Health

Summary

Ms C complained about the medical practice on behalf of her five-year-old son. Ms C complained that the GP failed to diagnose her son's tonsillitis over the course of two appointments. Ms C told us that the GP should have diagnosed tonsillitis rather than referring her son to the paediatric team at a hospital in the board's area. The practice advised that, at the first appointment, the GP had been able to examine Ms C's son, despite him being upset. The GP did not observe any infection, and based on his symptoms, diagnosed Ms C's son with hand and mouth disease. At a second appointment, the GP examined Ms C's son. At this appointment the GP had not been able to take all of the measurements they had wanted to during the consultation. As a result, the GP felt that the diagnosis was unclear and referred Ms C's son to the paediatric team at the hospital. Ms C also complained that the GP refused to arrange an ambulance to transport her son to the hospital. The GP offered patient transport, however Ms C felt that this was not suitable as it would have taken too long.

We took independent GP advice. The adviser examined the records and confirmed that the GP examined Ms C's son in line with General Medical Council (GMC) guidance. The adviser confirmed that it was appropriate for the GP to refer Ms C's son to the hospital given that he was presenting with persistent symptoms. The adviser also confirmed that the GP's actions regarding transport to the hospital were appropriate as ambulances should only be used in an emergency. We found no evidence that the GP had failed to provide the appropriate clinical treatment. We did not uphold this complaint.

Summary

Mr C complained on behalf of his late brother (Mr A), who had been a patient at Monklands Hospital. Mr A went missing from the ward but staff failed to notice his absence for a period of several hours. Subsequently, Mr A died outwith the hospital premises a few days later. Mr C complained to the board about the care and treatment they provided to Mr A. His complaints related to observation, medication and shared accommodation on the ward.

In response to Mr C's complaints, the board carried out a significant adverse event review (SAER), which is a type of investigation designed to identify what, how and why a particular adverse event happened. The SAER concluded that ward staff had not observed Mr A properly in terms of their procedures and, therefore, his care fell below a reasonable standard. The review also found that, when Mr A's absence was established, staff did not properly share this information with each other and did not escalate the matter in a timely manner. As a result of the failings identified by the SAER, the board took action to address these issues. Mr C then brought his complaints to us.

We took independent advice from two clinical advisers. We found evidence to support that Mr A's medication was appropriately managed. In addition, his transfer from a single room to shared accommodation was reasonable. Although the board's SAER found that staff had not properly observed Mr A, we were critical that the SAER did not explore the reasons why this failing occurred. We were also concerned that the SAER did not identify evidence of poor recording-keeping by staff in terms of Mr A's medical and risk assessments. We considered that Mr A may have been at higher risk than what had been determined. Due to the poor standard of record-keeping we could not conclude for certain whether Mr A's observation level should have been increased. However, we considered that a greater awareness was required by staff. Whilst we noted that further steps had been taken by the board to address the failings they had identified, we recommended additional action to be taken to ensure these issues do not happen again.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the poor record-keeping and for the failings identified in relation to observations. 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:

• Standardised documents relating to medical and risk assessment should be completed properly.
• The board should ensure that adverse event reviews adequately identify all failures and the underlying causes of untoward events, in line with relevant guidance.
• The findings of this complaint should be fed back to relevant staff in a supportive way.
• Time off the ward should be properly documented and failure to return plans should identify when a patient fails to return to the ward.

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 to us that the board had failed to provide reasonable care and treatment to his late sister (Ms A) when she was admitted to Wishaw General Hospital. Ms A had injured her hip in a fall. Scans were carried out in the hospital to explore concerns that she may have fractured her pelvis. These scans did not show any obvious fractures and Ms A was discharged from hospital two days after her admission.

Ms A died several days later. A post-mortem was carried out and the cause of death was found to be deep vein thrombosis (DVT) resulting in pulmonary embolism (where a blood clot in the leg travels up and blocks one of the blood vessels in the lungs). Mr C complained that Ms A had not been given any medication to prevent this when she was discharged from hospital.

We took independent advice from a consultant trauma and orthopaedic surgeon. We found that a risk assessment for DVT should have been carried out when Ms A was admitted to the hospital ward, but that there was no evidence this had been done. Ms A's risk of DVT should also have been reviewed during her period of admission and this would have indicated that she was at increased risk of DVT.

