Health

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) when he attended the out-of-hours primary care emergency centre at the Victoria Ambulatory Care Hospital. He was discharged home but a few days later was admitted to the emergency department of Queen Elizabeth University Hospital, where he was treated for a severe chest infection with possible underlying heart problems. After some hours Mr A's condition was considered to be near to death and it was indicated that he was suffering from aortic stenosis (a narrowing of the left ventricle of the heart, which can cause problems such as heart failure) and fluid on his lungs. Mr A was later transferred to the medical high dependency unit where he was reviewed and underwent numerous tests. He was then transferred to the intensive care unit, where he later died.

Mrs C complained to the board and when she remained unhappy with their response she brought her complaints to us. Mrs C complained to us that:

the assessment of Mr A at the out-of-hours service was unreasonable

the care and treatment provided to Mr A at Queen Elizabeth University Hospital was unreasonable

the communication with herself, Mr A, and the family during Mr A's admission was poor

the board failed to respond fully to her complaints.

We took independent advice from a nurse practitioner and from consultants in emergency medicine and cardiology. We found that Mr A had been reasonably and appropriately assessed at the out-of-hours service and we did not uphold this aspect of the complaint.

We found that it would have been better if Mr A had been seen and assessed by the cardiologist shortly after his admission to Queen Elizabeth University Hospital, rather than the cardiologist only speaking to the emergency medicine team on the phone, which is what had happened. A face-to-face assessment would have allowed for a better assessment, and for a discussion with Mr A and Mrs C about Mr A's symptoms, treatment and prognosis. We also found that opportunities were missed to keep Mrs C updated on Mr A's condition. As such, we upheld Mrs C's complaints about the care and treatment provided to Mr A, and about the communication with the family.

With regards to the board's complaints handling, we found that the board addressed all of the concerns that were raised with them. We were satisfied that the responses were provided promptly and with appropriate detail. We did not uphold Mrs C's complaint about the board's complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise that a cardiologist did not see Mr A sooner. The apology should meet the standards set out in the SPSO guidelines on an apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for missing opportunities to keep Mrs C fully updated on Mr A's condition.

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

• In cases of aortic stenosis, a cardiologist should assess and physically examine the patient as soon as possible.
• Relatives should be updated on their family member's condition and care.

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 his care and treatment over two admissions to the Royal Alexandra Hospital was inadequate.

Mr C had suffered from two separate incidences of a collapsed lung in quick succession. During the first admission, Mr C disputed the board's position that it had been reasonable to discharge him. During the second admission Mr C's condition worsened. An x-ray was requested and preparations were made for inserting a chest drain. There was then significant deterioration in Mr C's condition. The board accepted that Mr C could have died due to this deterioration. The board said that they did not believe a critical incident review (CIR) was appropriate in the circumstances. They said that Mr C had been suffering from a complex condition and that it was this, rather than any failings by staff, which had contributed to the deterioration. Mr C disputed this, and he disputed the standard of the nursing care he received. Mr C said his deterioration had not been noticed because he was not being monitored properly.

We took independent medical and nursing advice. The medical adviser said that the decision to discharge Mr C following his first admission was appropriate and was supported by the medical evidence. However, the adviser found that during Mr C's second admission there had been a failure by medical staff to identify that a chest drain had not been correctly inserted, which had contributed to his deterioration. It would therefore have been appropriate to conduct an CIR. The medical adviser noted that Mr C's condition could have deteriorated very quickly and it could not be assumed that the severity of Mr C's condition and deterioration was due to an absence of clinical observation. The nursing advice we received found that, aside from some acknowledged failings, the overall standard of care was reasonable. The board had accepted the nursing failings and had taken action to address them.

We found that the board should have conducted a CIR into Mr C's deterioration during his second admission, as this could have identified useful learning for staff. We also found that the board should provide evidence that it had followed through with the work it had committed to in order to address the nursing failings it had accepted had taken place. On balance, we upheld Mr C's complaint that the care and treatment provided to him across the two admissions had been inadequate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failings in his care, and for failing to carry out a critical incident review. This apology should comply with SPSO guidelines on making an apology.

