Health

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Ms C complained that the board had failed to provide a reasonable standard of nursing care to Mrs A's late husband (Mr A) when he was a patient at Inverclyde Royal Hospital. Ms C further complained that the board failed to provide Mr A's family with a definitive cause of death, and that their significant clinical incident investigation was not completed in a timely manner.

We took independent advice from a nursing adviser and a consultant physician. We found that there were failings in the nursing care provided to Mr A and we upheld this complaint. However, we considered that the board had appropriately identified and apologised for these failings, and had carried out a large number of improvement actions. We did not make any recommendations in relation to this aspect of Ms C's complaint.

We found that, whilst it was reasonable that clinicians were initially uncertain as to Mr A's cause of death, it was unreasonable that they disagreed about it in front of Mrs A and other family members at a meeting. Therefore, we upheld this complaint. We noted that the board had apologised for this matter, and we made a recommendation in relation to this aspect of the complaint.

Finally, we found that the board had unreasonably failed to complete their significant clinical incident investigation report in a timely manner, and we upheld this aspect of the complaint. However, we found that the board had taken appropriate action to address this failing and so we did not make any recommendations in this regard.

Recommendations

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

• When appropriate, a preparatory meeting of the staff involved should be carried out prior to meeting with families about complaints, in order to allow meetings to go more smoothly and to avoid potential disagreements amongst staff in front of families.

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 made a number of complaints to us about the care and treatment she received from the board's community psychiatric nurse (CPN) service. Her complaints included concerns about the allocation of a CPN and discharge arrangements. She also complained about the board's handling of her complaint.

We took independent advice from a mental health nurse and from a consultant psychiatrist. Ms C complained that the board had arranged a meeting without her consent after she made a complaint about a support worker. We found that the board's records indicated that Ms C had agreed to the meeting and we did not uphold the complaint.

Ms C also complained that the board had unreasonably allocated her a CPN that she could not work with. We found that it had been reasonable for the board to appoint this member of staff as Ms C's CPN. We did not uphold this aspect of her complaint.

Ms C complained that the board refused her support from a CPN that had previously been agreed. We found that staff had met Ms C to discuss the support she needed from CPNs. They then arranged to speak to her consultant psychiatrist to clarify what had been agreed. The psychiatrist said that this matter should be discussed at her next review meeting. We considered this had been reasonable and did not uphold this aspect of her complaint.

Ms C complained that she had then been discharged from the CPN service. We found that given the support she was receiving from other agencies at that time, there was no need for CPN involvement in her care. We did not uphold this complaint.

Finally, Ms C complained to us about the board's handling of her complaint. She said that she considered that the board should have contacted her mental health officer to discuss her complaints. We found that it had not been necessary for the board to do so to investigate the complaints. We did not uphold this aspect of Ms C's complaint.

Summary

Mr C, who works for a voluntary agency, complained on behalf of the family of Miss A. Miss A had suffered complex medical problems from birth. Mr C complained that Miss A had not been provided with appropriate care and treatment at the Southern General Hospital and Yorkhill Children's Hospital. He said the family believed there had been repeated failures by medical and nursing staff. They believed that they had not been communicated with appropriately and the board had failed to action their complaint in accordance with the NHS procedure. Miss A had had to undergo surgery on her windpipe and had multiple medical complications, which required on-going medical treatment.

We took independent advice from a consultant paediatrician and a paediatric nurse (specialists in the care of infants, children and young people). They concluded that the main failing on the part of the board was the failure to appoint a lead clinician to oversee Miss A's treatment. While we found that the clinical care and treatment provided to Miss A had been appropriate, this failure to appoint a lead clinician had contributed to the communication failures with the family. The nursing advice we received was that staff had not monitored Miss A's oxygen saturation levels appropriately and that the family had been forced to request that oxygen monitoring be provided.

We found that the board had failed to communicate adequately with the family and, although they had acknowledged this, we found that the board had provided no evidence to show that they had taken steps to avoid a reoccurrence. We also found that the board's response to the complaint had taken an unreasonable length of time and that the responses the family had received had been inaccurate.

We asked the board to apologise for their failings and take a number of actions to address them.

Recommendations

We recommended that the board:

• provide evidence that they have reviewed their oxygen saturation monitoring policy to ensure it corresponds with national guidance for children;
• review care planning for children with respiratory vulnerabilities to ensure that pulse oximetry values (used to measure the oxygen level of the blood) are monitored;
• review care planning to ensure that parental concerns for the child are recorded;
• remind the nursing staff involved in Miss A's care of the importance of comprehensive respiratory care plans to ensure less experienced staff are able to monitor patients effectively;
• provide evidence of the outcomes of the multi-disciplinary review considering continuity of care between acute and community services;
• provide evidence of the outcomes from the multi-disciplinary review of the allocation of lead-care coordinators;
• provide evidence of the changes made to the process for feeding back sleep study results to the parents of children undergoing treatment;
• review their processes in relation to complaint handling of complex cases where more than one department is involved to ensure that a single clinical lead is appointed to oversee the response; and
• apologise for the failings we identified.

