Health

Summary

Miss C complained about the dental care and treatment provided to her after she was diagnosed with gum disease. She complained that the dentist did not offer to refer her to a specialist for treatment, and instead recommended that she have her teeth professionally cleaned every three months. Miss C also complained that the dentist had not taken x-rays to assess for bone loss in the four years since she was diagnosed with gum disease. Miss C felt that as a result of the dentist's ineffective treatment of her gum disease, her condition had become worse.

We took independent dental advice. We found that whilst the treatment provided by the dentist to Miss C was reasonable in some respects, we found that they had not offered Miss C the opportunity to see a specialist for her gum disease when she was first diagnosed. We also found that the dentist had failed to follow guidelines with regards to charting the progression of the gum disease. We further found that the dentist had failed to record basic periodontal examination (BPE) scores, which according to the relevant guidance should be recorded at every appointment. We also found that the dentist failed to follow good practice and take radiographs when Miss C's BPE score was four (any score of four or above is considered to require monitoring and/or treatment). On this basis, we upheld Miss C's complaint.

Miss C also complained that the dentist did not reasonably respond to her complaint. We found that the complaint response did not tell Miss C that she could bring her complaint to us if she remained dissatisfied. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to provide her with appropriate dental care and treatment for her gum disease.
• Apologise to Miss C for failing to respond reasonably to her complaint.

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

• When appropriate, offers to refer should be made. The offer and the response should be recorded.
• Charting should be carried out annually for patients who have undergone periodontal treatment.
• BPE scoring should be undertaken at least annually for all patients, in line with guidance.
• Radiographs should be taken for patients with a BPE score of four, in line with good practice.

In relation to complaints handling, we recommended:

• Complaint responses should include details for the SPSO.

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 complained that the board unreasonably made changes to the arrangements for her to see the board's community psychiatric nursing (CPN) service. She said that her appointments with the CPN service had been changed from weekly to once every three weeks and that the appointments were held in a hospital rather than at her home. We took independent advice from a mental health nurse. We found that the board did not adequately listen to Ms C and did not take her views into account when it was decided to make these changes to her appointments. We upheld this aspect of Ms C's complaint.

Ms C also complained about the care she had received from the CPN service. We also took independent advice from a mental health nurse on this aspect of the complaint. We found that the care Ms C had received had not been of a reasonable standard. Ms C said that she had left messages on the service's answer machine, but that no one had called her back. The board's response to Ms C's complaint referred to restrictions in relation to the frequency of her phone calls, but there was no care plan or documentation within the case notes that outlined what these restrictions should be. We found that a care plan or protocol should have been in place to manage phone communication with Ms C, which could then have been followed by any member of staff. We also found that the board had failed to respond to correspondence from Ms C's GP and had failed to keep the GP adequately informed about her care. In light of these failings, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not adequately listening to her and for not taking into account her views when it was decided to change her CPN appointment arrangements. Also apologise for the failings in CPN care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Arrange a discussion with Ms C about her needs and wishes. A care plan should be created which reflects these. A mutually suitable location for visits should also be agreed between Ms C and a member of the CPN team. If Ms C does not wish to engage with this process, a care plan should still be created to guide the interventions of the team and this should be shared with Ms C.
• The care plan referred to above should be put in place and within it there should be:
• risk assessments
• agreements on phone use and any limitations around this
• what can reasonably be expected in terms of return of any messages left for staff to ensure no misunderstanding
• the frequency and location of visits
• identification of goals
• any psychological therapies.

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

• To ensure that care is provided to a reasonable standard, the pathway and available interventions for people with Ms C's conditions should be reasonable, evidence-based and appropriate. The board should ensure that staff are implementing them appropriately.
• To ensure that care is provided to a reasonable standard, the arrangements for clinical and case load supervision of CPNs should be adequate and should enable staff to reflect upon their performance and discuss individual cases in depth.
• There should be regular and timely communication of any changes to care to relevant GPs and other health care providers who are part of the wider multi-disciplinary team.

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). Mrs A had undergone a colonoscopy (a procedure to examine the inner lining of the large intestine) at University Hospital Crosshouse and, during the procedure, a complication had occurred which caused a perforated bowel. As a result of the perforated bowel, Mrs A had to undergo emergency surgery and she spent time in an intensive care unit. Mrs A required a temporary colostomy (a surgical procedure where an opening is formed in the abdomen). Mr C complained that the colonoscopy was not carried out to a reasonable standard.