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

• The board should review Mr C's second admission and his subsequent deterioration with the clinical staff involved. This review should include what action was taken to review the x-ray taken and the action taken on Mr C's subsequent deterioration. This review should also include evidence of the resultant learning or improvements.

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 husband (Mr A) about the care and treatment he received at the Institute of Neurological Sciences at the former Southern General Hospital. Mr A was treated for spontaneous intracranial hypotension (low fluid pressure inside the head) which is a condition that can be caused by the development of a leak of cerebrospinal fluid (a fluid found in the brain and spine that provides protection for the brain). Mrs C submitted three separate complaint letters to the board over a number of months. Her complaints related to the investigative procedures that were carried out in an attempt to locate the site of the leak, the care and treatment provided to Mr A, and the board's handling of her complaint.

We took independent advice from a consultant neurologist and a consultant neuro-radiologist. We found that an initial scan was not accurately reported which the board had identified themselves and apologised for. They also took steps to address the matter to prevent recurrence. Whilst we noted that this error caused some delay in Mr A's treatment, we did not consider that it had significantly affected his outcome given that the scan had not shown the actual site of the leak. In addition, we did not consider that a neuro-surgery referral was indicated because no definite site of a leak had been identified. We also considered that the type of scanning machine used was appropriate. We did not uphold this aspect of the complaint.

We did not identify any significant failings in obtaining Mr A's consent to another investigative procedure but considered that there should have been a record of a discussion with Mr A that there was a risk it could cause worsening headaches. We did not identify any concerns about the way in which the procedure was carried out and considered it was accurately reported. A further scan carried out a week later was also properly reported and Mr A received reasonable care and treatment afterwards. We did not uphold this aspect of the complaint.

In terms of the board's handling of Mrs C's complaints correspondence, we identified that there was undue delay in their final response which the board accepted and had apologised for. We found that the board had regularly updated Mrs C about the delays and explained the reasons for this. We identified that the board had given inaccurate information to Mrs C about requesting and agreeing extensions to the 20-working-day target for responding to complaints. We also found that the board should have explained in an earlier letter to Mrs C that Mr A's initial scan was inaccurately reported, although they addressed this in later correspondence. We upheld this aspect of the complaint. The board explained that they had already taken action to prevent these issues from arising again in the future, and we requested that they send us evidence of this.

Summary

Mr C complained that, following his discharge from hospital, his medical practice unreasonably failed to contact him for more than 48 hours, and unreasonably failed to carry out a home visit despite his request for one. The practice responded to his complaint by apologising for any lack of care which Mr C felt he had received, but explained that the discharging unit at the hospital usually take responsibility for co-ordinating with community care and district nursing teams. They also noted that where there was a medical need for immediate post-discharge medical input, hospital clinicians would usually communicate this directly to the practice. We noted that Mr C requested a home visit when on the way home from hospital by visiting the practice and dropping off a letter.

We took independent advice from a GP adviser. The adviser reviewed Mr C's medical records and said there was no indication that a house visit was necessary, as it appeared that Mr C was able to attend the practice for an appointment. The adviser also noted that the decision whether or not to offer a home visit lies with the clinician, and should be based on clinical need. The adviser confirmed that it is not routine practice for GPs to contact patients who have been discharged from hospital once they have returned home, although they may do so following a review of the patient's discharge medication and history. The adviser noted that in this case the practice had reviewed Mr C's medication and history and contacted him by phone within 48 hours of his request and considered this reasonable.

The adviser also commented that if there was a clinical need for contact from the GP, this would have been detailed on the discharge letter from the hospital. There was no request for contact in Mr C's discharge letter. It was unfortunate that reception staff at the practice did not make clear to Mr C that home visits would only be carried out on the basis of clinical need, and by phone request on the day. However, we were satisfied that the evidence suggested that a home visit was not required, and that the time taken by the practice to contact Mr C following discharge was reasonable. We did not uphold this complaint.

Summary

Mrs C complained that the board failed to care for her in a sensitive manner at Aberdeen Maternity Hospital after she had a miscarriage. Mrs C said that she had found staff to be lacking in empathy. There had also been some confusion in relation to the forms which required to be completed to confirm her wishes for disposal of the foetal remains. Mrs C said that she understood that she had completed the forms required and that she would not be contacted again unless there was any foetal abnormality, but she was contacted a couple of days later and asked to return to the ward to complete another form. Although Mrs C had stated her wish for the cremated remains to be scattered without her being present, she then received a phone call several months later advising that the ashes were ready to be collected.

