Health

Summary

Ms C was in the early stages of pregnancy when she had a miscarriage. Ms C complained about the care that she received when she contacted the board's early pregnancy service by phone and she was concerned that appropriate testing had not been carried out following the miscarriage. Ms C also complained about the way that staff had communicated both with her and between departments, as she had to explain to a member of staff carrying out a scan that the pregnancy had miscarried.

We took independent advice from a nursing adviser and from a midwifery adviser. We found that the clinical advice Ms C was given was reasonable and that the management of the miscarriage was in line with relevant guidance. We also found that some testing had been carried out following the miscarriage and that further investigations were not required in Ms C's circumstances. We did not uphold Ms C's complaint about the care provided to her by the early pregnancy service.

Regarding communication, we found that, on some occasions, it had been difficult for Ms C to reach someone at the early pregnancy service. We found that the board had identified a programme of enhanced communication training to be implemented as a result of Ms C's concerns. We also found that the board planned to change their process when referring women for scans so that more information was available to the scanning staff. 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 the failing in communication between staff. 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:

• Patients should have a 24 hour contact phone number for the early pregnancy service, in line with national 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 support provided to her following the birth of her daughter at the Victoria Hospital. She raised concerns about both her hospital care and her care in the community following her discharge. In particular, she complained about a lack of breastfeeding support, which she considered contributed to her subsequent development of postnatal depression.

We took independent advice from a midwifery adviser, who reviewed the records and concluded that appropriate support was provided to Mrs C by both the hospital and community midwives, and by the breastfeeding support worker who visited her the day after discharge. It was noted that an apparent breakdown in communication within the breastfeeding support team meant that they did not follow up with Mrs C as planned. The board had already acknowledged this oversight and undertook to discuss how they can better document requests for follow-up. The adviser also observed that the community midwives documented Mrs C's tearfulness and low mood but that they did not pass this information on to the health visiting team, as they should have. It was noted that the board had asked the community midwives to carry out a piece of work in relation to women's emotional states. On balance, we did not uphold the complaint but we made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the breastfeeding support team's failure to contact her to arrange a follow-up appointment; and for the community midwives' failure to pass on details of her low mood to the health visitor. 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:

• The breastfeeding support team should review their follow-up referral process and implement measures to ensure follow-up appointments are not missed in future.

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 medical treatment and nursing care that her late mother (Mrs A) received at Victoria Hospital. Mrs A had been diagnosed with advanced lung cancer and was admitted to hospital with symptoms of nausea and persistent vomiting. The issues Mrs C raised concern about related to a lack of blood testing to monitor Mrs A's kidney function as she had chronic kidney disease, that no intravenous (IV) fluids were given over two specific days and that fluids were not appropriately monitored, that there was a delay in a urinary catheter being inserted and that communication with the family was poor.

We took independent advice from a consultant in respiratory medicine and from a nurse. We found that there were a number of unreasonable delays in relation to Mrs A's medical care and treatment. We considered that if IV fluids had been administered in a timely manner, this may have delayed or prevented the development of an acute kidney injury (the inability to turn waste material into urine) and may have allowed Mrs A to spend more time with her family. We upheld Mrs C's complaint about medical care and treatment.

In terms of the nursing care, we found that there was a lack of comprehensive monitoring of Mrs A's fluid intake and urine output which the board's complaint investigation did not identify. We considered that such monitoring may have helped assist medical staff identify issues with urinary output sooner. We upheld Mrs C's complaint about nursing care.

We noted that the board had accepted that there were problems with the way in which staff had communicated with Mrs C and the family. Therefore, we have asked the board to provide evidence of the action that they said they would be taking to address this. However, we also recommended that the board take further action to address how they review the care and treatment of patients as their response to the complaint contained inaccurate information.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in Mrs A's medical and nursing care, and for the fact that the board's complaints investigation was not thorough enough.

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

• Review by a senior doctor for patients admitted as an emergency should be carried out in a timely manner.
• Difficulties with IV access should be escalated in an appropriate and timely manner.
• Fluid balance charts should be fully completed when indicated.
• Appropriate clinicians should be involved in the review of patient care to ensure that comprehensive responses to complaints are provided.