We took independent advice from a consultant general and colorectal surgeon. We found that a colonoscopy was the appropriate and recommended procedure in Mrs A's case, taking into account her existing medical conditions. We also found that the doctors involved in the colonoscopy had the relevant experience and were suitably qualified to carry it out. The board said that the perforated bowel was a recognised complication and risk of the colonoscopy. They also said that when the perforation occurred it was quickly recognised and prompt and appropriate action was taken. The board had apologised for the complication that had occurred, and had set out the action they had taken to improve clinical safety.

Taking account of the evidence and the independent advice we received, we did not uphold Mr C's complaint. However, we did ask the board to provide us with evidence of the action they said they had taken, and we made a recommendation to the board with a view to encouraging learning from this complaint.

Recommendations

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

• Where serious incidents occur in colonoscopy procedures, they should be reviewed at least quarterly.

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 complained about the care and treatment provided to her late father (Mr A), who had bowel cancer. She complained that there was an unreasonable delay between a referral being made by Mr A's GP and his treatment starting at Ninewells Hospital. Ms C also complained that the care and treatment provided to Mr A in Ninewells Hospital was unreasonable. She raised further concerns that the standard of communication between the board and Mr A and his family was poor. Finally, Ms C complained that the board's handling of her complaint was unreasonable.

We took independent advice from a consultant gastroenterologist and a consultant colorectal surgeon. We found that there was an unreasonable delay between the referral by Mr A's GP and his treatment starting at the hospital. Mr A's GP had made a routine referral to the board's colorectal service and we found that this referral should have been reprioritised by the board as urgent because Mr A had high risk symptoms. In view of this, we upheld this aspect of Ms C's complaint.

Mr A had elective right hemicolectomy (removal of the right side of the large bowel through keyhole surgery). Four days after this, he returned to theatre for emergency surgery. Following this surgery Mr A was transferred to the intensive care unit (ICU), where he died the following day. We found that the surgery and the care Mr A received in the ICU had been reasonable. However, we found that there was an unreasonable delay in starting Mr A on antibiotics when his condition deteriorated in the ICU. We were also concerned that the frequency of consultant review following Mr A's surgery was not in line with published good surgical practice standards. We also found that the standard of record-keeping was unreasonable, particularly as there were gaps in the medical records. In light of this, we upheld this aspect of Ms C's complaint.

We found that the communication with Ms C, Mr A and the wider family about Mr A's care and treatment had been unreasonable. We further found that the consent for the initial surgery was not obtained in line with guidance from the Royal College of Surgeons. As such, we upheld Ms C's complaint.

Finally, the board accepted that the handling of Ms C's complaint had been unreasonable and said that they had taken action to improve their complaints handling. In view of the failings identified, we upheld this aspect of Ms C's complaint, but did not make any recommendations about this as the board had already taken action.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• the unreasonable delay between the referral to the board and the commencement of treatment
• the unreasonable care and treatment provided to Mr A
• the unreasonable communication and poor complaints handling.

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

• Referrals to the colorectal service from GPs should be appropriately validated to ensure that patients with high risk symptoms are prioritised. In order to facilitate this, the referral form for GP referrals to the colorectal service should ensure the proper documentation of details of symptoms, such as the extent of weight loss and anaemia.
• Appropriate action should be taken in the event of deterioration of a patient, especially in the event of a rise in early warning signs. Antibiotics should be administered in line with the board's observation chart.
• In-patients should be reviewed by a consultant surgeon (or equivalent), in line with the published good surgical practice standards.
• Surgeons should obtain the patient's consent in the pre-operative clinics, as per guidance from the Royal College of Surgeons. Patients should be provided with a copy of the consent form for reference and reflection at that time.
• Patients and/or their relatives should be kept fully informed after critical illness events.
• Medical staff should maintain reasonable medical records, in line with General Medical Council 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

Ms C complained to us that the Scottish Ambulance Service (the ambulance service) had delayed in responding to an alarm call made by her late mother (Mrs A). Mrs A lived in an assisted living complex and had made an alarm call to an alarm receiving centre (this was a private company that was not part of the ambulance service). She did not respond when the alarm receiving centre answered the call and they contacted the ambulance service. An emergency ambulance was dispatched to Mrs A's home, but it was then decided that this should be stood down and that another non-emergency ambulance would attend. On arrival at Mrs A's home paramedics found that she had died.

We took independent advice from a medical adviser, who is involved in the training of paramedics and who regularly works alongside them in the provision of pre-hospital care. We found that it had been reasonable for the ambulance service to cancel the emergency ambulance and to respond to the call using a non-emergency ambulance. This was in line with the agreed protocol and, as there was no information at that time to confirm that there was an urgent threat to life, we found that the time taken by the ambulance service to respond had been reasonable. The advice we received was that the risk of ambulances responding to calls using emergency blue light driving conditions for calls which turned out not to be life-threatening emergencies had to be taken into account. We did not uphold the complaint.