We took independent advice from a nursing adviser, who noted that the board's correspondence with Mrs C had been poor, and that their apology in their response to her complaint had fallen short of a reasonable standard. We found that, although the board had apologised for some of the failings in Mrs C's care, they had failed to address all of the questions she had raised with them. We upheld Mrs C's complaint. We noted that the board had changed their processes in relation to recording patients' wishes about foetal remains, so we did not make any recommendations in this regard. However, we did recommend that the board re-issue an apology to Mrs C that is in line with SPSO guidance on apology.

Recommendations

What we asked the organisation to do in this case:

• The board should re-issue an apology for the failings identified. The apology should comply with the SPSO guidance on apology.

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 service, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) when he was admitted to Dr Gray's Hospital. Mr A suffered from congestive heart failure and was admitted to the hospital due to feeling tired and unwell, having chest pain, weight gain, nausea and vomiting. Ms C complained that the medical care and treatment provided to Mr A was unreasonable, and that he was not discharged in a reasonable way.

We took independent advice from a consultant physician. We found that, whilst overall assessments of Mr A and the general care and treatment provided to him was of a reasonable standard, there were gaps in weight monitoring. We noted that the board had previously addressed this matter. We also found that the issue of Mr A's internal defibrillator (a small device implanted into the body used to treat abnormal heart rhythms) was not recorded as having been discussed when a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place, and that the general record-keeping around the DNACPR decision was poor. We upheld this aspect of Ms C's complaint.

With regards to Mr A's discharge, we found that it was not reasonable to discharge Mr A as he had only recently been changed from having his medicine administered intravenously (into a vein) to taking it orally, and he was still on supplemental oxygen therapy at the point of the discharge decision. The adviser was critical that these issues were not monitored further prior to Mr A's discharge. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to provide a reasonable standard of medical care and treatment to Mr A during his admission and for failing to ensure that Mr A was discharged in a reasonable way. 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:

• Discussions around de-activation of internal defibrillators should occur and be documented at the same time as discussions around DNACPR. DNACPR decisions should be adequately documented and should include the reason for the decision.
• Any switch from intravenous to oral medication should be checked to be effective, supplementary oxygen should be stopped and oxygen levels should be monitored prior to discharge.

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 A) about the care provided by the practice following a phone consultation. The day following her discharge from hospital for heart bypass surgery, Mrs A called the practice for advice. A GP called her back a short time later and discussed medication with her. At this time, Mrs A reported a clicking sensation in her chest. The GP reassured her about this sensation and advised her to contact the practice again if she became more unwell. Mrs A's condition deteriorated later that day and she was admitted to hospital, where she was treated for an infection.

Ms C raised concern that the GP did not identify that Mrs A had an infection and felt that a home visit should have been carried out. We took independent advice from a GP adviser. Whilst they noted that the GP's clinical record of the consultation was brief, on balance, the adviser considered that the assessment and care provided was reasonable. We accepted this advice and we did not uphold this complaint.

Summary

Mrs C complained about the care and treatment that staff at Forth Valley Royal Hospital provided to her over a number of years.

Mrs C was seen by the board's consultant orthopaedic surgeon and elected to have knee replacement surgery. She experienced some pain and discomfort following the surgery, and was seen during this time by an orthopaedic nurse. Approximately three years later, Mrs C continued to experience pain and discomfort and was then seen by two additional consultant orthopaedic surgeons.

Mrs C raised concerns that the knee replacement surgery was carried out inadequately as she felt that the board had provided her with a knee prosthesis that was too small. She also raised concerns about the monitoring that the board provided following her surgery. She also complained about the level of care and treatment that the board provided when she was seen by consultant orthopaedic surgeons over the following years.

We took independent advice from a consultant orthopaedic surgeon. We found that there was no evidence from the records and x-rays that the prosthesis was the wrong size, or that there was any other error in the initial surgery. We noted that there is an inherent risk that surgery will result in a patient experiencing ongoing pain and difficulties, without this being caused by any failure in the surgery. We did not uphold this aspect of Mrs C's complaint.