Summary

Mr C complained to us that the practice had failed to manage his medication in an appropriate manner. He had been on pramipexole medication (used as treatment for Parkinson's disease and restless legs syndrome) for four years and he said that during that period the practice had not reviewed the medication. Mr C said that the practice had also increased the medication dosage without telling him and that he had experienced severe side effects. Mr C felt that the practice should have kept the medication under review and informed him of the change in dosage.

We took independent advice from a GP adviser. We found that, during the period in question, Mr C had not reported to the practice that he was having side effects from the medication. The practice had invited Mr C to attend for a review of his medication on five occasions, but he had not responded. Mr C was also reviewed on two occasions when he attended the practice to discuss other clinical matters. We also found that it was appropriate for a pharmacist to advise Mr C of the increase in the dosage of the medication, rather than have him make an appointment with a GP. We did not uphold Mr C's complaint.

Summary

Miss C complained that the medical practice had failed to carry out an appropriate assessment or refer her late father (Mr A) to hospital when he attended a consultation. Mr A was very breathless and suffered from pulmonary fibrosis (scarring of the lungs). The GP did not take Mr A's temperature or provide medication, as they felt that no further treatment was required at that time. Mr A was told to wait until his next scheduled respiratory clinic at the hospital, which was in nine days time. When Mr A attended the clinic, a clinician arranged an immediate hospital admission. Mr A deteriorated and died a few days later. Miss C felt that the GP should have referred Mr A to hospital sooner.

We took independent advice from an adviser in general practice medicine. We concluded that, although the GP had arranged for an ECG (electrocardiogram - test to check the rhythm of the heart), the GP failed to record Mr A's oxygen saturation, temperature and blood pressure. We found that the GP had failed to carry out an examination of the heart, which would have been appropriate for a patient who had presented with increased breathlessness and chest pains. We also concluded that, while it was possible that the GP's decision for Mr A to wait until his clinic appointment may have been reasonable, we were unable to establish this as the standard of record-keeping for the consultation was inadequate. We upheld Miss C's complaint that the GP failed to provide Mr A with appropriate treatment in view of his reported symptoms. However, in view of the inadequate record-keeping, we could make no finding on the complaint that the GP should have referred Mr A for a hospital assessment.

Recommendations

What we asked the organisation to do in this case:

• Send Miss C a written apology for the failure to carry out a thorough assessment in view of Mr A's reported symptoms.
• Send a written apology to Miss C for the inadequacies in record-keeping which meant we could not determine whether a hospital referral was required.

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

• The GP involved should ensure that a thorough assessment is carried out in view of a patient's reported symptoms.
• The GP involved should ensure that their record-keeping meets the standard of what would be expected under the General Medical Council's Good Medical Practice guidance, in terms of clinical assessment, record-keeping and safety netting.

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 that the treatment the board provided to her son (Mr A) was not of a reasonable standard. The board carried out investigations about the role of their staff in the complaint. They found that Mrs C had not advised the board's staff of concerns about her son's health, and had only notified Mr A's social worker. Mrs C subsequently accepted that there was no complaint to pursue against NHS staff, and the investigation with our office was not taken any further.

Summary

Mrs C complained about the cardiology care and treatment given to her late husband (Mr A) when he was a patient at Aberdeen Royal Infirmary. Mr A was admitted to hospital and reported having chest pains and shortage of breath. During his admission, Mr A was also seen by the diabetic team and urology advice was taken.

The next month, he attended the cardiology clinic and he was noted to have continuing and increasing breathing difficulties. It was recommended that he be admitted for tests. However, in order to first rule out an infection, he was referred to the Acute Medical Initial Assessment Unit (AMIA). A few months later, Mr A was admitted to the AMIA for the second time as he was reporting chest pains and breathlessness. The cardiology team were contacted and it was decided only to manage his medical conditions, and not for him to have a clinical review at that time. He was later discharged.

Mr A died the following month and Mrs C believed that this was as a result of the pills he had been taking and she said that she felt he had not been treated properly. She also said that communication had been poor and that Mr A's unexpected death came as an enormous shock. She complained to the board and they considered that Mr A had been treated appropriately. Mrs C then brought her complaints to us.

