Health

Summary

Mr C complained about the care and treatment his late father (Mr A) received at the Royal Alexandra Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing and treating Mr A's metastatic melanoma (skin cancer that has spread). Mr C also complained about a failure to communicate clearly from the outset to Mr A that he was suspected to have cancer.

We took independent advice from a plastic surgeon. We found that appropriate investigations were carried out into Mr A's condition. However, we found that Mr A's treatment plan should have been discussed by the multi-disciplinary team when there were concerning findings from his full body scan. We also found that it would have been appropriate for Mr A to have been offered a scan. We upheld this aspect of the complaint.

We found that discussions with Mr A about his condition were not recorded. The board acknowledged failings in their record-keeping and outlined steps that they had taken to address this. We upheld the complaint and we have asked the board to provide evidence of the action that they said they have taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in referring Mr A to the regional multi-disciplinary team to discuss his treatment plan; for not offering a scan and for the failure to properly document discussions with Mr A in which he was told he might have cancer.

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

• High risk cases of melanoma should be discussed by the regional multi-disciplinary team before surgical treatment is carried out.

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 aspects of the physiotherapy care provided to her child (child A), who has complex care needs.

Mrs C complained that the physiotherapy provided to child A did not reflect their needs. We took independent advice from a physiotherapist. We found that, for the most part, child A received appropriate physiotherapy for their condition. Although we found some gaps in the record-keeping, we concluded that, on the whole, the care and treatment provided to child A was reasonable. We did not uphold this aspect of the complaint.

Mrs C also raised concern that the board failed to provide appropriate physiotherapy input to child A following administration of a treatment at a hospital in another health board's area. We found that the board had appropriately liaised with the other health board, and that child A received an increase in physiotherapy following the treatment. We found this to be reasonable and we did not uphold this aspect of the complaint.

Lastly, Mrs C complained that the board had not communicated with her reasonably about a change in physiotherapy service provided to child A and that child A would no longer be working with a physiotherapy assistant. We found that the board had arranged an event to update families about changes in the physiotherapy service. However, we found that, in the period prior to this, there was no evidence to suggest that Mrs C was informed that child A would no longer be working with the physiotherapy assistant. The advice we received also noted that there was no evidence that a reduction in the frequency of physiotherapy input was discussed with Mrs C. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and child A for the lack of documented reasons for the change in frequency of physiotherapy input; the lack of communication in relation to this; and failure to inform Mrs C that child A would no longer be working with the physiotherapy assistant. 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:

• Physiotherapy staff should explain decisions and ensure children, young people and families fully understand them and their implications, especially if the final decision is not what they hoped for. Staff should also document decisions and the communication of these in the 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 suffers from post-traumatic stress disorder and has a longstanding difficulty leaving his house as a consequence. Mr C complained that the practice unreasonably decided that he was not housebound. Mr C's psychiatrist wrote to the practice noting their view that his longstanding mental health difficulties effectively rendered him housebound. The practice had previously refused a request from Mr C for a home visit on the basis that he had managed to attend the surgery in the preceding months. Mr C contacted the practice to ask them to clarify their position in light of his psychiatrist's letter, and they maintained that he is not housebound.

We took independent advice from a GP, who considered that the practice's home visit policy was overly rigid in that it appeared to require a purely physical inability to travel and did not give due regard to Mr C's mental disability. Therefore, we upheld this complaint.

Mr C also complained that the practice failed to disclose relevant information to his psychiatrist when discussing his situation over the phone. This pre-dated the psychiatrist's letter and the psychiatrist appeared to agree with the practice at that time that Mr C was not housebound. Mr C considered that the conclusions drawn by his psychiatrist would have been altered if the long standing nature of his condition and its symptoms had been discussed. However, we noted that the psychiatrist was already aware of Mr C's long term symptoms and medical history from previous assessments by them. The purpose of the call was to find out if there were any current issues that they needed to be aware of. We found that it was reasonable for the practice not to refer to more details of Mr C's past medical history during the phone call. Therefore, we did not uphold this complaint.

In addition, Mr C complained that the practice did not advise him of his right to approach us on completion of their complaints process. The practice complaints policy and NHS complaints handling procedure states that complainants must be notified of their right to approach our office at the end of their internal complaints procedure. Therefore, we upheld this complaint. However, we noted that the practice accepted this failing and they proposed changes to the way they do things to prevent this happening again, therefore we did not make any further recommendations in relation to this.

Recommendations

What we asked the organisation to do in this case:

• The practice should apologise to Mr C for the fact that their policy on home visits did not give appropriate weight to the nature of his mental health disability. 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 practice should review their home visit policy and ensure that it has due regard to mental health as well as physical health disability, as defined by the Equalities Act 2010.