We upheld Mrs C's complaint about monitoring. We found that there was evidence of Mrs C expressing pain and discomfort during her reviews with an orthopaedic nurse that should have led to her being reviewed by a consultant orthopaedic surgeon, or should have led to some communication from a consultant.

We did not uphold Mrs C's complaint about the subsequent care and treatment she received when she reported problems with her knee in the following years. We found that the documented views of the board's consultant orthopaedic surgeons were not unreasonable, and that the treatment provided was appropriate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in monitoring following her surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at 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 that the board provided to her late brother (Mr A).

Mr A attended the emergency department at Forth Valley Royal Hospital. After performing an examination and taking blood tests, staff considered that he had gastroenteritis (inflammation of the stomach and intestines). Mr A returned the next day, and staff continued to feel he was suffering from a viral illness. Mr A was seen the following day by an out-of-hours GP. He was then admitted to the board's acute assessment unit, who performed a range of further tests. The tests were normal, and Mr A returned home. He was seen the next day by a further out-of-hours GP. Mr A returned to the board's emergency department the following day, and was again admitted to the acute assessment unit. Over the subsequent days, Mr A's condition deteriorated and he was diagnosed with carcinomatous meningitis (a type of cancer). Mr A died a number of days after his second admission to the acute assessment unit.

Mrs C complained that the board unreasonably delayed in diagnosing Mr A with carcinomatous meningitis. She also said that staff unreasonably discharged Mr A from the hospital on several occasions. Finally, she said that staff unreasonably failed to provide effective pain relief.

We took independent advice from a consultant in emergency medicine, an out-of-hours GP, and a consultant in acute medicine. We found that carcinomatous meningitis is a rare form of cancer that is aggressive and that it presented atypically in this case. We found that staff carried out appropriate investigations, and that it was not unreasonable for them not to identify the cancer at an earlier stage. We identified one delay in reporting an x-ray, although this did not appear to impact on the timescale for diagnosis. As such, we did not uphold Mrs C's complaint about an unreasonable delay in diagnosing Mr A.

Regarding Mrs C's complaint about the discharges, we found that staff had a reasonable basis for considering Mr A was suffering from gastroenteritis, and therefore, it was appropriate to discharge him. We did not uphold this aspect of Mrs C's complaint.

In relation to Mr A's pain relief, we found that this could have been managed better during Mr A's final admission. While we noted the board's concern to balance pain control with consciousness level, we considered that the dosage could have been adjusted to a more appropriate level. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the failings in pain control and the delay in reporting the x-ray. 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:

• X-rays should be reported promptly, to minimise the danger that results are missed.
• In similar cases, staff should effectively balance pain control with level of consciousness.

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) at Forth Valley Royal Hospital. Mrs A was admitted to the hospital following a collapse at home. During her admission, she fell and sustained serious injuries. Mrs C believed that the fall in hospital contributed to Mrs A's death a few days later, and that healthcare professionals failed to take appropriate action to minimise the risk of Mrs A falling, particularly in light of her complex medical history. Mrs C also raised concerns about complaints handling issues, including a failure to respond thoroughly and a delay.

We took independent advice from a nursing adviser who specialises in falls prevention and a medical adviser who specialises in acute medicine. We found that, while there was evidence that nursing staff had highlighted Mrs A's risk of falling and had put in place a number of interventions to address it, there were shortcomings in this. Mrs A's condition deteriorated shortly before her fall and we found that a further review of her needs should have been carried out then. We also found that, in the lead up to the fall, the amount of time that Mrs A was left on a commode with little supervision was excessive. Having said that, the advice we accepted was that the fall did not directly lead to her death. On balance, we upheld this aspect of Mrs C's complaint.

With regards to Mrs C's concerns about complaints handling, we found that the board's investigation was thorough and their position that they could not give Mrs C a definitive account of how Mrs A fell because nobody saw it was reasonable in the circumstances. However, we upheld the complaint because the time it took the board to respond to Mrs C was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to take all reasonable steps to minimise the risk of Mrs A falling.
• Apologise to Mrs C for failing to deal with her complaint within a reasonable timescale.

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

• All reasonable steps should be taken to minimise the risk of patients falling.

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.