Health

Summary

Ms C complained about the care and treatment her late mother (Mrs A) received at Aberdeen Royal Infirmary. In particular, Ms C complained that her mother was not given appropriate treatment at A&E in response to her symptoms. Ms C also considered that her mother should have been transferred to the high dependency unit when her condition deteriorated. Ms C complained that nurses delayed in administering antibiotics and failed to monitor her mother closely enough. Mrs A died of sepsis (a blood infection) several hours after her admission. The board accepted an unreasonable delay in nursing staff administering antibiotics, but considered the care to have been otherwise reasonable.

During our investigation we took independent medical advice from a consultant in emergency medicine and from a nurse. The emergency medicine adviser considered that the standard of medical care and treatment at A&E was of a high standard. They also considered that it was reasonable not to transfer Mrs A to the high dependency unit as her outlook was poor, given her age, the severity of her symptoms and her pre-existing condition. The nursing adviser considered Mrs A was appropriately monitored by nursing staff. We therefore did not uphold these aspects of Ms C's complaint. However, both advisers considered there was an unreasonable delay in nursing staff administering antibiotics, although they considered that this was unlikely to have made any difference to Mrs A's condition. We upheld this aspect of the complaint and we made a recommendation in light of our findings.

Recommendations

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

• Antibiotics should be administered by nursing staff within the agreed timeframe.

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 is an independent mental health advocate, complained on behalf of her client (Mr A) in relation to community mental health (CMH) nursing care Mr A received after discharge from Dr Gray's Hospital. Mr A took a large overdose of alcohol and prescription drugs two weeks after discharge and said that, without the support of his family, he would have completed suicide. In addition to the complaint about nursing care, Mr A also felt that the introduction of occupational therapy (OT) services prior to his discharge could have benefited him and aided his recovery.

We took independent advice from a mental health nursing adviser. We found that the CMH nursing care offered to Mr A had been reasonable. The CMH nurse had visited Mr A within five days of his discharge, which the adviser considered to be good practice. The nurse had appropriately discussed coping strategies with Mr A and had made sure that he was aware of other sources of support available as they were going on leave for two weeks.

The working relationship with the CMH nurse broke down after they returned from leave. Mr A requested a different CMH nurse, but his psychiatrist referred him instead to OT services. This referral was not successful either, again due to problems in the working relationship. We considered that the aftercare provided by the board was reasonable, although the adviser highlighted some shortcomings in the records, which we fed back to the board. The board confirmed that Mr A was involved in his discharge planning, but there was no evidence to support this. Aside from shortcomings in record-keeping, we considered the CMH nursing care provided to Mr A to have been reasonable and we did not uphold Mr C's complaint.

We considered that OT services would largely have overlapped with the support being offered by the CMH team, and saw no evidence to support the complaint that OT input in hospital would have made a significant difference to how Mr A coped post discharge. We did not uphold this complaint.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by the practice. In particular, she complained that Mrs A had not been seen by a medical professional before antibiotics were prescribed to her, and, futher, that she had not been seen when the antibiotics were subsequently changed.

We took independent advice from an advanced nurse practitioner. We found that a home visit should have been carried out before the antibiotics were prescribed to Mrs A and that, as such a visit did not take place, it was even more important that a review should have been undertaken of Mrs A before her antibiotics were changed. The advice we received was that there was a lack of detail in the clinical records and that it was not clear from the records what symptoms Mrs A had when the decision to change antibiotics was made. We were concerned that the practice had failed to follow guidelines that all older patients suspected of having a urinary tract infection, like Mrs A was, should be seen and fully examined. In light of these failings, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the practice had inappropriately decided not to undertake a home visit after she had contacted them a number of times. We found that, when the visit was requested, Mrs A had deteriorated and she needed to be seen or arrangements needed to be made for admission to hospital. We also found that, whilst reasonable advice had been given to Mrs C to contact the ambulance service if Mrs A's condition deteriorated, there was a delay in this advice being given to Mrs C. The practice accepted that a home visit should have been carried out. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the member of staff she was complaining about had responded to her complaint. We found that neither the Scottish Government guidance on complaints handing which was in place at the time of the complaint, or the new NHS Scotland model complaints handling procedure introduced since the complaint was made, specified that the person being complained about should not handle a complaint. In view of this, we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in relation to the clinical treatment provided to Mrs A and for the failure to carry out home visits.

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

• The practice should follow guidelines in relation to diagnosing urinary tract infections in adults aged 65 and over.
• The practice should maintain records in line with relevant 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

Mrs C complained about the care and treatment of her late mother (Mrs A). Mrs A became unwell and was seen initially by an out-of-hours doctor, who diagnosed infection and prescribed antibiotics. Mrs C called the practice and spoke to a GP the following day as Mrs A was still unwell, and a home visit was arranged for the following day. When a GP reviewed Mrs A at home the next day, arrangements were made to admit her to the GP unit in a local care home. From there, she was transferred to hospital in the early hours of the following morning, where she deteriorated and died five days later.