We found that Ms A should have been prescribed medication to prevent DVT on the night she was admitted. There should also have been a documented discussion about whether she should receive this medication when she was discharged, although the records suggested that she had regained her full mobility at that time. A formal risk assessment for DVT when Ms A was admitted to hospital would have provided enough concern for her to be prescribed TED stockings (stockings that help to prevent blood clots) whilst she was a patient and also on discharge. Given these failings, we upheld Mr C's complaint, although we were unable to say whether or not adequate treatment would have prevented Ms A's death.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide appropriate care and treatment to Ms A. 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 admitted to hospital should be assessed for DVT risk in line with national guidance, appropriate treatment should be instigated and the patient's DVT risk should be routinely reviewed during their stay in hospital.
• Patients, particularly those admitted to an orthopaedic department, should be adequately assessed for their safety before discharge and the assessment should be clearly 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

Mr C complained that the board did not obtain his consent to carry out a vasectomy (a procedure where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) at Hairmyres Hospital, as he said that he was not fully advised of the risks in advance. He also complained that his vasectomy was not performed appropriately, as afterwards he developed complications such as a blood clot and chronic pain.

We took independent advice from a consultant urologist. The adviser considered that Mr C was properly told about the risks of having a vasectomy in advance. However, the adviser said that Mr C should have been given or emailed an information leaflet, instead of being directed to a website for information about vasectomies. The adviser also considered that the consent form Mr C signed for the procedure should have included the need to use contraception until sterilisation (inability to reproduce) had been proven.

The adviser found that a highly unusual step was taken to complete the vasectomy. The adviser considered that it was not reasonable to do this without Mr C's specific consent, as it could have increased the risk of complications. Even if Mr C's consent had been obtained, the adviser considered that it would not have been reasonable to take this step, as it would not have made procedure easier to carry out. In addition, the adviser found a discrepancy between the typed and handwritten records of the procedure, which was of concern. The adviser also found that Mr C should have been given surgical stockings after the procedure to prevent deep vein thrombosis. We upheld both aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain appropriate consent from him and for failing to carry out the vasectomy to a reasonable standard. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients should either be given copies of the information leaflets or better guidance about how to find them, if they are directed to a website.
• The vasectomy consent form should tell patients to use back-up contraception (until they have provided enough semen specimens that are clear of sperm to confirm sterilisation has been achieved).
• Staff should ensure that more complex vasectomy cases are identified in advance of anaesthesia, so that additional or unusual steps can be planned with patient consent.
• All procedures should be appropriately documented in the medical records.
• The clinicians involved should reflect on the adviser's comments that it was not reasonable to take the unusual step that they did take to complete Mr C's vasectomy.
• Patients should be given surgical stockings to prevent deep vein thrombosis, unless it would cause the patient harm.

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, who is a solicitor, complained on behalf of his client (Mrs B) about the care and treatment provided to Mrs B's late brother (Mr A) during three admissions to Monklands Hospital in the months leading up to his death. Mr A suffered from alcohol liver disease and hepatic encephalopathy (a deterioration of brain function due to liver failure). Mr C complained that the medical care and treatment provided to Mr A was not of a reasonable standard, that the nursing care was unreasonable, that the communication with the family was poor and that the board failed to adequately investigate and respond to complaints.

Regarding medical care and treatment, the family were particularly concerned that Mr A had been discharged following his second admission when they felt he was not medically fit to be discharged. We took independent advice from a consultant physician and from a senior nurse. We found that Mr A's fitness was appropriately assessed at that time. We also found that, while on the whole Mr A received a reasonable standard of care and treatment, there were some failings in medical care and record-keeping. Specifically, we noted that a final discharge summary was not completed following Mr A's first admission, and that the actual date of discharge was not clear from the notes. We also found that, when Mr A suffered a fall overnight, he was not reviewed by a doctor until the following afternoon. The advice we received was that this review should have happened in the morning. We were also critical that, when this review did take place, the doctor who reviewed Mr A failed to document this assessment. The family had also expressed concerns about Mr A's weight loss and the board had said that this was due to deliberate fluid loss. Whilst we found that deliberate fluid loss was a factor, we considered that there was also a nutritional element that should have been acted upon sooner. In light of these failings, we upheld Mr C's complaint about medical care and treatment.