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 a consultation that his brother (Mr A) had with an out-of-hours service doctor. Mr A was referred to the on-call doctor by NHS 24 when he called to report pain in his chest and both arms. Mr A was examined by the on-call doctor who considered that muscular pain was the likely cause. Mr A returned home, however, later that evening he was taken to the emergency department by Mr C and was ultimately diagnosed with a heart attack. Mr C complained to the board about the consultation with the on-call doctor as he considered that Mr A's condition should have been identified sooner. Mr C was also concerned that the board's response to his complaint was unreasonable.

We took independent advice from a GP experienced in out-of-hours care. We found that Mr A did not have the typical presentation of a heart attack and consequently, this could not have been foreseen by the on-call doctor. We found that arriving at what later turned out to be an incorrect diagnosis did not mean that the on-call doctor was at fault and we found that there was evidence that they had adequately and appropriately assessed Mr A. We did not uphold this aspect of Mr C's complaint.

Regarding Mr C's complaint about the board's response to his concerns, we found that there was a minor inaccuracy in the response and that there was a lack of evidence that Mr C had been kept properly updated when the timescale for responding to his complaint passed. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the timescales for responding to his complaint were not made clear. The apology should meet the standards set out in the SPSO guidelines on apology available at https://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 she had received from the board. However, during our investigation we were advised that Mrs C had commenced legal action against the board. We must not investigate any matter which has been, or is being, considered in a court of law. Therefore we did not take these aspects of Mrs C's complaint forwards.

Mrs C also raised concern about the board's handling of her complaint. We found that the board failed to provide updates and delayed in advising Mrs C that her complaint was out of time and would not be investigated, in line with the complaints procedure. We upheld this aspect of Mrs C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• The board should review their arrangements for assessing new complaints to ensure that, where a complaint is out of time, this is identified in line with the model complaints handling procedure. Guidance and standards for good investigations are set out in the SPSO Investigations toolkit, available at http://www.valuingcomplaints.org.uk/learning-and-improvement/best-practice-resources/decision-making-tool.

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 provided to his mother (Mrs A) during her admission to University Hospital Crosshouse. He raised particular concerns about an initial cancer misdiagnosis for what was a chest infection / pneumonia. We took independent medical advice from a consultant physician who considered that it was reasonable for medical staff to have considered the possibility of a cancer diagnosis given Mrs A's presentation and background. They advised that this did not impact on the treatment provided as reasonable steps were taken to continue to treat for infection, while planning appropriate investigations. However, the adviser said it appeared that communication with the family may have been unduly weighted towards the likelihood of cancer. In addition, they noted that there was a delay in the clinical team receiving an x-ray report, which might have contributed to the lack of clarity and prolonged the apparent overestimation of the probability of an underlying cancer. On balance, we did not uphold this aspect of the complaint but we made some recommendations.

Mr C complained that the focus on a cancer diagnosis led to a delay in commencing appropriate treatment. He noted that Mrs A's blood pressure rose unchecked resulting in her suffering a stroke. While the adviser reiterated that treatment for infection was appropriately continued, they identified that the treatment choice for the initial 24 hours was unreasonable. They noted that Mrs A's CURB 65 score (a score which guides treatment for community acquired pneumonia) should have been calculated and this would have indicated the need for a second antibiotic. After the initial 24 hours, however, the adviser noted that a stronger antibiotic was appropriately administered. The adviser noted that there were factors preventing optimal monitoring and treatment of Mrs A's blood pressure, but they considered the management of this was reasonable in the circumstances. They noted that there were other potential factors which might have contributed to Mrs A's stroke and could not solely attribute this to her blood pressure. On balance, we did not uphold this aspect of the complaint but we made a recommendation for action by the board in relation to the initial choice of antibiotic.

Mr C also raised concerns about the board's handling of his complaint. We were critical of the board in this regard. We did not consider there to be sufficient evidence to demonstrate that the issues raised were thoroughly investigated. In particular, no written report of the investigation was produced. A meeting was held and this was followed by a short letter detailing some action points. This was issued outwith the required 20 working day period and no explanation for the delay was given. Mr C then had to chase on several occasions for updates on actions taken and, even then, the board did not sufficiently demonstrate learning from the complaint. There was also an oversight by the board in terms of timely further contact with Mr C, for which they had already apologised. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the family for the failings in relation to communication, medical treatment, and 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.

