Health

Summary

C complained about the care and treatment provided to their late spouse (A) by the board while they were an in-patient at hospital. During A's admission they were diagnosed with stage 4 cancer and COVID-19. A died of COVID-19 in hospital.

C complained to the board about A's care and treatment. C also complained about communication with A's family. The board apologised for aspects of their communication, but did not identify any failings with A's care and treatment. C remained unhappy and asked us to investigate.

C complained about the care and treatment A received for COVID-19 and about the communication A's family received regarding their COVID-19 diagnosis. C complained that the board had failed to adequately investigate the complaint and had failed to adequately investigate how A caught COVID-19.

We took independent advice from a general medicine adviser. We found that aspects of the care A received after their COVID-19 diagnosis, along with aspects of the board's communication with A's family regarding A's COVID-19 diagnosis and treatment were unreasonable. We also found that the board's response to C's complaint contained inaccuracies and that there was a lack of detail. We found that the response failed to adequately address, from a medical perspective, the concerns C had raised, in particular, in relation to A's COVID-19 diagnosis. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failure to provide A with reasonable care and treatment, failure to adequately investigate C's complaint and for failure to communicate adequately with C about A's COVID-19 infection. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• DNACPR forms should be appropriately completed by staff who should ensure its implications are discussed with and fully understood by the patient and/or family members at the time of completion. When a patient tests positive for COVID-19, in particular where they have other serious underlying illnesses, a detailed medical review of the patient should be carried out as soon as possible. The reasons for treatment decisions should be clearly documented on a TEP. Prompt consideration should be given to closing a ward where an outbreak of COVID-19 occurs.
• Patients families should receive clear explanations, and be provided with appropriate information that addresses their concerns when responding to complaints.
• Communication with patients and/or their families should be proactive and timely, especially in relation to a serious diagnosis. Where discussions have taken place they 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

C complained about the care and treatment that their relative (A) received from the board. A had a history of dementia and was admitted to hospital. C complained that during A's admission the family were given inaccurate information about COVID-19 visiting restrictions, and about the care and treatment that A was receiving. A had also fallen whilst in hospital and C questioned how this could have happened.

We took independent advice from a nursing adviser. We found that there had been failings in A's care, and in the communication with C and the family. A should have received enhanced monitoring prior to the fall, although it was not possible to determine how the fall had taken place.

We considered that the board had accepted this and provided evidence of the actions that they were taking to improve care for patients and communication with families. We found that these actions were a reasonable and proportionate response and the board had provided evidence that they were implementing the changes required. C's complaints were upheld, as there were acknowledged failings in A's care, however, no further recommendations were made.

Summary

C complained about the care and treatment provided to their parent (A) by the practice. Over a period of several months, A and/or family members had multiple contacts with the practice. A started to physically decline more rapidly and was experiencing severe pain which was presumed to be from a prolapse (a displacement of a part or organ of the body from its normal position).

Shortly afterwards, there was a more acute clinical deterioration and an Out-of-Hours medical assessment concluded that A was terminally ill and in need of end-of-life care. There were subsequent assessments by the practice and discussion on best management. A's care was continued at home with general practitioner (GP) and district nurse involvement until A's death.

We took independent advice from a GP adviser. We found that there were occasions where a face-to-face review or examination of A would have been appropriate, or where a more comprehensive assessment of the history and more detailed management discussion would have been reasonable.

Whilst a number of the reviews and adjustments of medication made by the practice were reasonable, we found that there was a lack of medication review on two occasions.

We found that the documentation of the consultations was often lacking in detail and that there was little history or clinical findings to support clinical decisions taken. On some occasions, consultations were not documented at all. Overall, we upheld the complaint that the practice failed to provide reasonable care and treatment to A.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Consideration should be given to assessing elderly patients with confusion face to face following communications about a deterioration in their condition and any decisions should be recorded. If a decision is taken not to assess a patient in this way, the reasons for this should be recorded.
• Consideration should be given to examining patients following communications about a deterioration in their condition and any decisions should be recorded. If a decision is taken not to assess a patient in this way the reasons for this should be recorded.
• Pain medication should be appropriately reviewed to see if it is adequately working.
• Patients should be given timely, clear and accurate information about the management options for their condition.
• The position in relation to referrals to other specialist services should have been discussed in a timely way without delay.
• The practice should ensure the standard of record keeping meets General Medical Council Good Medical Practice standards.

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

C is a former patient of the medical practice. C complained to the practice that they failed to address their enquiries about their healthcare, which they submitted to the practice in writing and by email. The practice decided that they could not meet C’s expectations and concluded that there was a breakdown in the doctor/patient relationship. The pracitice subsequently removed C from their patient list. C complained to the practice but were dissatisfied with the response that they received.