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 dentist failed to provide her with a reasonable standard of dental care and treatment. Ms C attended the dentist over a number of months, concerned about a number of issues. Ms C had experienced pain in one of her teeth which she subsequently discovered had a crack in it. She said that the dentist failed to investigate this appropriately. As a result, Ms C said an adjoining tooth was extracted, and she was unreasonably prescribed three courses of antibiotics before the cracked tooth was extracted. Ms C also had to receive root canal treatment on another tooth which had an infection Ms C said that as a result of the failings, she was in pain for months and needed to get veneers or implants to close the gap at the front of her mouth because she could not eat or smile.

We took independent advice from two dentists. We found that there were significant failings around record-keeping, the prescription of antibiotics, and the management of two teeth. We also found that the dentist was not in a position to appropriately monitor any potential decay progression, which was unreasonable. However, we did not find that the extractions were unnecessary. On balance, we found that the care and treatment Ms C received was unreasonable and therefore. we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to follow relevant guidelines and standards. 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:

• Records should meet the relevant standards and the dentist should become fully aware of and comply with the requirements of these standards.
• Ensure that the approach to patient care is in line with professional guidance (including key skills in primary dental care and management of acute dental problems) and complies with the new guidance due in 2018 in relation to x-rays (Ionising Radiation (Medical Exposure) Regulations).

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, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the communication with Mrs B's husband (Mr A). Mr A suffered some stroke like symptoms and his GP referred him to the hospital for a scan to check if he had had a stroke or transient ischaemic attack (TIA or 'mini-stroke'). A doctor discussed the results of the scan with Mr A in an appointment at the TIA clinic, about two weeks after his initial symptoms. It was recorded that Mr A was at risk of a further stroke, and the doctor recommended that he take medication to reduce this. Mr A suffered a further stroke some months after this, and later died. Mrs B said that Mr A never told her about the results of the scan, and she queried whether he had fully understood this, given he was suffering from confusion. Mrs B felt it was unreasonable for the doctor to share this information with Mr A at an appointment he attended alone, and not with her.

We took independent advice from a consultant in general medicine and medicine for the elderly. We found that Mr A's confusion was temporary and that there was nothing in the records to suggest he was not able to understand the information given or that he needed support during the appointment. We did not uphold Mrs C's complaint. We noted that the board had said that they had learned from the complaint and that they were changing the appointment letters for this clinic to suggest that patients may wish to bring someone with them.

Summary

Ms C complained that the board unreasonably failed to identify her hip fracture. Following a referral to Ninewells hospital, Ms C was reviewed by a consultant orthopaedic and trauma surgeon who considered that she had strained a ligament in her knee. She was then referred for physiotherapy for mobilisation and rehabilitation. Ms C was reviewed over the following months and developed progressively worsening pain. A subsequent x-ray identified a hip fracture.

We took independent advice from a consultant orthopaedic surgeon and a physiotherapist. Ms C noted that no x-ray was performed at the consultation with the surgeon. The board said that an appropriate examination was carried out, and that this examination gave no indication that an x-ray was required. The orthopaedic surgeon adviser said that the examination was not recorded in sufficient detail in Ms C's medical record, and that it provided inadequate evidence that a hip fracture was excluded.

Ms C also raised concern about the subsequent physiotherapy appointments. The physiotherapist adviser considered that, throughout the physiotherapy sessions, there were indications that the initial diagnosis of ligament strain of the knee may have been incorrect. We found that there was a failure to re-evaluate the situation in light of Ms C's increasing pain and deteriorating mobility. We considered that this contributed to the delay in identifying the hip fracture. Finally, we found that there was failings in recording of assessments and pain scores during these appointments. However, we noted that the board had acknowledged this failing and had taken steps to address this.

Overall, we found that the board unreasonably failed to identify Ms C's hip fracture and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for unreasonably failing to identify her hip fracture and for the failings in record-keeping.The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should carry out full and appropriate examinations and assessments, and record these in contemporary 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 complained about the care and treatment his late father (Mr A) received at Perth Royal Infirmary (hospital 1). Mr A was suffering from a chest infection and was also experiencing periods of delirium. Mr A was discharged from hospital 1 to a community hospital (hospital 2) in another health board area, but they refused to admit him due to his condition and he was transferred by ambulance to another hospital (hospital 3). Mr A was later admitted to hospital 2, where he died a short time later. Mr C complained that the decision to discharge Mr A from hospital 1 was unreasonable and that there was an unreasonable delay in replacing his hearing aids which were lost during his admission.

