Health

Summary

Mrs C attended two consultations with the practice who had recently taken over from her previous practice. She had attended her previous practice five years earlier after she had experienced an increase in epileptic seizures.

Mrs C complained that, during these two consultations, the practice unreasonably focussed on the events of five years previously. She raised concerns that the practice placed undue focus on the reporting requirements of the Driver and Vehicle Licencing Agency (DVLA) and she found it difficult to get her health concerns across. Mrs C also complained that, during the first consultation, she was unreasonably prescribed the wrong dosage of epilepsy medication.

We found that the first of the two consultations was Mrs C's first with the practice altogether, following them taking over the running of her local practice. Her prior consultation with her previous practice noted concerns about the management of her epilepsy and an intention to notify the DVLA. We took independent medical advice from a GP, who confirmed that DVLA guidance requires patients with epilepsy to notify them. We considered that it was reasonable for the practice to discuss Mrs C's epilepsy and DVLA reporting requirements during her consultations. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that she was prescribed the wrong dosage of her epilepsy medication. We found that there had been a prescribing error and that the practice did not address this when responding to Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint. However, we noted that the practice acknowledged that the error was their fault and that this was fixed before any medication was actually issued.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the prescribing error and for failing to address her complaint about this.The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-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

Mrs C complained about the care and treatment provided to her late husband (Mr A) at University Hospital Ayr. Mrs C felt that Mr A was kept in the emergency department for too long before being admitted to the hospital, and that he was not appropriately assessed during this time.

We took advice from a consultant in emergency medicine and a stroke consultant. We found that, overall, the care provided to Mr A by the emergency department staff was reasonable but that they failed to complete transfer observations and handover documentation. We found that the initial assessment of Mr A by the stroke team was poor. We acknowledged that the diagnosis of a stroke, such as the one Mr A suffered, can be difficult to diagnose, however, we found that there was a failure to scan Mr A in the appropriate manner and reasoning for decisions made were not documented clearly. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that there was a lack of communication to keep her advised of Mr A's diagnosis and treatment. We found that, overall, the medical records showed a reasonable level of communication with Mrs C and, therefore, we did not uphold this aspect of her complaint.

Finally, Mrs C complained that the board's handling of her complaint was unreasonable. We found that, throughout the complaints process, there had been a number of failings including delays and a lack of communication. Therefore, we upheld this aspect of Mrs C's complaint. However, since these events occurred, a new complaints handling policy had been implemented by the board and we therefore made no further recommendations on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with appropriate clinical treatment; and for failing to handle Mrs C's complaint in a reasonable manner. 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:

• Transfer observations and handover documentation should be completed appropriately by the emergency department to ensure patients are safe to be transferred and appropriate information is passed on to the receiving ward area.
• Assessments made by members of the stroke team, and reasoning for any decisions made, should be documented clearly.

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 (Mrs B). Ms C raised concerns that the board did not take appropriate action in relation to an ulcer on Mrs B's daughter (Ms A)'s heel. Ms A had a number of complex health conditions, including diabetes, and Ms C complained that neither the podiatrist that saw Ms A, nor the surgeon that saw her, raised any alarm about the fact the heel wound was getting worse.

We took independent advice from a podiatrist and from a surgeon. We found that Ms A should have been seen by the lead podiatrist at an earlier point and that this may have resulted in a swifter referral to a specialist team. We also found that the podiatry team failed to appropriately use diabetic foot screening tools. We further found that the surgeon that saw Ms A recommended a treatment that would not be normal practice and did not document any reason for this. We found that whilst they reasonably arranged a scan for Ms A's foot, this should have been done at an earlier point, and a management plan should have been made. We also found that the board's own complaints investigation did not identify or address the failings in the care provided to Ms A.

We upheld this complaint. However, since the events of this complaint, the board had implemented a detailed and comprehensive action plan to improve the care pathways for diabetic feet, which we found reasonable. We, therefore, limited our recommendations to areas which we felt had not been covered by the board's action plan.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. 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 diabetic foot ulcers should be referred to the lead podiatrist or the vascular service as appropriate in a timely manner, and diabetic foot ulcers should be assessed in line with diabetic foot screening tools.
• In similar cases, surgeons should be aware of what action to take.