C complained that the practice failed to respond to C's complaint and earlier correspondence, and that the practice did not follow reasonable process when removing C from their patient list.

In respect of how they responded to C’s correspondence, we agreed that the situation became complex. While C did not always get a response to their correspondence, we concluded that the practice acted reasonably overall. We recognised that the practice were trying to meet the individual needs of their patient, but the situation had become untenable. We did not uphold this aspect of C’s complaint, however we provided feedback to the practice on their handling of the complaint.

With regard to the decision to remove C from the patient list, we concluded that the practice failed to follow General Medical Council (GMC) guidelines as they did not warn C that they were considering removing C from the patient list. We upheld this aspect of the complaint and recommended that the practice apologise to C and take steps to ensure they have an appropriate policy in place.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow GMC guidelines and warn them that they were considering de-registering them from the patient list. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All staff should be familiar with the requirements of the GMC guidelines for ending the professional relationship with 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.

Summary

C made a complaint to the practice regarding the care and treatment provided to their late spouse (A). A attended the practice with pain and a family history of cancer. C said that the practice caused unnecessary suffering and stress to A and their family through misdiagnosis of A's condition. They also said that there was an unreasonable delay in progressing the ultrasound and that this led to poor management of A's pain. A was later diagnosed with lung cancer.

We took independent advice from a general practitioner adviser. We found that overall the practice did provide reasonable care to A. We found that the practice took reasonable steps to investigate A's symptoms and their actions were reasonable based on the information known at the time. As such we did not uphold the complaint.

Summary

C complained about the care and treatment that their parent (A) received from the board. A was admitted to hospital and later discharged into a care home. C complained that during A's admission to hospital, communication with the family was very poor. Despite numerous requests for a call from clinical staff, no contact was made and the family were left with very little information as to A's condition or the treatment that they were receiving. C complained that as a result of this the family did not have sufficient information to make informed decisions about A's care. C said that they could see that A's health was declining. A died a few days later.

A's discharge notes recorded that they had vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory), significant cognitive impairment, and lacked capacity for health and welfare decisions. C highlighted that A's hospital records made no mention of a dementia diagnosis and that this was never discussed with the family. C questioned whether A's capacity to consent to changes in their medication and about treatment was properly assessed.

C complained about poor communication from the clinical team and about the assessment and treatment of A prior to the decision to transfer them to the care home. C said that, had the family known the extent of A's deterioration, they would have arranged for them to be cared for at home, rather than in the care home.

In their response to C's complaint the board acknowledged C's concerns about not speaking with clinical staff. They said that attempts were made for A to be assessed by a Mental Health Liaison Nurse but that this was not possible due to A's level of distress. A was deemed medically stable for discharge to a care home. C was dissatisfied with the board's response and brought their complaint to our office.

We took independent advice from a consultant geriatrician adviser (an expert in the health and care of older adults). We found that A was initially appropriately assessed for capacity to make decisions but that this was not appropriately reviewed during their admission. Further reviews could have resulted in further investigations of A's condition. As a result, we found that the assessment and treatment of A was unreasonable.

With respect to the assessment of A prior to discharge, we found that discharge went ahead without proper consideration of their condition at the time and was therefore unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informa.on-leaflets.

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

• The board should provide us with a full and detailed update as to the outcome of the reviews outlined in their action plan and any resulting changes to policies or procedures.

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

C complained that the practice failed to properly investigate their hip pain symptoms, resulting in a delayed cancer diagnosis. C raised concerns that questions were not asked, or tests carried out, that might have led to an earlier diagnosis. The practice responded to the complaint and carried out a Significant Event Analysis (SEA). They noted that a muscular injury was suspected at the initial consultation. At the time of the second consultation, an x-ray had been incorrectly reported as normal by the hospital. Therefore, the practice were not alerted to any need for further tests at that time.

We took independent medical advice from a GP. We found the practice's management of C reasonable at the initial presentation. However, when C re-presented a month later with worsening bone pain despite a normal x-ray, further investigation (blood tests) should have been carried out. C was then diagnosed after orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) review the following month. We upheld C's complaint. However, given the extensive nature of the disease identified, we did not consider that further investigation by the practice at the second consultation would have altered the overall outcome.

We also found that the SEA should have reflected the further investigation that should have been considered at the second consultation. We gave some feedback to the practice on learning from adverse events, with reference to Healthcare Improvement Scotland's relevant guidance.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out further investigations when they re-presented with ongoing and worsening pain. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Blood tests should be considered when patients present with worsening bone pain.

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

C, an adult with attention deficit hyperactivity disorder (ADHD), autism, and pathological demand avoidance (PDA) complained that the board failed to diagnose their conditions when they should have done.

