Health

Summary

Mr C was being treated at the Beatson Cancer Centre when his cannula became dislodged causing chemotherapy to leak into the surrounding tissue and skin. He was taken to Glasgow Royal Infirmary and a procedure was carried out to remove the chemotherapy. Mr C complained that the nursing staff had not properly inserted the cannula or monitored his treatment. Mr C also complained that staff did not appear to know what to do following the incident, and he raised concerns about the length of time it took to be referred to plastic surgery.

We took independent advice from a nursing adviser. We found that whilst Mr C was aware that he had to report any problems with his cannula to staff, the nursing staff had not documented having given this advice. The board had acknowledged this failure in record-keeping when responding to the complaint and advised of the action they had taken to address the matter. We identified further evidence of poor record-keeping which was not in line with Nursing and Midwifery Council guidance in terms of the accuracy of information documented and that several nursing care entries were not timed.

We did not find clear evidence to show that the nursing staff had failed to properly insert or monitor the cannula. In addition, we identified that there was evidence to demonstrate that the appropriate action was taken following the incident to address the leakage. We also found that there was no undue delay in Mr C being transferred to Glasgow Royal Infirmary. We did not uphold the complaint.

Recommendations

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

• Staff should ensure full and accurate records are documented in line with Nursing and Midwifery 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

Mr C complained that after being put on the waiting list for a transurethral resection of the prostate (surgery used to treat urinary problems caused by an enlarged prostate), he was not given an appointment within the 12 week treatment time guarantee timescale, and that he was not updated about this or his place on the waiting list.

We took independent advice from a consultant urologist and found that the delay Mr C had experienced was unreasonable. Whilst the board had provided evidence of a number of actions they had taken to address the extended waiting times for urology services, including employing more urology consultants and opening extra theatre lists, they had not provided evidence that the board had taken steps to arrange for the procedure to be carried out by another NHS health board or by another provider as is stipulated by the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012. We also found that Mr C should have been contacted by the board and advised of the delay in treatment. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in providing him with an appointment for transurethral resection of the prostate. 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:

• When the treatment time guarantee is not going to be met, the board should take reasonable steps to arrange for the provision of the procedure by another NHS health board or another provider, as set out in the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012.
• Patients should be advised when the treatment time guarantee is not going to be met, and given an explanation as to why this is.

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, who works for an advocacy and support agency, complained on behalf of his client (Mrs A). Mrs A complained about the care her late son (Mr A) received at Queen Elizabeth University Hospital after he was taken there by emergency ambulance. It was identified that Mr A was suffering from limb and life threatening ischemia (a lack of blood supply that could be life threatening or cause the loss of a limb) requiring urgent surgery. Mrs A complained that the board's consultant vascular surgeon did not share this information with the family in a more private area of the hospital, that there was a lack of action by staff in response to Mr A having complained of severe stomach pain following surgery, and that Mr A had been placed in a single room containing equipment prior to his death a few days later.

We took independent advice from a consultant vascular surgeon. We found that, although the cubicle environment in the emergency department was not ideal, the communication that took place with Mr A and the family was reasonable and we did not uphold this complaint. We also considered that there was no undue delay in carrying out a scan following the surgery after Mr A's concerns about his stomach pain were identified. We did not uphold this complaint. We further identified that the board had reflected on the family's concerns about there being equipment stored in the single room due to essential maintenance work. They acknowledged that this should have been explained to the family at the time and they apologised for this. We concluded that it was not unreasonable to transfer Mr A to the single room to allow the family more privacy, and on balance we did not uphold this complaint.

Summary

Mr C complained about the care and treatment provided to his late wife (Mrs A) when she was a patient at Inverclyde Royal Hospital. Mrs A suffered from vascular dementia (a type of dementia caused by reduced blood flow to the brain) and was admitted to hospital for further assessment when she became confused, possibly due to a urine infection. Mrs A's condition deteriorated and she died two weeks after being admitted to hospital. Mr C said that she was not given appropriate medication within a reasonable time and that staff failed to communicate with him in a reasonable way.

We took independent medical advice from an adviser who specialises in general medicine. We found that the board provided a reasonable standard of care and treatment and that Mrs A's deterioration was recognised in a reasonable time and treated appropriately. We also found evidence that healthcare professionals had discussed Mrs A's condition with Mr C. We did not uphold the complaint.

Summary

Mrs C complained about the treatment she received at the Queen Elizabeth University Hospital during labour. Mrs C's concerns included that during the delivery, she sustained a tear which resulted in significant bowel problems. Mrs C also said the board failed to provide her with appropriate follow-up treatment for her bowel problems.