In relation to complaints handling, we recommended:

• The board's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

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 (Mrs B). Ms C raised concerns that Mrs B's daughter (Ms A) had not been provided appropriate care and treatment for an ulcer on her heel by practice nurses. Ms A had complex health conditions, including diabetes, and over several months practice nurses were dressing and monitoring the ulcer on her heel. The wound deteriorated and Ms A had to have an above the knee amputation as a result.

We took independent advice from a practice nurse. We found that the dressings and wound cleansing products used by the practice nurses were not in line with guidance, and that the ulcer was not assessed in line with Scottish Intercollegiate Guidelines Network guidelines. We also found that, given Ms A's other health conditions, the practice nurses should have taken steps to involve other specialisms at an earlier point. We found that it was not possible to say whether an earlier referral to a specialist would have prevented the deterioration in the wound, but we found that it would have resulted in a more controlled care experience. We also found that the practice's own complaints investigation did not identify or address the failings in the care provided to Ms A. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to take appropriate action in relation to Ms A's heel wound and for failing to identify these issues in the complaint response. 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:

• Practice nurses and other clinical staff within the practice should be practising in accordance with the agreed wound formulary, unless there is a clear and robust clinical reason for opting for a non-formulary product, in which case, this should be clearly documented.
• Management of diabetic foot ulcers should be carried out in accordance with Scottish Intercollegiate Guidelines Network guidelines for the management of diabetic foot ulcers.
• Expert input should always be asked for if dealing with a difficult wound that is not healing.

In relation to complaints handling, we recommended:

• The practice's complaints handling procedure should ensure that failings (and good practice) are identified, and should enable learning from complaints to inform service development and improvement.

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 he had been refused a patient escort to his hospital appointment. Mr C lives far away from the hospital and said that he could not travel on his own due to his health conditions. The board said that Mr C did not meet the criteria for a patient escort.

We took independent advice from a nurse. They said that there was insufficient evidence to demonstrate that the board had reasonably assessed Mr C's health conditions and their impact on his ability to travel. We considered that it was not clear why Mr C did not meet the criteria and what, potentially, would be sufficient to meet the criteria. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with a full rationale for the decision not to allow him a patient escort.

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 attended the dentist to receive restoration treatment which included having a filling replaced, and previous fillings smoothed over as they still had overhangs of amalgam (mixture used to fill the teeth). The dentist who provided the treatment was undergoing vocational training, and was supervised by another dentist. Miss C complained that the treatment she received was below a reasonable standard.

We took independent advice from a dentist and found that overhangs of amalgam were still partially present, despite having been smoothed, and a significant gap was created between two teeth. Both the remnant amalgam and the gap were risks to Miss C's dental health, in particular as she had an underlying risk of tooth decay. We found that the treatment provided to Miss C was below a reasonable standard and, therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for providing treatment below a reasonable standard. 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 dentist's supervisor should ensure that the dentist has a periodontal update, concentrating on the impact of poor restoration contouring.

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, an advocacy and support worker, complained on behalf of her client (Mr A) about the care and treatment he received at Ninewells Hospital. Mr A suffered an injury in which his fingertip was severed at the joint and he wanted to have surgery to have it reattached. However, he was referred for terminalisation surgery (where the finger is shortened and the remaining soft tissue is used to cover the amputated finger stump) instead. Following the surgery, Mr A experienced severe pain and his injury did not heal as quickly as he had hoped. Ms C complained that the board failed to provide Mr A with appropriate medical treatment and that nursing staff failed to appropriately assess and manage Mr A's pain before discharging him home.

We took independent medical advice from a plastic and hand surgeon, and from a nurse. The plastic and hand surgeon adviser considered that terminalisation surgery was the appropriate treatment for Mr A's injury. They explained that the outcome of reattachment surgery was likely to be poor and had higher risks than terminalisation surgery. Therefore, we did not uphold this aspect of Ms C's complaint.

The board accepted that Mr A's pain was not assessed and managed by nursing staff prior to his discharge and apologised for this. They explained that action had been taken to ensure learning from this case. The nursing adviser considered the nursing care was unreasonable so we upheld this aspect of Ms C's complaint. We asked the board to provide evidence of the action they have taken.