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

• Medical staff should be guided by the CURB 65 score when treating for community acquired pneumonia.
• Medical staff should communicate clearly with patients and relatives to ensure they understand any diagnostic uncertainty, and the purpose and aims of the treatment options being explored.
• Clinicians should know how to easily ask for a radiology opinion and, where a formal x-ray report is required, this should be returned to the clinical team within a reasonable timeframe.

In relation to complaints handling, we recommended:

• The board should review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities regarding complaints handling, as set out in the Can I help you? 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's mother (Mrs A) broke her ankle in a fall. Although Mrs A had a complex medical history, including cancer and diabetes, the decision was taken at Ninewells Hospital to fix the ankle surgically. After a period of care in the hospital, Mrs A was discharged to a nursing home. During an out-patient review, it was discovered that the ankle wounds had broken down and that the metal work used to fix the fracture had become exposed. Mrs A was admitted to hospital again and underwent further surgery to remove the metal work. Mrs A was discharged back to the nursing home a few weeks later. At a further out-patient follow up, it was found that Mrs A had an infection in the ankle wound and that the bone had not grown back together. She was admitted to hospital again for treatment with antibiotics and wound care. It was considered that amputation could be necessary to control Mrs A's pain and to improve her quality of life. Amputation surgery did not take place and Mrs A was later discharged back to the nursing home.

Mrs C complained about the skin and pressure care that her mother received at the hospital across these admissions as Mrs A had developed pressure ulcers on her heel and lower back. Mrs C also complained about communication with the family in relation to amputation surgery. Mrs C and her siblings held power of attorney for Mrs A and they were concerned that the surgery was planned to go ahead without appropriate discussions with them. During their own consideration of this complaint, the board identified areas for improvement in relation to a number of areas, including pressure and skin care.

After taking independent advice from a nursing adviser, we upheld Mrs C's complaint about skin and pressure care. We found that there was a lack of evidence to demonstrate appropriate skin and pressure care had been provided. The advice we received highlighted that pressure injury to Mrs A's foot could have been avoidable with different care and that pressure area risk assessment documentation had not been properly completed for Mrs A. The board's policy on pressure ulcer prevention was not considered to have been appropriately followed in this case. The nursing adviser was asked to review the improvement plan implemented by the board following their own consideration of this complaint. The advice we received was that this did not adequately address all the failings identified. We made a number of recommendations about this as a result.

In relation to Mrs C's complaint about the board's communication with the family regarding amputation surgery, we took additional independent advice from a consultant orthopaedic surgeon. The advice we received was that it was reasonable to consider amputation in Mrs A's case, although this was not the only option available for her care and treatment. Mrs C was concerned that Mrs A had been listed for theatre and that surgery would have proceeded if she had not happened to visit her mother at the hospital. Mrs C was shocked to be told by nursing staff that Mrs A was listed for theatre the next day and spoke to a doctor to explain that she did not consider amputation to be the right thing for her mother. The advice we received was that it was reasonable to list Mrs A for theatre when the final decision on surgery had not yet been made as this avoids delay. We found that there was no evidence that amputation surgery would have gone ahead without Mrs C or her siblings being consulted further. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in pressure care. The apology should meet the standards set out in the SPSO guidance on apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• We said that:
• The appropriate risk assessment documentation should be correctly completed by nursing staff caring for patients.
• Pressure injuries and moisture lesions should be accurately diagnosed and graded.
• Wound assessment should be carried out for pressure ulcer care and wound assessment charts should be completed.
• Accurate records should be maintained in relation to nursing care, in line with the Nursing and Midwifery Council Code on record-keeping.

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 have set.

Summary

Mrs C complained about the care and treatment provided to her at Perth Royal Infirmary when she had back problems. Mrs C complained that when she attended the A&E department on two occasions, she was not appropriately assessed before being redirected to another service. Mrs C also complained that, when she was admitted to the hospital, she was not provided with appropriate pain relief medication and that there was a delay in her being given surgery. Mrs C further complained that the information passed from A&E to her GP was not appropriately detailed.