Mrs C complained that, when she called the practice, they did not arrange for Mrs A to be reviewed that day. We took independent advice from a GP adviser, who considered that the GP carried out an appropriate assessment and, based on the information gathered, took steps to arrange for Mrs A to be reviewed within a reasonable timescale. We accepted the advice and did not uphold the complaint.

Mrs C also complained that the GP who reviewed Mrs A at home should have arranged to admit her directly to hospital. She also raised concerns that the GP retrospectively altered Mrs A's recorded oxygen saturation level. The practice indicated that this was to rectify a typing error. We were advised that the originally recorded level should have led to a direct hospital admission, whereas the amended level was in keeping with the actions taken. We were unable to establish the true picture and, therefore, could not conclude that there was an unreasonable failure to admit Mrs A to hospital. As such, we did not uphold the complaint however we made a recommendation in relation to record-keeping.

Recommendations

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

• The practice should take steps to clarify whether the entry in the clinical records accurately reflects the date that it was retrospectively amended. If it does not this should be rectified to ensure complete clarity.

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 of her late mother (Mrs A), initially by an out-of-hours doctor and then following an admission to Aberdeen Royal Infirmary. The out-of-hours doctor visited when Mrs A became unwell and diagnosed infection, prescribing antibiotics. Two days later Mrs A was admitted by her GP to a GP unit in a local care home. From there she was admitted to hospital in the early hours of the following morning with sepsis (a blood infection) secondary to pneumonia. After an initial improvement, she deteriorated and died five days later.

Mrs C complained that the out-of-hours doctor should have admitted her mother to hospital. We took independent advice from a GP adviser, who considered that the doctor appropriately assessed Mrs A and treated her in line with relevant guidelines. We were advised that there were no clear signs at the time that might reasonably have led the doctor to suspect a diagnosis of pneumonia and necessity for hospital admission. We accepted this advice and did not uphold the complaint.

Mrs C also complained that the family were told by hospital staff to administer Mrs A's regular medication from her own supply, and also that there was a 12 hour delay in commencing treatment for her presenting condition. We took independent advice from a hospital adviser, who confirmed that it was not good practice to expect relatives to administer medication. However, the board had already acknowledged this and appropriately highlighted the issue to staff. The adviser noted that the medication was appropriately recorded so no safety issues were apparent. In terms of treating Mrs A's presenting condition, the adviser noted that she had a NEWS score (an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration. A NEWS score of five or more is linked to increased likelihood of death or admission to an intensive care unit ) of seven on admission. This elevated score should have prompted early recognition of the severity of the illness and more timely treatment. The adviser considered that a 12 hour delay in commencing antibiotics was unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the unreasonable delay in commencing antibiotic treatment following Mrs A's admission. 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:

• Patients with an elevated NEWS score should be promptly investigated and treated.

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 had a scan at the Golden Jubilee National Hospital. A mass was discovered on his lung, which could have been either a spread of his existing bowel cancer or a new lung cancer. His consultant arranged some tests to help determine which it was, but because they were busy, they asked another consultant to carry out the tests. Both consultants thought that the other would be responsible for Mr C's ongoing care, so neither of them wrote a discharge letter. While Mr C attended a follow up appointment at the second consultant's clinic, he saw another doctor who referred him back to the first consultant, instead of to the multi-disciplinary team (MDT), which is what should have happened. The first consultant did not see the referral.

Mr C and his GP both tried to contact the first consultant to find out what was happening, but it is not clear whether Mr C's phone messages were passed on and his GP's letter was not seen by the first consultant. Eventually, about six months after the scan, Mr C's GP spoke with the first consultant, who then referred Mr C to the MDT for consideration and Mr C was offered palliative radiotherapy. Mr C was told that his cancer was terminal, and he was concerned that the delay may have affected this outcome. He complained to the board about this.

In response to Mr C's complaint, the board accepted that there was an unreasonable delay and a failure to communicate with Mr C about his treatment. They apologised for this and said that they had taken action to prevent this happening again. The board had put in place a new protocol for passing care between two consultants, and a message book to ensure phone messages are recorded and signed off by consultants. The board said that the delay would not have affected the outcome in Mr C's case, although they acknowledged that palliative radiotherapy should have been offered sooner. Mr C remained unhappy and brought his complaints to us.

We took independent advice from a thoracic surgeon (a surgeon who deals with treatment of conditions of the organs inside the chest). We found that the delay in arranging treatment for the mass on Mr C's lung was unreasonable. We upheld this complaint, however we noted that, although Mr C's cancer grew during this time, the delay would not have affected his outcome, as surgery or radical radiotherapy would not have been available even if he had been considered immediately. As the board had already put in place measures to avoid this happening again in the future, we did not make any further recommendations in this regard.

Mr C also complained that the hospital failed to communicate reasonably with him about the arrangements for his treatment. We found that there were failings in communication, including a failure by the first consultant to pick up on two important letters. We upheld this aspect of Mr C's complaint. We noted that the board had already taken some steps to avoid similar failings occuring in the future, however we made a further recommendation regarding mail processes.