Mr C raised several concerns about the nursing care and treatment provided to Mr A. We identified that nursing staff had failed to make medical staff aware of a vomiting episode on the morning of Mr A's discharge following his second admission which, had it been shared, may have influenced the medical staff's thinking when assessing Mr A's fitness for discharge. However, we found that this appeared to be an isolated failing, which the board had already acknowledged and apologised for. The family had also been concerned that an appropriate package of home care was not in place for Mr A following his second discharge. We found that adequate arrangements were made, and we noted that responsibility for the delivery of these arrangements lay with social services and not the board. We did not uphold Mr C's complaint about nursing care.

In terms of communication, we found inconsistencies and a lack of clarity in the information conveyed to the family about the seriousness of Mr A's condition. We found that the language used may not have helped the family to fully understand that Mr A's illness was terminal. The family had also raised concerns that their repeated requests to speak to another consultant were not actioned. The board had noted that these requests did not appear to have been passed on, and they had agreed to implement a process to document requests for meetings with medical staff in the future. Overall, we concluded that the communication with the family was not of a reasonable standard and we upheld this complaint.

In relation to complaints handling, we considered that the board could have responded in more detail and could have provided clearer explanations in some instances. However, given the complexity of the complaint and the significant number of issues raised, we were satisfied that, on the whole, the board's response was reasonable and proportionate, and that considerable time and effort had been spent attempting to address the family's concerns. On balance, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the identified failings in relation to medical care and treatment, medical record-keeping and communication.

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

• Patient discharge dates should be clearly recorded in the clinical notes.
• Medical reviews should take place within a reasonable timeframe following patient falls.
• Medical reviews should be documented in patient records.
• Medical staff should ensure they remain aware of patients' nutritional status and take appropriate action to address any identified malnutrition.
• Consistent information should be provided, and clear language should be used, when communicating with patients and their relatives regarding the patient's condition and prognosis.

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 to us that staff at the dental practice unreasonably informed him that he was exempt from NHS charges for dental treatment. Mr C said that, when he started a course of dental treatment at the practice, he told the staff that he was in receipt of carer's allowance and they completed a form and said that he would be exempt from NHS treatment costs. He was subsequently contacted by NHS Counter Fraud Services who said that he had fraudulently claimed exemption as he had completed the form stating that he was in receipt of income-based Jobseeker's Allowance, which was not the case. Mr C was asked to pay the costs of the NHS treatment along with a penalty charge. He maintained that while he had signed the form, he had not ticked the box which stated that he was in receipt of income-based Jobseeker's Allowance.

We took independent advice from an adviser in general dentistry and concluded that there would have been a discussion with staff about whether Mr C was exempt from charges. There was reference in his dental records that Mr C thought he was exempt from charges as he was a full time carer. We were unable to establish who had ticked the box to indicate that Mr C was in receipt of income-based Jobseeker's Allowance, but the form did contain Mr C's signature. The staff maintained that they would not have ticked the box as they do not know the patient's financial situation and that the onus was on the patient to ensure that they were signing a form which was accurate. It was noted that following Mr C's representations, NHS Counter Fraud Services had waived the penalty charge aspect and therefore he was only liable to pay the costs of the dental treatment. We did not uphold the complaint.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr A) at Raigmore Hospital over a number of months leading up to his death. In particular, she said that his medical care was poor. Mrs C said that, despite his many illnesses and poor prognosis, Mr A underwent surgery which may have extended his life but that this was at the expense of his quality of life. She also raised concerns about the nursing care provided to Mr A and complained that the communication with herself and Mr A about his illnesses was not clear.

We took independent advice from a consultant surgeon and from a nurse. We found that Mr A's medical care and treatment had been in keeping with standard practice in Scotland. We found that his care had been fully discussed with him and that he had agreed to the treatments he was given. Accordingly, we did not uphold this aspect of Mrs C's complaint. Similarly, we did not uphold Mrs C's complaint about poor communication as there was evidence to show that matters had been fully discussed with Mr A and Mrs C. However, we found that Mr A's nursing care had not been reasonable as we found that the notes kept were poor and were not completed in accordance with the Nursing and Midwifery Council code. We upheld this part of the complaint.

Recommendations

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

• Documentation should be completed as required in accordance with the Nursing and Midwifery Council code.