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr A). Mr A had an operation at Ninewells Hospital and continued to suffer pain for over a year after the operation. Ms C complained that:

Mr A suffered unreasonable pain after his operation;

Mr A had to wait an unreasonable amount of time to be assessed about his pain management;

the board took an unreasonable length of time to establish the source of Mr A's pain;

the board provided an unreasonable treatment pathway for Mr A's chronic pain; and

the board unreasonably failed to tell Mr A that he could have obtained alternative treatment outwith their area.

We took independent advice from consultants in surgery, anaesthetics and pain management. We found that Mr A did have to wait too long for a referral to the pain clinic, where there were further delays in him being seen. We upheld Ms C's complaint that Mr A had to wait an unreasonable amount of time to be assessed about his pain management.

We found that Mr A did suffer from pain after his operation, but that the care and treatment he had been given had been reasonable. We also found that the approach used to assess Mr A's pain was the correct approach, though it did take time. We found that Mr A's treatment options within the board had not been exhausted. We, therefore, did not uphold any of the other aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delays in him being seen by the pain clinic. 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:

• Action should be taken to ensure that patients are seen in a timely manner.

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 treatment a dentist provided to her over a number of years. We took independent advice from a dental adviser. We found that there was a failure by the dentist to observe decay in three teeth, and possibly other teeth. Consequently, the dentist failed to plan for the management and treatment of the affected teeth. This meant that Miss C's decay profile was wrong, and she did not receive the level of observation and intervention needed, which led to an increase in the risk of decay and a significant impact on the health of her gums. We also found that fillings placed by the dentist were of a poor standard. We concluded that the treatment provided to Miss C was below a reasonable standard and we upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to observe decay, which meant a failure to plan appropriately for the management and treatment of her teeth. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• The dentist should make a payment to Miss C, equivalent to the costs of care and treatment provided (excluding an amount already paid as a goodwill gesture) as redress for Miss C not getting the level of observation and intervention needed.

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

• The dentist should ensure that they have the professional knowledge and skills to understand and act on decay diagnosis on radiographs.
• The dentist should ensure that they have the professional knowledge and skills to achieve proper placement and finishing of fillings within teeth.

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 and Mrs C complained that midwives at Gilbert Bain Hospital failed to recognise that Mrs C had hyponatraemia (low blood sodium levels). Mrs C was given advice to drink more fluids, which made her condition more severe. Mr and Mrs C also complained that the board failed to handle their complaint and the review into Mrs C's care appropriately. In particular, they considered the review wrongly concluded Mrs C had a condition called syndrome of inappropriate antidiuretic hormone production (SIADH - the excessive secretion of antidiuretic hormone resulting in, among other things, water retention and dilution of the blood) when she actually had hyponatraemia. Mr and Mrs C considered the board failed to identify appropriate learning from the review and share it with them.

The board accepted that Mrs C was given inappropriate advice to drink fluids by midwives. However, they said it was unreasonable to expect midwives to have recognised she had SIADH, as it is very rare. The board considered they had undertaken a thorough review of Mr and Mrs C's care and complaint. They explained they had taken learning from it forward by training staff on recognising SIADH.

During our investigation we took independent medical advice from a midwife and from a consultant in general medicine.

The midwife adviser considered that the midwives carried out appropriate observations and tests in light of Mrs C's symptoms. They considered the advice given to Mrs C to drink more fluids was reasonable in light of those symptoms. Therefore, we did not uphold this aspect of the complaint.

The midwife adviser considered that the board undertook an appropriate review into Mrs C's care. However, there was a delay in sharing the action plan with Mr and Mrs C. The general medicine adviser considered it was reasonable that the board diagnosed Mrs C with SIADH following the review. They explained that Mrs C had hyponatraemia, which can have many causes, one of which is SIADH. However, given hyponatraemia is much more common than SIADH, the general medicine adviser considered the board should have trained staff on recognising and treating hyponatraemia as well as SIADH. In light of the failings we found in identifying learning from the review and in sharing it with Mr and Mrs C, we upheld this aspect of the complaint. We made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to appropriately identify the learning from their case and share it with them at the time. 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:

• Reviews should be transparent and any learning should be shared with all those involved in the adverse event, including patients.
• The board should provide a reasonable standard of care to patients with hyponatraemia, whatever its underlying cause, with adequate staff training in place to support this.

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.