Recommendations

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

• Consultants should have robust mail processes in place to ensure that important letters are not missed or overlooked.

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 her husband (Mr A) received at Forth Valley Royal Hospital. Mr A was admitted to hospital after sustaining a fracture to his thigh bone. An operation was carried out to insert a pin into the thigh bone to secure the fracture. During the operation, the wrong size of screw was used to fix the pin to the bone. Medical staff discussed this situation with Mr A following the operation, and it was agreed that a further operation would be carried out to replace the screws with those of a correct size. This operation was completed successfully and, after a period of recovery, Mr A was discharged home. Mr A was then re-admitted to hospital after he became unwell. The board carried out blood tests which showed signs of infection, yet it was not clear where the source of the infection was. Mr A's condition deteriorated and he died from a bowel condition related to the infection.

Mrs C complained that the wrong screw was used in the first operation and she felt that the second operation had caused the infection that led to Mr C's death. The board apologised to Mrs C about the use of the wrong screw and informed us that this issue had been discussed at a number of clinical meetings in order to prevent the issue from happening again.

We took independent advice from a consultant orthopaedic and trauma surgeon. They considered that the care and treatment provided to Mr A was reasonable, with the exception of the use of the incorrect screws. The adviser said that, in their opinion, the infection related to Mr A's re-admission was not linked to the orthopaedic treatment he received. Although we were unable to conclude that the orthopaedic treatment received led to Mr A's death, we upheld this complaint and asked that the board send us evidence of the steps they said they had already taken to prevent this from happening again.

Summary

Mrs C complained about the care and treatment her husband (Mr A) received during an admission to St Andrew's Community Hospital for a period of rehabilitation. She complained that Mr A's suspected urinary tract infection and delirium were not treated appropriately and with sufficient urgency, thus prolonging his admission unnecessarily. She also raised concerns that he was inappropriately sedated over the weekend prior to discharge.

We took independent advice from a GP adviser who considered that Mr A received appropriate treatment for his infection symptoms and delirium. They noted in particular that his blood results were negative for infection when Mrs C first requested more aggressive antibiotic treatment. The adviser also considered it clinically reasonable to prescribe a sleeping tablet as a trial to treat restlessness at night, although they said that it would have been good practice for staff to have discussed this with Mrs C in advance. The board had already acknowledged that it would have been helpful for this to have been discussed with Mrs C. We accepted the advice received and concluded that the medical care provided to Mr A was reasonable. We did not uphold the complaint.

Summary

After the birth of her child at Borders General Hospital, Mrs C made a number of complaints about the procedures involved. She said that there was a failure to obtain properly informed consent for intimate examinations and that the board provided incorrect information about who had acted as a chaperone. She also complained that the board did not ensure that she was anaesthetised by an anaesthetist of sufficient seniority given that she had scoliosis (a musculoskeletal disorder in which there is a sideways curvature of the spine). Mrs C also complained that she and her new born baby were not given reasonable nursing care when she was in hospital.

The board said that they had followed their usual practice of obtaining implied consent to treatment set against a background of the clinical care they had already given. They also said that they had provided the correct name of the chaperone as requested and that Mrs C's spinal injection had been performed by both a consultant and a senior trainee. They were also of the view that Mrs C's nursing care had been reasonable.

We took independent advice from a consultant in obstetrics and gynaecology and a consultant in obstetrics and general anaesthesia. We also took independent nursing advice. We found that implied consent was insufficient for intimate examinations and that consent must be recorded in patients' notes. It was not recorded in Mrs C's notes and, therefore, we upheld this complaint.

Regarding Mrs C's other complaints, we found evidence in the notes to confirm who had acted as chaperone and we found that Mrs C had been given her anaesthetic reasonably by clinicians of appropriate seniority and expertise. We found no evidence of unreasonable nursing care. As such, we did not uphold these aspects of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to seek formal consent for intimate examinations.

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

• The board should develop a guideline on consent for intimate examinations and the use of chaperones, with reference to national guidance, including documentation.

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 that staff at the dental practice had failed to deal appropriately with his concerns that his gums continued to bleed after having four teeth extracted. He was on warfarin medication (a medication to prevent blood clots) which meant that he was at high risk of bleeding. He reported this to the dentist, who said that it would be alright and he could leave the practice. When Mr C got home, the bleeding continued and he contacted the practice again and was asked to attend. He saw a second dentist who also said that he was not to worry and that the bleeding would stop. However, the bleeding continued that evening and Mr C had to attend hospital, where the bleeding eventually stopped and he was sent home.

We took independent advice from an adviser in general dentistry and concluded that the second dentist was aware that Mr C was on warfarin medication and that they had repeated the advice given earlier by the first dentist about what Mr C should do in the event of bleeding from his gums. We considered this to be reasonable and we did not uphold the complaint.