Mr C raised concerns that hospital 1 had treated Mr A for a chest infection, and hospital 2 also identified a chest infection. Mr C therefore considered that Mr A was discharged from hospital 1 with an unresolved infection and he questioned whether this was appropriate. We took independent medical advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that Mr A's observations were stable leading up to his discharge from hospital 1. We did not consider that there was any evidence to suggest Mr A was not fit for discharge. We noted that Mr A quickly developed a further infection but we did not consider that this was identifiable, or could reasonably have been predicted, at the time of discharge. Therefore, we did not uphold this aspect of Mr C's complaint. However, the adviser noted that there was no evidence of medical staff having formally assessed Mr A's delirium using a recognised screening tool and we therefore, made a recommendation regarding this.

In relation to the hearing aids, the board apologised to Mr C for the loss of these. In responding to our enquiries, they offered a fuller explanation of the steps followed in replacing them. We found that the timescale described for replacing the hearing aids was typical for such a process. Therefore, we did not uphold this aspect of Mr C's complaint, but we were critical of the level of explanation offered to Mr C when responding to his complaint. We provided some feedback to the board in this regard.

Recommendations

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

• Medical staff should formally assess patients' delirium using a recommended screening tool, such as those recommended by Healthcare Improvement Scotland.

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 that his father (Mr A) received at Perth Royal Infirmary following a fall. Mr C was concerned that a fracture was not identified until Mr A had been in hospital for eight days. Whilst in hospital, Mr A also suffered a period of delirium. Mr C complained about communication issues and the way that Mr A had been transferred between wards at the hospital. Finally, Mr C also considered that the board had not handled his complaint reasonably.

We took independent advice from an emergency department consultant, an acute care consultant and a nursing adviser. We found that there was no documentation of an examination of Mr A's neck in the emergency department. As the x-rays that were taken had been difficult to interpret, further action should have been taken to rule out fracture, or clear reasons should have been recorded for not doing this. We considered that there were opportunities to diagnose the fracture at an earlier stage. In regards to Mr A's delirium, we found that the care he received was reasonable, although there was some areas where practice could be improved.

In relation to communication issues and transfers within the hospital, we found that nursing notes indicated that Mr A was in pain but that this information did not appear to have been shared with medical staff. We also found that Mr C had not been kept properly updated regarding Mr A's moves within the hospital. We noted that Mr A's moves had been reasonable however, on one occasion, he was transferred during a meal which was inappropriate.

In relation to complaints handling, we found that the board had not addressed Mr C's concerns about the delay in diagnosing Mr A's fracture in their response and that Mr C was not kept appropriately updated during the complaints process.

We upheld all of Mr C's complaints. However, we noted that the board identified some failings in their consideration of this case and had apologised for these.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in diagnosing the fracture; for not fully addressing his concerns; and for not keeping him updated during the complaint process. 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:

• Medical staff should keep comprehensive medical records.
• Where x-rays are inadequate, consideration should be given to further imaging or discussion with the on call radiologist. If this is not considered necessary, the rationale should be clearly documented in the medical records.
• There should be a mechanism in place for nursing staff to make medical staff aware of issues with continuing pain. Consideration should be given to unitary records and reviewing how nursing/medical staff communicate during formal handovers.
• Consider the adoption of Health Improvement Scotland's 'Think Delirium' as a means to try to reduce delirium in hospital and manage it appropriately, particularly liaising with relatives.

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 and support agency, complained on behalf of her client (Mr B) about the care and treatment provided to Mr B's wife (Mrs A) at Gilbert Bain Hospital. Mrs A had pancreatic cancer and when she was admitted to hospital she could not eat. She was later assessed for palliative surgery (surgery which provides relief, but not a cure) at a different hospital, and was ultimately unable to have this surgery. Mr B felt that the reason his wife could not undergo the surgery was because she was not given adequate nutritional support (the giving of nutrients, either intravenously (directly into a vein) or by drip feeding through a tube placed in the digestive system) at Gilbert Bain Hospital.

We took independent advice from a consultant physician. We found that it was reasonable not to give Mrs A nutritional support until a decision was made to assess her for palliative surgery at the second hospital. Therefore, we did not uphold the complaint. However, we found that there were discussions between the two hospitals that were not recorded, so we made a recommendation to address this.

Recommendations

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

• Medical staff should maintain records of verbal conversations with staff at other hospitals in the medical 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

Ms C complained about the care and treatment provided to her late partner (Mr A) by the ambulance service. She felt that the service should have taken Mr A to hospital when they attended him and he was unwell with diarrhoea, because several days later Mr A was diagnosed with a perforated duodenal ulcer (when the lining of the stomach splits due to a sore).

We took independent advice from a consultant in emergency medicine who is involved in the training of paramedics and who works alongside them in the provision of pre-hospital care. We found that the ambulance service appropriately assessed Mr A and reasonably contacted an out-of-hours GP to further assess Mr A. We did not uphold this complaint.