Health

Summary

Mr C complained on behalf of his wife (Mrs A). Mr C complained that, when his wife attended the accident and emergency department at Gilbert Bain Hospital following a fall, she was not given appropriate care and treatment. Mr C also complained that the GPs at Mrs A's GP practice did not provide her with appropriate care and treatment for problems that she had with her legs, and that staff attitudes towards Mrs A at the practice were unreasonable.

We took independent advice from a consultant in emergency medicine and from a GP adviser. We found that, when Mrs A attended the accident and emergency department following her fall, a full and thorough history and assessment were carried out. We considered that the care and treatment provided to her were reasonable. We also found that the care given to Mrs A for the problems with her legs by the GP practice was reasonable, and that there was no evidence that the attitude of practice staff towards Mrs A was unreasonable. We did not uphold Mr C's complaints.

Summary

Mrs C complained to us that the medical practice had failed to provide appropriate care and treatment to her father (Mr A) who had fallen whilst coming out of the shower. Mr A was seen by three GPs from the practice over a two week period, who treated him for a knee injury. Mr A then called an out-of-hours service and was seen by a different GP. It was found he had a fractured hip and he was taken to hospital where a rod and pins were inserted into his leg. Mrs C felt the GPs at the practice had failed to diagnose the hip fracture.

We took independent advice from an adviser in general practice medicine and concluded that at no time during the three GP consultations did Mr A complain of hip pain or hip injury and that there were no symptoms which indicated that his hip was fractured. There was also no report that he was unable to walk or bear weight which would have been an indication of a hip problem. We found that the GPs involved reasonably concluded from Mr A's reported symptoms that he had injured his knee and they provided appropriate treatment. We did not uphold the complaint.

Summary

Mr C was diagnosed with motor neurone disease (MND - a rare condition that progressively damages parts of the nervous system) a number of years ago, and his health has been regularly monitored since then. When his condition did not progress in the way that would be expected of MND he was sent to another consultant neurologist for a further opinion as to the likely cause of his symptoms. This consultant told Mr C that they did not think he had MND. Following that consultation he was seen a few months later by his regular consultant, although the notes from the previous consultation were not available at that time. Once Mr C's regular consultant had obtained the notes, they followed up with a letter to Mr C's GP. In this letter the consultant advised that Mr C was thought to have distal hereditary motor neuropathy (a progressive disorder that affects nerve cells in the spinal cord which results in muscle weakness and affects movement). The letter, a copy of which the GP provided to Mr C, contained a lot of medical terminology. Mr C contacted the consultant's secretary, saying he did not understand the new diagnosis and wanted more information. He hoped to have another appointment at which he could ask some questions, but was given a routine appointment for a year ahead. He was unhappy about the refusal of an earlier appointment, as the matter was causing some anxiety. He also wondered why it had taken so long to reach the new diagnosis.

We took independent advice from a consultant neurologist, who considered the consultant's communications to have been clear and detailed. The adviser noted that a covering letter was sent out after Mr C expressed some confusion about the letter with a lot of medical terminology in it. The adviser considered that this covering letter could have been sent out with the inital letter. Although the adviser was not critical of the clinical care, they considered that it would have been better practice for the consultant to have agreed to seeing Mr C earlier, given that he had been diagnosed with a life-threatening condition and was expressing a lack of understanding about the implications of his new diagnosis. We noted that if this had been arranged it would likely have given Mr C some assurance and may have avoided the need for him to pursue his complaint. We also found that the board did not provide the consultant with clear detail of the complaint to us, and therefore an opportunity was missed to resolve Mr C's complaint at an earlier stage. We upheld this aspect of the complaint.

With regards to the new diagnosis, the adviser explained that there is no single exclusive diagnostic test for MND and that it remains a clinical diagnosis based on examination over a period of time. It was only as time passed, and Mr C's condition did not progress in the way that would be expected of MND, that other rarer conditions were considered. The doctors treating him were alert to this and our adviser had no criticism of his clinical care or the timescale of the diagnosis. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not providing an appointment sooner than his scheduled one to explain his diagnosis in more detail.
• Provide an appointment sooner than the one currently scheduled. This appointment should be with a different consultant.

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

• The consultant should reflect on their refusal of an earlier appointment, taking all of the circumstances into account and in particular the significant change in diagnosis and uncertainty about its implications.

In relation to complaints handling, we recommended:

• The board should reflect on their internal complaints handling, with particular focus on communication, to ensure that clinical staff involved in a complaint are fully aware of the exact nature of the complaint when they are responding to it.

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 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.