assured by the advice we recieved that the prescription of inhalers was reasonable and that there was nothing to indicate that this masked an underlying heart condition. The adviser did not consider that Mrs A's death could reasonably have been forseen by the GPs at the practice, and they concluded that the care provided to her by the practice was reasonable. We accepted this advice and we did not uphold Mrs C's complaint.

Summary

Mrs C underwent dental work. After she submitted the invoice to her dental insurer, they refused to cover most of the costs as the work had been charged on a private treatment basis and the insurance policy only covered NHS costs. Mrs C complained that her dentist had never discussed this with her. She said that if she had known that the work was going to be charged at private costs she would not have agreed to it.

Mrs C's dental records included entries documenting discussion about the work being charged on a private basis, and an entry stating that she was given a written estimate. A copy of the written estimate was provided to us, showing itemised NHS and private treatment costs. We concluded that the fact that the work would be charged on a private treatment basis had been discussed with Mrs C. As such, we did not uphold her complaint.

Summary

Ms C's mother (Mrs A) had a number of health concerns and she required numerous hospital admissions over the course of two years. Ms C complained about the removal of diazepam (a medication used to treat anxiety) from her mother's medication regime during one of her admissions. Mrs A had been taking diazepam regularly for over forty years, and Ms C believed that its sudden withdrawal had caused delirium, which led to a worsening of Mrs A's dementia and her eventually having to go into a care home.

The board did not consider that Mrs A's increased confusion was necessarily caused by the withdrawal of diazepam. They noted that there were a number of other possible causes, including several long-term conditions and other issues, including acute infections. They accepted, however, that there had been some shortcomings when recording medicines on admission and on discharge and they identified this as a learning point.

We took independent advice from a consultant in acute medicine. We found that there are often multiple potential causes for delirium, and the adviser thought it unlikely that Mrs A's decline was attributable to diazepam withdrawal. We noted that there appeared to be admissions during which Mrs A was not administered any diazepam and showed no signs of withdrawal. Given that Mrs A was on a relatively low dose, the adviser did not think the withdrawal had caused Mrs A's delirium and decline. We therefore did not uphold this complaint.

Ms C also complained that the board failed to ensure that her mother was receiving reasonable medication therapy following the decision to stop her diazepam medication. The board had found during review that an alternative was prescribed and administered, albeit inconsistently. We found that Mrs A was on other medications which may have alleviated the need for a substitute and we noted that Mrs A had managed for several days during one admission without diazepam and without any signs of withdrawal. The adviser therefore thought it reasonable to have stopped this medication, assuming that withdrawal would not occur. We found that, at a later date, a susbtitute was introduced to Mrs A's medication regime, and the adviser did not consider that this was needed before this point. Therefore, we did not uphold this complaint.

Summary

Mr C complained about the care and treatment that the board provided to his late mother (Mrs A) at Wishaw General Hospital.

Mrs A became ill and she was taken to the hospital by ambulance. Staff examined her and considered that she had pneumonia (a lung infection) and acute kidney injury. Mrs A also had symptoms of life-threatening sepsis (a blood infection). Given Mrs A's condition, staff made a Do Not Attempt Cardiopulmonary Resuscitation decision (DNACPR decision - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops). Mrs A's condition continued to deteriorate, and she died early the next morning. Mr C raised specific concerns about the DNACPR decision, and the medication provided to Mrs A.

We took independent advice from a consultant in acute medicine. We found that, given the medical condition that Mrs A was in, it was reasonable for a DNACPR decision to be made. There was evidence of discussion with a senior consultant and with the family. We also found that the medication prescribed to Mrs A as reflected in the medical records was reasonable. We did not uphold Mr C's complaint.

Whilst we did not uphold the complaint, we found that the board were unable to provide a completed DNACPR form from their records. Therefore, we made a recommendation to address this.

Recommendations

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

• DNACPR forms should be completed and filed 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

Mr C developed a lump on his ear and his GP referred him to Hairmyres Hospital for investigations. Mr C was seen at the dermatology clinic at the hospital six weeks after his GP referral. He was diagnosed with squamous cell carcinoma of the ear (a type of cancer in the skin's cells). Mr C was routinely referred to the hospital's plastic surgery department for treatment and he was offered a plastic surgery appointment around two months later. In the meantime, Mr C contacted the dermatology clinic, as the lump on his ear was increasing in size daily. Mr C's referral to the plastic surgery department was upgraded to urgent and he was offered an appointment a week later. When Mr C attended that appointment, he confirmed that he had already arranged private surgery to treat his squamous cell carcinoma, as he felt the treatment time at the hospital had been too long. Mr C complained to us about delays in diagnosing and treating his squamous cell carcinoma.

We took independent advice from a consultant dermatologist. We found that there was no unreasonable delay in the hospital diagnosing Mr C's squamous cell carcinoma. However, we found that squamous cell carcinoma on the ear is considered a high-risk site, as it has the potential to spread around the body. Therefore, we considered that Mr C should have been urgently referred to the plastic surgery department after his diagnosis. We found that it was unclear whether Mr C would have been treated within the 18 week referral to treatment standard, which applies to 90 percent of all routine surgeries in Scotland. We considered that this standard may not have been met, given how complex the surgery would be and how long Mr C's clinical journey had already taken. We recognised that it is not a 100 percent standard, but given the level of risk of having squamous cell carcinoma on the ear, we considered that Mr C should have been treated within that timescale. For this reason, we upheld Mr C's complaint. However, we did not recommend that Mr C's private treatment costs be refunded. This is because we noted that he had arranged private surgery before he received a date for surgery from the hospital. Although we had concerns that the hospital may not have met the 18 week standard, we were unable to say with certainty they would not have done so, and so we did not consider it to be reasonable to recommend that the board reimburse Mr C's private treatment costs.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for referring him to plastic surgery as a routine referral when his squamous cell carcinoma was on a high-risk site. 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:

• Patients with squamous cell carcinoma should receive the appropriate treatment, from the correct clinician(s), at the appropriate time, taking into account the relevant clinical 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 on behalf of his neighbour (Mr A) about the care and treatment provided to Mr A for kidney stones at Raigmore Hospital. Mr A had a number of surgical procedures over the course of a year to remove his kidney stones, however none of these were successful and Mr A was referred to a different health board for further treatment.

