Health

Summary

Miss C's mother (Miss A) had lung cancer which had spread to her brain. The steroid medication she was taking to alleviate the symptoms caused psychotic symptoms, requiring an admission to Dumfries and Galloway Royal Infirmary. One day when her family went to visit they were unable to find her. They subsequently found her in a stairwell, disorientated and upset. Miss C complained about the board's failure to ensure that Miss A did not leave the ward. She also complained that the board's complaints handling was unreasonable.

We took independent advice from a nursing adviser. The adviser highlighted the importance of the balance to be struck between weighing the risks of staff monitoring patients and promoting some independence and dignity. In their response to the complaint the board said that the ward was extremely busy and that, although staff did their best to ensure that vulnerable patients were monitored, they were extremely sorry and disappointed that on this occasion they were unable to prevent Miss A from leaving. We considered the board's response to the complaint to have been reasonable and did not consider that Miss A should have been under closer supervision. We did not uphold this aspect of Miss C's complaint.

We found the board's complaints handling to have been poor. The family's complaint was initially not taken forward because it was believed that Miss A's consent was required, and she lacked capacity to give consent. We found that the board failed to communicate their reasons for not taking the complaint forward, and did not investigate until the Patient Advice and Support Service became involved. We upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in their complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints handling staff should be confident about when consent is required before a complaint can be investigated. In this instance, matters could have been investigated without the need for Miss A's consent.

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 that her GP practice was not recognising her mental health problems and that they refused to carry out home visits. Miss C told us that she believes she has agoraphobia (a fear of entering open or crowded places, of leaving one's own home, or of being in places from which escape is difficult), although she has not been given a formal diagnosis.

Miss C wanted a diagnosis of agoraphobia and also had various concerns about her physical health. Given her condition, she wanted to be seen at home. In their response to our enquiry, the practice confirmed that Miss C had been referred to mental health services and that they had prescribed appropriate medication. They explained that they would always discourage home visits as they are not the correct setting for most medical problems. They said that in Miss C's case, they had concerns about visiting at home due to a mental health assessment which identified a concern that home visits could have a negative effect on Miss C's wellbeing.

We took independent advice from a GP adviser. We found that the treatment provided to Miss C was reasonable and the adviser had no concerns about the care provided by the practice. In relation to the home visit requests, the adviser noted that Miss C had not been diagnosed with an acute mental illness which would stop her from attending the surgery. They said that unless the patient is housebound, patients are best seen in a practice environment. We found that the practice had taken reasonable measures to support Miss C by offering quiet appointment times, phone consultations and offering home visits from a community psychiatric team. We noted that Miss C had declined to engage with services or treatment to help her, and considered that there was no further action the practice could reasonably take. Therefore, we did not uphold either of these complaints.

Summary

Mr C complained about a consultation he had at the fracture clinic at Perth Royal Infirmary and the following care and treatment he received. Mr C was referred to the clinic after he fell and injured his hip. Prior to attending the consultation, an x-ray of Mr C's hip had been arranged by his GP, whilst an MRI scan had been carried out privately. Mr C brought the written MRI report to the consultation, but did not bring the imaging CD. After examination, the surgeon decided that conservative treatment (medical treatment avoiding radical therapy or an operation) was appropriate and they arranged to review Mr C in three months' time. Mr C obtained a different opinion on the treatment of his injury from a surgeon at a different NHS board. Mr C then agreed to have surgery on his hip at this same NHS board and said that this improved his condition.

Mr C raised concern that the surgeon at Perth Royal Infirmary failed to carry out an appropriate assessment of his condition. Mr C felt that the surgeon should have reviewed the MRI images and spoken to the radiologist who carried out the MRI privately. We received independent advice from a consultant orthopaedic surgeon. They said that Mr C was responsible for providing the MRI images, if he wished for them to be considered. The adviser considered that the assessment carried out was reasonable, and we did not uphold the complaint.