We obtained independent medical advice on the complaint from a consultant obstetrician and gynaecologist. The adviser explained that Mrs C sustained a third degree perineal tear (a tear which involves the muscles around the anus which contract to provide continence of faeces) during labour. They said that third degree perineal tears were a recognised complication of vaginal birth, and that Mrs C's records suggested that she was informed of the risk of this complication before the birth of her baby. We noted that the board apologised for the added pain and discomfort Mrs C experienced as a result of the tear. We considered this to be reasonable and did not uphold this part of Mrs C's complaint.

The adviser confirmed that Mrs C was appropriately seen in a specialist clinic 11 weeks and 25 weeks after the delivery of her baby daughter and that the treatment she received during the appointments was reasonable. However, it appeared that Mrs C did not receive the planned physiotherapy treatment following her first clinic appointment. We were critical of the board in this regard and upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mrs C with a written apology.

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

• Staff should arrange follow-up physiotherapy treatment for patients in cases such as this.

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, who works for an advocacy and support agency, complained on behalf of his client (Mr A) about the care and treatment that was provided to his late wife (Mrs A) at Queen Elizabeth University Hospital. Mrs A had been referred to the board by her GP after she was diagnosed with Cushing's syndrome (a collection of symptoms caused by high levels of the cortisol hormone in the body). Mrs A attended the hospital and remained there until she died two months later.

In investigating Mr C's complaints, we took independent advice from a consultant in acute medicine. On the basis of the advice we received, we upheld Mr C's complaint that the board failed to provide reasonable care and treatment for Mrs A during her admission to the hospital. The advice we received was that when Mrs A's condition deteriorated, this was recognised and responded to in an appropriate manner. However, there were aspects of her care that were unreasonable. In particular, she had recurrent bouts of sepsis which were not adequately investigated and her elevated blood glucose and low potassium levels were not investigated. Mrs A also had a fever of unknown origin and this was not recognised or investigated promptly. In addition, the advice we received was that Mrs A was moved unreasonably on multiple occasions between wards and hospitals. We found that, despite an elevated national early warning score (a system that determines the degree of illness of a patient), Mrs A was transferred to a hospital that was unable to look after a patient who required oxygen, and so she was subsequently transferred back to the Queen Elizabeth University Hospital.

We also upheld Mr C's complaint that the board had failed to communicate with Mr A about his wife's condition during her admission. The advice we received was that there was little evidence in the medical records to demonstrate that Mr A was informed of Mrs A's multiple transfers, or the rationale for these transfers. We considered that the level of communication was unreasonable.

We did not uphold Mr C's complaint that the board had failed to respond fully to Mr A's complaint. We were satisfied that the board had reasonably responded to the issues raised by him in his letter of complaint to them.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to provide Mrs A with appropriate care and treatment. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to communicate adequately with Mr A. 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:

• Where possible, moving a patient multiple times should be avoided. The rationale for necessary moves should be clearly recorded in the medical records.
• Patients with elevated national early warning scores should not be transferred without further medical review and adequate handover.
• Communication between 'giving' and 'receiving' units regarding a patients needs should include national early earning scores and any requirement for oxygen.
• The handover process should ensure that events that happen overnight, even those perceived as small, are relayed to the day team for action. Abnormal blood results should be appropriately flagged and consideration given to an alert if the same patient has
• Patients with ongoing low potassium levels should be reviewed by appropriate specialist teams.
• Microbiology input and review should be sought for patients with recurrent sepsis.
• Families should be given sufficient opportunities to discuss their concerns and raise questions with clinical staff; especially in situations where the admission is prolonged and complex.

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's son (Mr A) is in long-term foster care. He has ear problems requiring him to attend hospital. Ms C complained that she was not always informed of Mr A's appointments and that, on occasion, appointments for him were cancelled without her knowledge or permission. She said that although she wanted to discuss Mr A's diagnosis and prognosis with his consultant, her request to do so was refused. She further complained that the board refused unreasonably to send her a detailed consent form in advance of the surgery he required.

Ms C made her complaint to the board who confirmed that there had been difficulty in always keeping her informed of Mr A's appointments because of the limitations of their current patient management system and also due to human error. They apologised that this had been the case but said that they had had discussions to improve the system. They said that in the interim they had appointed a member of staff to regularly check the system in order to update Ms C. However, they denied that appointments for Mr A had been cancelled unreasonably or that staff had not been prepared to discuss his care with Ms C. They said that she had been spoken to and given explanatory information about Mr A's condition and about the operation he needed.