C told us that the board said they stopped considering diagnosis of conditions such as ADHD and autism when a patient reached the age of 25 years old. C complained that this practice led to them being misdiagnosed which prevented them from obtaining access to appropriate medication, particularly, medication to help with the management of ADHD.

The board said that the understanding of developmental disorders in adulthood, including high functioning autism and ADHD was very limited during the mid 1990s (when C felt they should have been diagnosed). The board felt any potential delay in diagnosis should be considered in line with the expectations and understanding of psychiatric practice at the time. In C's case, it appears C experienced a number of other physical and mental health problems that would not be solely accounted for by diagnoses of autism and/or ADHD, although these conditions may have been predisposing factors.

We took independent advice from a general adult consultant psychiatrist. We found that the timing of the recognition and diagnoses made were reasonable and that there was no evidence to suggest that the recommended treatment for ADHD was delayed or withheld because of prescriptions of other medications. We also noted, at this point in time, there are appropriate guidelines and clinical guidance for clinicians to follow, in relation to pervasive developmental disorders in adults.

Whilst we recognise that C was not diagnosed with ADHD and autism until relatively recently, we consider that the care and treatment provided to C was reasonable in the circumstances at that time. We also consider treatment provided for other diagnosed conditions was reasonable and did not prevent or delay C's later diagnoses of ADHD and autism.

We noted that the board may have diagnosed these conditions differently in the past but did not see any evidence to suggest that the board's current practice fails to consider diagnoses of ADHD and/or autism in adults over the age of 25 years old.

Therefore, we did not uphold C's complaint. We did note that it may have been helpful to carry out a more detailed ADHD assessment before commencing medication and provided the board with some feedback on this point.

Summary

C complained that they did not receive appropriate care and treatment from their GP practice in relation to the diagnosis and treatment of menopause symptoms.

C felt the practice did not take their menopause symptoms seriously and that GPs were not up to date with current guidance when C was offered antidepressants in response to menopause symptoms. As such, C complained that the practice failed to recognise and appropriately treat the symptoms of menopause, leading to a delay in diagnosis and treatment. The practice considered that the care and treatment provided to C had been reasonable.

We took independent advice from a GP. We found that there had been a number of missed opportunities to diagnose menopause, that consideration had not been given to the relevant NICE Guideline NG23 (National Institute for Health and Care Excellence guideline on Menopause: Diagnosis and Management), and that GPs had failed to consider alternative hormone replacement treatment (HRT) preparations during a period of national shortage. This led to a delay in the diagnosis and treatment of C's menopause. As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in diagnosis and treatment of their menopause symptoms. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Where patients report symptoms of menopause, they should be appropriately assessed in accordance with relevant national 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

C complained about the care and treatment provided to their adult child (A) by the board. A had an extensive history of epilepsy and was diagnosed with ictal asystole (a rare but potentially devastating complication of epileptic seizures). A was referred by the board's neurology service (specialists in disorders of the nervous system) to the cardiology service due to ongoing seizures with loss of consciousness which could not be controlled with medication. A was fitted with a pacemaker but later developed severe headaches and a rash. A was advised to stop taking recently prescribed tablets and that the rash was likely caused by the ointment used when the pacemaker was fitted.

A few days later, A was finding it difficult to breathe and called NHS 24. Paramedics attended A at home but A was not admitted to hospital. A phoned NHS 24 again the following day and when paramedics attended, they took advice from an emergency medical consultant at the hospital who advised that A should take paracetamol and see the GP the following morning.

A was advised by the GP to attend the COVID-19 hub where A collapsed and was taken to hospital. A was admitted to hospital and died the following day from sepsis (a life-threatening reaction to an infection).

C complained that the board's cardiology service failed to provide reasonable care and treatment to A. We took independent advice from a consultant cardiologist. We found that there was a failure to provide a clear timeframe on the day of the pacemaker implantation and a failure to take reasonable action when A developed a rash following the procedure. We also found that the board failed to identify the asystole earlier but had already acknowledged this in their complaint response to C. Given these failings, we upheld this part of C's complaint.

C complained that an emergency medical consultant unreasonably told the paramedic that A should take paracetamol and see the GP the following morning. We took independent advice from a consultant in emergency medicine. We found that there were failings in the assessment of A and that given the deranged physiology (disturbance of normal bodily functioning), repeated presentation and symptoms, the advice provided by the emergency medical consultant was unreasonable. Therefore, we upheld this part of C's complaint.

Finally, C complained that a doctor in the COVID-19 assessment centre unreasonably told C to take A home and put them to bed. We found no evidence to support this. Therefore, in the absence of any supporting records, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Full and complete information should be obtained during any virtual assessment of a patient so that advice is appropriately provided and recorded on the basis of that information.

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.