We took independent advice from a consultant urologist. We found that both the medical and surgical management of Mr A's kidney stones had been reasonable, despite the procedures failing to be successful. Therefore, we did not uphold this aspect of Mr C's complaint. However, we did find that the referral to the other health board was not appropriately recorded in Mr A's medical records and we made a recommendation regarding this.

Mr C also complained about the board's communication with Mr A. He said that it had not been explained to Mr A what the treatment plans were, and that the surgeon failed to visit him after his most recent surgical procedure to explain the next steps. We found that, although communication throughout much of the time Mr A was receiving treatment was reasonable, it was not reasonable that the surgeon failed to make plans for post-operative discussions. We also found that there was a failure to make a note of a phone call the surgeon had with Mr A. Additionally, we found that the board's complaint response was poor as it failed to sufficiently cover the points complained about. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to communicate with him reasonably. 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:

• Referrals to other health care providers should form a part of a patient's record.
• In similar situations, surgeons should proactively make arrangements to meet with patients post-operatively in order to discuss the operation and further management plans. Where this is not possible this should be raised with the patient in advance and an agreement on how to do this should be reached.
• Phone consultations which are part of clinical care should be recorded in writing in the patient's medical records.

In relation to complaints handling, we recommended:

• Complaint responses should fully address all issues raised by the initial complaint.

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 that the practice unreasonably removed her from the patient list. Mrs C had been expecting to receive a call from the receptionist about whether her adult son could have an appointment with a GP to discuss blood test results. Mrs C had earlier tried to speak to a GP by phone to see about an appointment for her son but was told that the GP would not speak to her. Mrs C left her contact details and asked that the practice return her call with details of an appointment time. Mrs C then received a phone call from the practice manager who said that the decision had been taken to remove her from the patient list. Mrs C could think of no reason why she had been removed from the patient list.

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 provide us with two examples of why they had concerns about Mrs C's actions, staff did not formally bring them to Mrs 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 Mrs 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

Ms C raised concerns about the way hospital nursing staff arranged a care package with the council for her late father (Mr A) upon his discharge from Glasgow Royal Infirmary. Mr A's discharge from hospital was delayed as Ms C was told that the care providers were closed over the holidays. After being discharged no carers arrived to assist Mr A. Ms C contacted the hospital but was told nothing could be done as it was the weekend and there was no out-of-hours service. Ms C complained that the board failed to ensure that a package of care was in place for Mr A on his discharge from hospital and that she was not provided with an out-of-hours emergency phone number for the care provider.

We considered that there was a failure to reasonably ensure that the council was contacted to put a package of care in place. We found that there was contradictory information regarding how the package of care had been arranged and who within the nursing staff had arranged it with the council. It was not possible to determine with any certainty who arranged this and what was arranged. We upheld this aspect of the complaint.

We also found that nursing staff were not aware of the fact that an out-of-hours number was available and could be called at the weekend and on public holidays. We found that it was possible that Mr A could have been provided with a package of care over the holidays or at the weekend if the out-of-hours service had been contacted by the nursing staff or if Ms C had been provided with the number. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to ensure that a care package was arranged with the council for Mr A's discharge from hospital.
• Apologise to Ms C for not calling the out-of-hours phone number for packages of care and for not providing Ms C with this number. The apology should meet the standards set out in 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:

• All nursing staff should be aware of the requirement to record who contacted the council to arrange a package of care; the name of the person this was arranged with; the date the care package would start and any discussion regarding the care the patient would require at home.
• All nursing staff should be aware of the out-of-hours contact phone number for packages of care for public holidays and weekends. Staff should contact this number where appropriate to do so. The number should be provided to families where appropriate to do so.

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 late father (Mr A) at the Glasgow Royal Infirmary. Miss C also complained about communication between the hospital staff and Mr A and his family.

Mr A was seen by the ear, nose and throat department due to having an ongoing hoarse voice and was subsequently referred to the respiratory department. Mr A was started on medication to treat tuberculosis (a bacterial infection mainly affecting the lungs). Mr A was later admitted to hospital due to shortness of breath and it was found he did not have tuberculosis, but lymphoma (a type of cancer). Miss C complained that the board did not consider other possible diagnoses and this resulted in a delay in reaching the correct diagnosis of lymphoma. Miss C also had concerns that the consultants involved in her father's care did not fully take into account his inability to eat properly and the effect this may have had on his existing diabetes.

We took independent advice from a consultant respiratory physician. We found that it was reasonable and appropriate to consider tuberculosis as the most likely diagnosis, and that this was in line with national guidance. The advice we received is that the consultants were open to alternative diagnoses, and that they reasonably took into account the effect of his illness on his diabetic control. Therefore, we did not uphold this aspect of Miss C's complaint.

Miss C complained about communication between the hospital staff and Mr A and his family. We noted that the board had acknowledged and apologised that communication was not of a good standard, and they had discussed this with the relevant staff to determine how this matter could be improved. We upheld this complaint, but found that the board had appropriately taken action on this matter and therefore did not make any further recommendations.