Summary

Mr C called 999 when his wife (Mrs A) became very unwell. A paramedic arrived five minutes later, and told Mr C that an ambulance would be on its way. However, the ambulance did not arrive for about half an hour, and only after the paramedic called to request back-up. During this time, Mrs A stopped breathing. The paramedic assisted her breathing and she recovered to some extent. However, after the ambulance arrived, Mrs A suffered a cardiac arrest. Staff carried out cardio-pulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops), which was successful at restoring her pulse. Staff transferred Mrs A to the ambulance and took her to hospital. While in the ambulance, Mrs A suffered a second cardiac arrest. Staff again began CPR, and this was continued until Mrs A was handed over to hospital staff. Hospital staff continued the CPR, but this was unsuccessful and Mrs A died in hospital shortly after her arrival. Mr C complained about the delay in the ambulance arriving and the lack of communication from ambulance service staff, including the way they handled his complaints.

The ambulance service upheld Mr C's complaints and apologised. They said there were opportunities to send an ambulance earlier, but these were missed. The ambulance service said they would discuss the communication complaint with the staff involved and senior managers would review their procedures to ensure that ambulance support is provided earlier in future. Mr C was dissatisfied with this response, and he brought his complaint to us.

We took independent advice from a consultant in emergency medicine. We found the delay in sending an ambulance was unreasonable, and a lack of clarity in the ambulance service's policies had contributed to this. However, we noted that the ambulance service have now updated their policies and adopted a new response model, which should prevent a recurrence of the failings in this case. We found the treatment of Mrs A's respiratory and cardiac arrests was appropriate. However, the clinical records were poor so it was not possible to determine whether the overall care and treatment was reasonable. We also found the ambulance service took an unreasonable time to respond to Mr C's complaint and did not provide a detailed explanation of the events, despite the investigating officer telling Mr C they would provide this. We upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the poor records kept by the paramedic and ambulance crew as this poor record-keeping meant it was not possible to determine whether the overall care and treatment given to Mrs A was reasonable. This apology should comply with SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Adverse incidents such as this should be reported and investigated through the ambulance service datix system (a system for tracking and reporting incidents).
• The Ambulance Control Centre dispatcher involved should reflect on and learn from Mr C's family's experience, with appropriate support.

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 to us about the care and treatment her husband (Mr A) had received from the board's evening district nursing service. Mrs C contacted us before we completed our investigation to say that she no longer wished to pursue the complaint, as the circumstances had changed. As such, we did not reach a decision on Mrs C's complaint.

Summary

Mr C complained about the care and treatment given to his grandmother (Mrs A), both at home and at Monklands Hospital, in the days prior to her death. He said that while Mrs A was at home, staff changed her opiate-based medication. He believed that Mrs A suffered withdrawal symptoms causing her to fall and he was unhappy that she had been persuaded to go to hospital when she had a long-standing wish to remain at home. He said that there was confusion after Mrs A's admittance and that her family were not kept informed of either her whereabouts or her condition. Mr C said that when the family were reunited with Mrs A, she was very distressed and wanted to go home. He said that the family were not told about Mrs A needing an ECG (electrocardiogram - a test to check the heart's rhythm), which caused her further distress. Following this ECG, and at the end of visiting time, Mrs A's family were asked to leave. Mrs A's condition deteriorated rapidly and she died. Mr C complained that he was not advised of the seriousness of his grandmother's condition and that her resuscitation status should have been discussed. He said the family were totally unprepared for her death and he was upset that Mrs A had died alone.

He complained to the board who acknowledged failures in communication but said that Mrs A's deterioration and death had not been anticipated. They explained the reasons why her resuscitation status had not been discussed and added that since Mr C's complaint, Mrs A's case had been discussed with staff and changes had been made to avoid a repetition of the situation for other patients under the board's care in future. Mr C remained dissatisfied and complained to us.

We took independent advice from a nursing adviser and from a consultant geriatrician. We found that the opiate-based medication Mrs A had been prescribed at home for her pain could have side effects, particularly leading to the increased risk of a fall. Her medication had been given a detailed review and changed in view of her presenting symptoms. While Mrs A's fall required her to be admitted to hospital, we found that this was more likely due to her slow heart rate and swollen legs rather than to her change in medication. We did not uphold the aspect of Mr C's complaint regarding changes to Mrs A's medication.