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 on behalf of her daughter (Mrs A) about the care and treatment provided to Mrs A at Raigmore Hospital. In particular, she complained that the board had failed to provide reasonable care and treatment when Mrs A had first attended the breast clinic at Raigmore Hospital and that Mrs A's breast cancer, which was diagnosed a few years later, may have been present at the initial consultation. Mrs C also complained that the board had unreasonably delayed in carrying out genetic testing.

We took independent advice from a consultant breast surgeon. We found that the care and treatment provided to Mrs A had been reasonable and that there had been no delay in diagnosing Mrs A's breast cancer. We also found that there had been no missed opportunities by the board to have diagnosed the cancer earlier. We did not uphold this aspect of Mrs C's complaint.

We also found that there had been no indication for genetic testing when Mrs A first attended the breast clinic and that there had been no red flag criteria to prompt genetic testing at that time. As such, we did not uphold this part of Mrs C's complaint.

Summary

Mrs C was admitted to Raigmore Hospital as she had a two day history of stomach pain and vomiting. She was found to have a small bowel obstruction for which she needed major surgery. The operation was carried out the next day and Mrs C was given an epidural (anaesthetic by spinal injection) and a general anaesthetic.

After the operation, Mrs C noted reduced mobility in her legs and a scan was carried out, but this showed no abnormality. Mrs C's mobility did not improve and she was seen by a neurologist and a repeat scan was performed but, again, was normal. It was explained to Mrs C that the likely cause of her lack of nerve sensation was a spinal stroke (where there is an interruption in blood flow to the spinal cord). Later, Mrs C complained to the board because she believed that she should not have been given an epidural and a general anaesthetic together because she had a history of heart problems. The board confirmed that she had had a spinal stroke, but said that the reason for it was unclear. Mrs C remained unhappy and brought her complaint to us.

We took independent advice from a consultant anaesthetist and a stroke specialist. We found that it was common practice for an epidural to be used in conjunction with a general anaesthetic for post-operative pain relief after major abdominal surgery like that given to Mrs C. We found that there was nothing in her medical history that would have discouraged clinicians from doing this and that the practice was in accordance with Royal College of Anaesthetists' advice. For this reason, we did not uphold the complaint. However, we also found that prior to the operation the full risks of an epidural, including the risk of nerve damage, were not discussed with Mrs C as we would have expected. We found that the consent checklist that was used did not have a box for relating to the risk of nerve damage. We made recommendations to address this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to fully discuss the risks of an epidural with Mrs C.

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

• The consultants involved in this case should use it as part of their reflective discussion in their annual appraisal.
• The consent checklist should include nerve damage as a risk to be discussed.

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 (Ms A). Ms C said that, following a referral from Ms A's GP because of her back pain, the orthopaedic department at Raigmore Hospital delayed unreasonably in offering Ms A an appointment and therefore delayed in offering her treatment.

The board acknowledged that there had been a delay and apologised for this. They said that this had been due to the demand for orthopaedic services and noted that Ms A had opted to begin investigations of her back pain privately. After a scan was carried out privately, an urgent GP referral was made to the board and Ms A then received an appointment. It was then determined that she would benefit from an operation.

However, because the board could not perform the operation within 12 weeks, Ms A exercised her right to have treatment outside the board's area. As a result of her complaint the board apologised and said that they had taken steps to avoid a similar situation occurring again in the future.

We took independent advice from a consultant orthopaedic and trauma surgeon. We found that the care and treatment offered to Ms A had been in accordance with national guidance. The adviser noted that Ms A had arranged a private consultation and scan whilst she was on the board's waiting list. The adviser said that this was a matter of her choice, as was her decision to go outwith the area for her operation. Nevertheless, there was no doubt that there had been delay in offering Ms A treatment. The board missed the initial 12 week waiting time after Ms A's first GP referral. They were also unable to meet the target for treatment after Ms A was seen subsequent to the urgent referral. Finally, the board had only discussed Ms A's options for treatment with her after the treatment time guarantee had expired. For these reasons, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for failing to make her aware that they would be unable to meet the required treatment standards until after the treatment target date had passed. Also apologise for failing to discuss the options for out of area treatment with Ms A until after the treatment time guarantee date had passed.

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

• Inform patients as soon as possible of any inability to meet treatment targets and provide them with information about the options available to them in the circumstances.

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.