Mr C also complained that the board had failed to provide him with the same care that he subsequently received from another health board. In response to our enquiries, the board said that, based on the information available to them, they could see no reason for surgery and were satisfied that conservative treatment was appropriate. The adviser was satisfied that the surgeon's diagnosis was reasonable and consistent with Mr C's symptoms and the radiological findings. The adviser said that it was appropriate for the surgeon to arrange to review Mr C again, but suggested that an earlier review might have been more reassuring for Mr C. The adviser did not consider the different treatment by another NHS board to reflect failure in care on the part of the board, and they were satisfied that the care and treatment provided by them was reasonable. We did not uphold this complaint.

Finally, Mr C raised concern about the quality of the board's complaint investigation. We found that the board's complaint response did provide an explanation about the surgeon's findings and a reason for the treatment they suggested. We noted that an independent clinician had reviewed the surgeon's findings and the medical records, which informed the board's response to the complaint. We were satisfied that the approach taken to investigating the complaint was reasonable, and we did not uphold this complaint.

Summary

Mr C complained that staff at Ninewells Hospital failed to consider a diagnosis of brugada syndrome when he was being investigated for fainting episodes. Brugada syndrome is a condition associated with blackouts, serious arrhythmias (where the heart can beat too slow, too fast or irregularly) and sudden death. The syndrome is characterised by a particular electrocardiogram (ECG - a test to check the heart's rhythm) abnormality, either spontaneously or after a drug test.

During investigation of his fainting episodes, Mr C was advised not to work or drive. Mr C experienced a further fainting episode when a cannula was being inserted into his vein prior to an ajmaline challenge (a drug test to identify the characteristic ECG pattern changes associated with brugada syndrome) being carried out. The ajmaline challenge did not go ahead and Mr C was dissatisfied that it was not rescheduled prior to being discharged from the cardiology service. Mr C moved and said that he was diagnosed with brugada syndrome following an ajmaline challenge at a different hospital.

We took independent advice from a consultant cardiologist. We found that there was evidence to demonstrate that hospital staff had considered the possibility of brugada syndrome. We considered that from the various tests carried out there was no evidence to support a diagnosis of brugada syndrome. We found that it was reasonable for staff to diagnose Mr C with vasovagal syncope (the temporary loss of consciousness due to a neurologically induced drop in blood pressure) and not to have rescheduled the ajmaline challenge. We did not uphold the complaint. However, we were critical of the time it took the board to investigate Mr C's fainting episodes. We also found that there was no evidence to clearly show that Mr C's diagnosis and the reasons for not rescheduling the ajmaline challenge had been fully explained to him. We made three recommendations to address these shortcomings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not ensuring that he was fully informed about his diagnosis. Also apologise for the time taken to investigate his fainting episodes. 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:

• Staff should ensure that, in similar cases, patients are fully informed about their diagnosis, including any decisions made in relation to further investigations, and clearly document when this has been done.
• Staff should ensure that investigations are carried out in a timely manner, particularly when patients are unable to work or drive.

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 and Mrs C complained about a delay in diagnosing their child (child A) with autism spectrum disorder (ASD). In particular, they complained that an autism diagnostic observation schedule (ADOS) was not carried out. Child A was subsequently diagnosed with ASD after an ADOS was carried out.

The board did not consider there was an unreasonable delay in diagnosing child A with ASD. They also explained that their ASD assessment pathway has developed since the events complained about occurred.

During our investigation we took independent advice from a consultant paediatrician. The adviser considered that child A should have been referred for a multi-disciplinary ASD assessment, given their family history, their symptoms and Mr and Mrs C's strong concerns. The adviser explained that an ADOS is not a requirement to diagnose ASD but that it can be a helpful tool. In light of the failure to refer child A for a multi-disciplinary ASD assessment, we upheld the complaint and 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 not referring child A for a multi-disciplinary autism spectrum disorder assessment. 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:

• Parental concerns should be taken into account when deciding if a child should be referred for an autism spectrum disorder assessment, in line with the relevant guidelines, as should any reported symptoms and family history of learning difficulties.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

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

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

Summary

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

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

Summary

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

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

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

In relation to complaints handling, we recommended:

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the nursing care that her father (Mr A) received whilst he was an in-patient at the Western General Hospital. During his admission, Mr A developed a pressure ulcer and Mrs C was concerned that this was not maintained hygienically or to a reasonable standard. Additionally, Mrs C complained that her father's discharge home was unreasonably delayed by a member of nursing staff.