We found that Mrs A's resuscitation status was not discussed with her or her family at the hospital, although there was evidence that they had been ready to talk about it. We upheld Mr C's complaints about the failure to discuss resuscitation status and keep the family updated, and the failure to reasonably take account of Mrs A's wishes regarding this. However, we found that there was no indication that Mrs A was close to death, and that she was being actively treated for her slow heart rate which is considered to be a reversible condition. As such, we did not uphold Mr C's complaint about the board failing to recognise deterioration in Mrs A's condition.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to listen to the family when they were ready to talk about resuscitation. This apology should comply with 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:

• Staff should be reminded to inform family members about what is happening to their relatives.

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 about the care and treatment his late wife (Mrs A) received from the board at Monklands Hospital. Mrs A was initially admitted to hospital for seven days, with concerns about her eating and her bowels not moving. She was discharged home for three days and received some medical treatment at home but was then readmitted to hospital. Mrs A died in hospital four weeks later. Mr C also said that the board withheld long-standing medication from his wife and that they failed to reasonably communicate with him during his wife's admission. Mr C explained that his wife had suffered a stroke previously, which impaired her ability to communicate.

We took independent advice from a consultant in general/stroke medicine and geriatrics. We did not consider that the board failed to provide reasonable care and treatment for Mrs A and did not uphold this part of the complaint. However, there were failings in the note-taking by hospital staff and we made a recommendation to address this.

The evidence suggested that Mrs A's medication was not prescribed for her during her second admission and that there was no clearly documented decision for this. We found that, as it was a long-standing medication and Mr C would have been well placed to judge the effect of this being withdrawn, the cessation of the medication should have been discussed with Mr C. We upheld this part of the complaint. We also considered that the board failed to reasonably communicate with Mr C during his wife's admission and we upheld this part of the complaint. We asked the board to provide evidence of the remedial action they said they had already taken in both of these areas.

Recommendations

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

• Staff should note details of conversations with patients' family members regarding patients' care and treatment in patients' medical records.

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 care and treatment provided to her late father (Mr A). Mr A attended the board's out-of-hours service at Monklands Hospital with throat pain and difficulty swallowing. He was seen by an out-of-hours nurse practitioner and an out-of-hours GP. An examination was performed and Mr A was not admitted at that time. Mr A's condition worsened the next day and he was admitted to the hospital where staff identified an abscess in his throat. Over the following days, Mr A had a number of operations and spent time in the intensive care unit (ICU). He was then discharged to the ear, nose and throat (ENT) ward. While on the ENT ward, Mr A suffered a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs) and died.

Miss C complained that the board's staff failed to appropriately admit Mr A to hospital when he attended the out-of-hours service, that they inappropriately discharged him from the ICU to the ENT ward, and that they failed to appropriately monitor him on the ENT ward. The board considered that Mr A had been provided with reasonable care and treatment by the out-of-hours service, and that he had been reasonably discharged from the ICU. However, they acknowledged that there had been some failures in their clinical observation policy on the ENT ward.

After obtaining independent advice from out-of-hours practitioners, we did not uphold Miss C's complaint about Mr A not being admitted to hospital. We found that there was evidence of an appropriate examination being made, and a reasonable basis for concluding that the problems Mr A was experiencing were due to tonsillitis. We found that it was reasonable for staff not to have admitted Mr A to hospital at that time.

We obtained independent advice from an intensive care specialist regarding Miss C's complaint about the decision to discharge Mr A from the ICU. We found that this decision was consistent with the relevant guidance and adhered to the standards of general practice. Therefore, we did not uphold Miss C's complaint in this regard.

We obtained independent nursing and medical advice regarding the monitoring of Mr A on the ENT ward. We found failings by nursing staff in following the board's clinical observation policy to act on Mr A's deteriorating early warning scores. We found that on one day, Mr A did not receive a dose of medication given to help prevent the development of deep vein thrombosis and pulmonary embolism. However, we did not find that Mr A's outcome would likely have been any different if he had received this medication. On balance, we upheld Miss C's complaint about how Mr A was monitored on the ENT ward.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and to Mr A's family for the failings in medical and nursing care. The should comply with 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:

• Staff should be aware of, and follow, the board's clinical observation policy, which requires them to act on deterioration when alerted by early warning scores.
• The circumstances of this case should be fully considered for wider learning (for example by discussing the case at a mortality and morbidity meeting).
• Patients should receive appropriate preventative medication for deep vein thrombosis, and this should be reflected in the relevant records.

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.