We made further enquiries of the board and also sought confirmation of Mr A's status as a looked after child. We obtained independent advice from a medical adviser on the matter of consent. We found that there had been problems in keeping Ms C up to date about Mr A's medical appointments but that, where appointments had been cancelled, cancellations had been made in accordance with the board's procedures. The board had also offered to meet with Ms C to discuss Mr A's diagnosis and prognosis but she had been unable to attend. We found that they had discussed it with her immediately before Mr A's operation and provided her with explanatory documentation. However, they could have given these explanatory leaflets sooner and so 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 failing to always keep her informed of Mr A's appointments.
• Apologise to Ms C for failing to provide her with information that she had requested about Mr A's diagnosis, prognosis and treatment. The apology should comply with SPSO's 'Guidance on Apology', which can be found at www.spso.org.uk/leaflets-and-guidance.

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

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mr A). Mr A said that his medical practice had not provided him with reasonable care and treatment regarding blood tests and referral for specialist opinion. Mr A attended the practice from 2011 with a low platelet count and a lymphocyte (a type of white blood cell) count that was intermittently rising but still within the range that would be considered normal.

Mr A was referred to the haematology department in 2012. He then attended the practice for blood tests several times from 2012 to 2015. The practice had requested advice from haematology in relation to follow-up and further tests but had not received this advice. The results of the blood tests carried out at the practice were similar to those in 2011 until 2015 when the lymphocyte count increased and tests indicated possible lymphoma (a type of cancer).

We took independent medical advice from a GP adviser and found that the practice had acted reasonably in relation to blood taken and analysed at the practice, so we did not uphold the complaint.

The practice had carried out an analysis of the events surrounding Mr A's case. The outcome of this was that advice requests to specialists would now be made in a way that would ensure a response regarding follow-up and advice.

Recommendations

What we asked the organisation to do in this case:

• The practice should issue a written apology to Mr A for failing to refer him to haematology to investigate abnormalities in blood test results.

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 he received at a prison healthcare centre after he was diagnosed with diabetes. Mr C was concerned that he did not receive appropriate medical care and treatment or support in relation to his diabetes. He also complained that there had been a delay in providing treatment for thrush, and complained that when he was admitted to hospital, staff at the prison health centre had not informed his next of kin. Finally, Mr C felt that his complaint had not been dealt with appropriately.

After taking independent GP advice, we upheld Mr C's complaint about medical care and treatment. While we found that most aspects of his diabetes care and treatment were reasonable, the adviser highlighted two separate days following hospital discharges where Mr C had not received his prescribed medications. We made recommendations to the board to address this.

We found that the board had taken reasonable steps to provide help and support to Mr C for his diabetes and identified no delays in the provision of thrush treatment. Consequently, we did not uphold these elements of Mr C's complaint. We also did not uphold his complaint about the health centre staff failing to inform his next of kin when he was admitted to hospital as we found that this was a matter for the Scottish Prison Service.

Finally, we upheld Mr C's complaint about the board's handling of his complaints as we found that they had not addressed all the issues raised. We made a recommendation to address this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing to Mr C for failing to give him his prescribed medication on two dates.
• Apologise in writing to Mr C for failing to address one of the concerns of his complaint.

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

• Medications that have been prescribed to a prisoner in hospital should be made available following discharge.

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

Summary

Mr C complained about the way his medication was handled by the prison healthcare centre, in particular that his medication had been stopped, the board had stopped his medication before investigating his complaint about the medication and that the board did not reinstate his medication.

We took independent GP advice. We found that the decision to stop Mr C's medication was taken in line with the board's and the General Medical Council's guidance on safe prescribing. Mr C had signed an agreement before starting the medication which set out the circumstances under which the medication could be stopped. We were satisfied that the decision to stop the medication was taken in line with this agreement. The evidence demonstrated that when Mr C's medication was being stopped, he was reviewed by a doctor and was offered support in line with policy. The advice we received was that the decision to not restart Mr C's medication was reasonable and in line with policy. We did not uphold these complaints.

Mr C was also unhappy with the handling of his complaints, in particular that there had been an unreasonable delay by the board in dealing with his complaint. He also said that the investigation of his complaint had been inadequate, and that the response to his complaint was unreasonable. We decided to consider these issues together. We were satisfied that the board had handled Mr C's complaint in line with the complaints process and therefore did not uphold his complaint about delay. We were also satisfied that the board had adequately investigated his complaint and did not uphold that complaint. Finally, we were satisfied that the board's response to Mr C's complaint was reasonable and did not uphold his complaint.