We took independent advice from a nursing adviser. We found that Mr A's risk of developing a pressure ulcer had not been accurately assessed and that pressure ulcer care had not been provided in line with relevant guidance. The advice we received highlighted a number of issues with record-keeping in relation to pressure ulcer care and also hygiene, including that a wound assessment chart was not completed for Mr A. We also found that a pressure relieving mattress was not ordered for Mr A until he had already developed a pressure ulcer. There was also no evidence that appropriate specialist input was sought with regards to Mr A's care. We upheld Mrs C's complaint about maintaining Mr A's hygiene and the pressure ulcer.

Regarding Mr A's discharge, the advice we received was that the delay of a few hours was reasonable as nursing staff were concerned that there may not have been anyone at home to be with Mr A when he arrived. We did identify communication issues around this, which were drawn to the board's attention, however, we found that the actions of nursing staff were reasonable and we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in pressure care. The apology should comply with the SPSO guidelines on making an apology, available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Appropriate risk assessments for pressure ulcers should be carried out accurately and all pressure care should be provided in line with the board's Pressure Area Care Pathway (2015).
• Patients should be nursed on a surface suitable to manage their risk of developing pressure ulcers, in line with the board's Protocol for Ordering Therapeutic Mattresses (2013).
• Wound assessment charts should be completed for patients like Mr A and injuries should be treated appropriately, in line with the relevant guidance.
• Appropriate referrals should be made for patients when specialist input is required.
• Full and accurate nursing care records should be kept for patients.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by the practice. Mrs C complained that the practice failed to appropriately monitor and treat Mrs A's symptoms after she was diagnosed with a heart condition. Mrs A was referred to cardiology by the practice a number of years ago and was diagnosed with a heart condition known as mitral regurgitation (when blood back flows through a valve in the heart called the mitral valve). She was prescribed diuretic medication (also known as water tablets - tablets which can help reduce the fluid build up that can occur when the heart is not working normally). When Mrs A was reviewed by cardiology again two years later, the condition was noted to have resolved and the cardiology clinic advised that the diuretic medication could be reduced and stopped. In line with Mrs A's wishes, she continued to take the medication for a further three years before it was stopped when she was found to have low sodium levels. In the interim, Mrs A had also been given a steroid inhaler for suspected asthma. Mrs A suffered a heart attack and died less than two months after stopping the diuretic medication.

Mrs C complained that stopping the diuretic medication contibuted to her mother's death. She raised concerns that closer monitoring of Mrs A's known heart condition did not occur. She also raised concerns that the steriod inhaler prescribed for breathlessness may have masked the underlying problems with Mrs A's heart. In particular, Mrs C did not consider that Mrs A received the appropriate attention required to properly identify the cause of the symptoms she presented with in the final months of her life.

We took independent advice from a GP adviser. We found that the management of Mrs A's symptoms was reasonable. The adviser noted that the cause of the mitral regurgitation was never established and that, when it appeared to have resolved, no ongoing cardiology follow-up was arranged. Had heart valve disease, which is one of the possible causes of mitral regurgitation, been identified, the adviser confirmed that this would have been followed up by the cardiology clinic, and not by the practice. In light of the cardiology clinic's advice that the diuretic medication could be stopped, alongside the low sodium level later found in Mrs A, we were advised that it was reasonable for the practice to have stopped this medication. We were also assured by the advice we recieved that the prescription of inhalers was reasonable and that there was nothing to indicate that this masked an underlying heart condition. The adviser did not consider that Mrs A's death could reasonably have been forseen by the GPs at the practice, and they concluded that the care provided to her by the practice was reasonable. We accepted this advice and we did not uphold Mrs C's complaint.