We took independent advice from a consultant cardiologist and we found that Mr A's cardiology care had not been of a reasonable standard. We found that Mr A and Mrs C had not been given the opportunity of cardiac rehabilitation education. We found that a diuretic (a drug that enables the body to get rid of excess fluids) was recommended to Mr A during his treatment, but that he declined this. The adviser was concerned that this was not discussed further with Mr A during subsequent admissions to hospital. We found that after his second admission to the AMIA, it may have been preferable for Mr A to have been reviewed by the cardiology team. We also found that during Mr A's final admission to hospital, his follow-up should have been more timely. For these reasons, we upheld Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in Mr A's care and treatment, and for the failings in communication. 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 should receive appropriate medical management including where appropriate, diuretic treatment. Contact between the acute medical and cardiology units should be improved.
• Information and education should be available to long-term cardiac patients.
• To avoid breakdowns in communication, staff should listen to patients and/or their carers and consider any concerns they express.

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, raised a complaint on behalf of her client (Mr A) about the care and treatment he received for a bunion from Golden Jubilee National Hospital. Specifically, she complained that appropriate surgery was not carried out, that the cause of infection following surgery was not properly investigated and that Mr A had not been advised of the problems which could occur with the surgery.

We took independent advice from a consultant orthopaedic trauma surgeon and found that there was evidence to support that discussion had taken place with Mr A about the recognised complications associated with the bunion surgery. Some of these included the possible risk of non-healing and a need for further surgery. We considered that the surgery was appropriate and that, whilst there was no clear evidence of infection post-surgery, it was appropriate to consider the possibility of infection when Mr A experienced problems following his surgery. We noted that the board had apologised to Mr A regarding the lack of communication about this. We concluded that there was no evidence of unreasonable treatment and that delayed healing had been the likely reason for Mr A's protracted recovery. We did not uphold the complaint.

Summary

Mr C attended his GP practice because he was concerned that he may have Lyme disease (an infection transmitted by ticks). He said that the practice failed to follow reasonable process in diagnosing him with Lyme disease. He was prescribed antibiotics on two occasions, some months apart. Mr C said that a GP had failed to note in his medical records that he had a reaction eight days into the second course of antibiotics, which Mr C said was crucial evidence that he had the disease. As a result of the practice's failure to recognise Mr C had Lyme disease, he said that he was concerned for his future health. Mr C also complained that the practice had failed to provide reasonable explanations in their response to his complaint.

We took independent advice from a GP adviser. We found that the treatment decisions and investigations carried out by the practice were reasonable in light of the symptoms Mr C presented with. We found that it was reasonable that the practice referred Mr C to several specialists, who did not confirm that Mr C had Lyme disease. We were satisfied that the standard of medical care and treatment was reasonable and we did not uphold the complaint.

In relation to complaints handling, we found that the practice properly explained the rationale behind the decision-making on treatment and managing Mr C's symptoms, and that the responses were fair and appropriate. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment provided to his late wife (Mrs A). Mrs A had amyloidosis (a condition caused by abnormal deposits of a protein called amyloid around tissues and organs in the body) and Mr C felt that the diagnostic process for this was slow. Mr C had concerns that biopsies undertaken by the board were found to be negative for amyloidosis, but were later found to be positive when tested at the UK's National Amyloidosis Centre. We took independent advice from a consultant physician, a cardiologist, and a pathologist. We did not find that there were any unreasonable delays in determining that Mrs A had amyloidosis. The advice we received was that it was reasonable that the National Amyloidosis Centre was able to make a diagnosis when the board did not, as the National Amyloidosis Centre is more experienced in the techniques for testing. We did not uphold this complaint.

Mr C also complained about failures in communication and failures in providing adequate support to Mrs A and her family during Mrs A's illness. We took independent advice from a consultant physician and found that the board's communication with the family throughout Mrs A's illness, and the support provided to Mrs A, was unreasonable and insufficient. We considered that a protocol for earlier involvement of specialist nurses, and consideration of how to access information from the National Amyloidosis Centre, would have minimised this issue. We made recommendations regarding this.

Finally, Mr C complained about the board's handling of his complaint. We found that the board had failed to meet deadlines and had failed to provide clear explanations to Mr C. We upheld this complaint. However, we found that the board had implemented a new complaints handling procedure since Mr C's complaints and so we did not make any recommendations around this issue.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to communicate with the family properly during Mrs A's illness, for failing to provide Mrs A with adequate support and for failing to handle Mr C's complaints about Mrs A's treatment reasonably.

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

• There should be a protocol for how to involve specialist nurses in the care of patients with very rare conditions, and where to get specialised information and support.
• The board should consider how they could access information and support from the National Amyloidosis Centre to provide to 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.