We took independent advice from an A&E consultant and from a neurosurgeon. We found that the first time Mrs C had presented to A&E she was appropriately assessed. However, we found that the second time she presented there was a failure to accurately document the assessment undertaken, which meant that it was not possible to say whether it was appropriate to have redirected Mrs C to another service. We upheld this aspect of Mrs C's complaint. We also found that when Mrs C was admitted to hospital, there was an unreasonable delay in providing her with pain relief, particularly as she had been recorded as being in severe pain. We also upheld this part of Mrs C's complaint.

With regards to her surgery we found that, based on Mrs C's symptoms, there was no unreasonable delay in her having surgery. We found that the time between Mrs C being admitted to hospital and undergoing surgery was unlikely to have had any negative impact on her outcome. We also found that the information passed from A&E to Mrs C's GP was reasonable and included all of the necessary information. We did not uphold these two aspects of Mrs C's complaint.

Mrs C had also complained that the board did not answer her question regarding whether her current condition could have been avoided had she received emergency surgery at an earlier point. Whilst we recognised that this was an important matter to Mrs C, we did not consider this question to have been clearly asked of the board when she initially complained. We did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to properly document her assessment during her second attendance at A&E. 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:

• Appropriate pain relief should be provided to patients, and staff should check with patients whether they require pain relief medication.

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 the board unreasonably removed her from a waiting list for orthodontic treatment. She also complained that they had failed to tell her that she had been removed from the waiting list and had not provided her with a reasonable explanation of why she had been removed.

We took independent advice from a dental surgeon. The adviser explained that there are two different types of orthodontic referral, one for consultation and the other for actual treatment. The advice we received was that Miss C's initial appointment was to assess whether she met the criteria for orthodontic treatment. The adviser said that Miss C had not met the required criteria and, therefore, she had not been placed a waiting list for orthodontic treatment. The adviser said that this decision was reasonable. The adviser also said that the board's decision not to provide Miss C with orthodontic treatment in subsequent years was reasonable and was in keeping with relevant guidance. We found that, as a result, Miss C had not been put on a waiting list for orthodontic treatment, which we found was reasonable. As she had not been put on a waiting list, she could not have been told that she had been removed from such a list. Therefore, we did not uphold those aspects of Miss C's complaint.

However, we found it concerning that, over a period of several years, Miss C appeared to be under the impression that she had been placed on a waiting list for orthodontic treatment. The adviser commented that Miss C may not have understood that there were two different types of waiting lists and that she did not appear to have been informed about the option of private orthodontic treatment until she complained to the board. We considered that it is essential that a patient understands their treatment plan and that this did not appear to have happened in Miss C's case. For this reason, we upheld Miss C's complaint that the board had not provided her with a reasonable explanation of why she had been removed from the list.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to appropriately communicate with her about her treatment and for failing to ensure that she fully understood her treatment plan, the different types of orthodontic waiting lists and the option of private orthodontic treatment. 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:

• Dental staff should explain to patients and ensure that they understand:
• their treatment plan
• the different types of orthodontic waiting lists
• the option of private orthodontic treatment when they are not entitled to NHS orthodontic treatment.

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 the ambulance service provided to his late mother (Mrs A).

Mrs A suffered a number of background conditions and she became unwell. The ambulance service received a phone call and paramedics attended. The paramedics assessed Mrs A as likely being medically unwell, with possible sepsis (a blood infection). There were difficulties moving Mrs A, and a second ambulance attended to assist paramedics. Mrs A was taken to hospital where her condition deteriorated and she died.

Mr C raised concerns about the actions of staff, including the time they took to move Mrs A, and the way they moved her. The ambulance service considered that the care and treatment provided to Mrs A was appropriate. They considered that staff performed a thorough assessment, and acted reasonably in the circumstances.

We took independent advice from a paramedic. We found evidence that all relevant observations and examinations were undertaken. Regarding the time taken to move Mrs A, we found that it was appropriate for paramedics to request a second ambulance to assist them in moving her and we found that the delay was not excessive in the circumstances. We found no evidence that Mrs A was incorrectly moved. We did not uphold Mr C's complaint.