Health

Summary

Mr C made a number of complaints about the care and treatment he received from a prison healthcare centre. In particular, Mr C complained that the board had not provided appropriate care and treatment for a particular medical condition he felt he had, and that they had not communicated with him reasonably about this condition.

We took independent advice from a GP adviser. We found that a number of investigations had been carried out and that none of these had confirmed the diagnosis of the condition that Mr C felt he had. We did not find evidence that the board had failed to provide appropriate treatment for this condition or that communication was unreasonable. We did not uphold these complaints.

Mr C complained further that the board failed to provide timely and appropriate care and treatment for a facial injury he sustained. We took independent advice from a nursing adviser who found that nursing staff failed to carry out a full nursing assessment of this injury and refer the issue to medical staff. We found that Mr C was then assessed by a GP after a two week delay. The GP adviser considered that the GP assessment was appropriate and noted that a timely referral to a specialist was then made. However, in view of the failings in nursing care, we upheld this aspect of the complaint and made two recommendations.

Mr C raised concerns about the pain relief medication he was prescribed and said this was ineffective. The GP adviser found that the medical records showed evidence of pain assessment and the GP's discussion with Mr C. The GP adviser said that they had no concerns about the pain relief provided to Mr C and concluded that this aspect of care was reasonable. We did not uphold this complaint.

Mr C was also unhappy about the way the healthcare centre responded to his concerns about his diet. The GP adviser found evidence that a GP made a request to the kitchens for a high fibre diet for Mr C and also found that Mr C had received dietary advice on a number of occasions. The adviser was satisfied that this dietary advice was appropriate, and overall they considered that the care provided was reasonable. We did not uphold this complaint.

Mr C also raised concern that the board failed to provide appropriate mental health input. We took independent advice from a psychiatric adviser in relation to this complaint. They found evidence that Mr C had a number of contacts with the mental health team and also noted that a mental health assessment was carried out shortly after Mr C's admission to the prison. They did not find evidence that there were delays in Mr C receiving input from a psychiatrist or mental health nurse. The psychiatric adviser concluded that the care Mr C received was reasonable, so we did not uphold this complaint.

Finally, Mr C complained that the prison healthcare centre did not provide him with appropriate treatment for his bowel condition and said that he was not prescribed a medication that helped his symptoms. The GP adviser found that this medication was initially prescribed to Mr C because the prison healthcare centre suspected that Mr C might have irritable bowel syndrome. The GP adviser found that Mr C was subsequently diagnosed with a different medical condition, which meant that this medication was no longer appropriate. The GP adviser was not critical that the prescription of this medication ended and considered Mr C received reasonable care and treatment. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to carry out an appropriate assessment of his facial injury. This should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Where a patient has sustained an injury, a full nursing assessment should be carried out and medical issues should be referred to medical staff, as appropriate.

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 that her mother (Mrs A) received prior to her death in University Hospital Ayr. Mrs A underwent major surgery and experienced post-operative complications. She was transferred to the medical high care ward for non-invasive ventilation (NIV, assistance with breathing using a mask). She had difficulty tolerating this treatment and it was recorded that she refused to continue with it. The family were called to come to the hospital and when they arrived they requested that NIV treatment be further attempted. However, the doctor did not agree to this. Mrs C complained that Mrs A had been confused since her surgery and that she did not have the capacity to refuse treatment.

We obtained independent medical advice from a consultant physician, who found that the evidence in the records showed that Mrs A had capacity to withdraw consent for further NIV treatment. The adviser explained that while the doctor considered the family's wish for further NIV, it was reasonable for them to decide that this would not be appropriate in view of Mrs A's expressed wishes and her clinical condition. In light of this, we did not uphold this aspect of the complaint.

However, we found that the family should have been involved in the decisions about NIV at an earlier stage, which the board had already acknowledged and apologised for. The adviser also noted that the decision not to continue treatment could have been explained more clearly to the family. In particular, it was noted that Mrs A's condition was poor and that further treatment was very unlikely to have been successful. This should have been sensitively communicated to the family, when instead the decision appeared to have been explained to them solely in terms of Mrs A having declined treatment. The adviser noted that national NIV guidelines had since been updated to require an individualised patient plan to be recorded at the start of treatment, which documents the agreed measures to be taken in the event of NIV failure.

Mrs C also complained that it took the board almost two years to address the issues she raised. We agreed that there was an unreasonable delay in the board responding to the complaint, and that their initial investigation was not thorough and robust. When they subsequently reviewed their initial findings, they reached a different view. Mrs C was provided with a copy of this review but we considered that she should also have received a further response specifically addressing the issues she had raised. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the time taken to investigate her complaint and the contradictory responses she received.

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

• Ensure that our findings are fed back to the doctor involved for reflection and learning.
• Review their NIV protocol in light of recent guidelines to ensure that the patient is involved wherever possible in formulating an individualised patient plan setting out the measures to be taken in the event of NIV failure.

In relation to complaints handling, we recommended:

• Review their arrangements for assessing new complaints to ensure that the level of investigation or review required is considered at an early stage.
• Review how their complaint procedure interacts with the procedure for reviews to ensure that the complaint response is not unduly delayed by the review and that a full response addressing the points of complaint is provided at the end of the process.

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 him by his dentist. Mr C attended his dentist after experiencing pain in his teeth. After taking x-rays and performing an examination, the dentist considered there was an abscess around the roots of a tooth supporting the bridge in Mr C's mouth. When Mr C re-attended to discuss this, the dentist documented offering options including an extraction. Some weeks later, the extraction was performed.

Mr C said he was persuaded to have the extraction and questioned whether this was appropriate treatment. He also said the dentures he was provided with were uncomfortable and ill-fitting. He said he told the dentist that he ground his teeth, and that the dentist offered a bite shield, which was not provided.

After obtaining independent advice from a dentist, we did not uphold Mr C's complaints. We found that there was evidence of options being discussed in the dental records, and consent to treatment. We found the treatment option of an extraction was reasonable in the circumstances. We considered the dentist provided appropriate advice about the dentures and the need to have them re-fitted. We noted that a bite shield would not usually be provided until the condition of a patient's teeth was stable.

Summary

Mr C complained to us that the board had failed to properly assess his mother (Mrs A) before she was discharged from Perth Royal Infirmary. He said that, as a result of this, Mrs A had to go into a care home for full-time care, which had cost the family over £20,000 in charges. We took independent advice from a consultant geriatrician. We found that Mrs A had been discharged without being adequately assessed. There was no evidence of a multi-disciplinary team discussion or of adequate occupational therapy input in the discharge planning process. In addition, we found that that the physiotherapy and nursing notes indicated that she should have had further assessment. Mr C had also raised concerns several times to different members of staff about Mrs A's ability to return home. We found that Mrs A should not have been discharged on the day that she was. In view of this, we upheld the complaint. However, it was likely that she would have been reviewed again a week later and it was possible that a reasonable decision could have been made at that time that she could be discharged. This could have been either to her own home or to a nursing home.

Mr C also complained that the board had not informed him of, or acted in accordance with, the relevant Scottish Government guidance on intermediary care following hospital discharge. The relevant guidance is normally used where care homes are being considered. In view of the fact that Mrs A had been discharged home, we found that there was no need to use the guidance. Although we found that staff had not taken sufficient account of Mr C's views at the time of Mrs A's discharge, on balance, we did not uphold this aspect of the complaint.

Finally, Mr C complained to us about the board's handling of his complaint. We found that the board had delayed in responding to Mr C and that the communication with him about a meeting had not been clear. In addition, the board's response said that it had been reasonable to discharge Mrs A. In view of these failings, we upheld the complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to appropriately assess Mrs A before she was discharged from hospital;
• reimburse Mrs A for the first seven days of her nursing home costs;
• provide evidence to us that they have taken steps to ensure that patients in the hospital receive care in line with Standard 5 of the 'Scottish Standard of Care for Hip Fracture Patients' in relation to discharge planning;
• issue a written apology to Mr C for their failings in relation to the handling of his complaint;
• feed back our findings on the handling of Mr C's complaint to the staff involved; and
• provide evidence to this office that they have taken steps to ensure that multi-disciplinary team meetings are documented in the records of patients.

Summary

Ms C complained about the care and treatment of her brother (Mr A). Mr A was diagnosed with liver disease and admitted to the acute medical unit at Ninewells Hospital a few weeks later. During the admission, he was also given medication for alcohol withdrawal. Mr A was diagnosed with acute kidney injury and treated with dialysis (a form of treatment that replicates many of the kidney's functions). Mr A's condition worsened suddenly, and he was transferred to intensive care, where he died.

Ms C raised a number of concerns, including that Mr A was missed during the doctor's ward round the morning after his admission and that he was not referred to kidney specialists sooner. Ms C felt the hospital was under-staffed over the weekend, and she felt this meant that Mr A's condition was not taken seriously until it was too late. Ms C was also concerned that Mr A was given varying doses of medication, instead of commencing with a high dose which is slowly reduced.

The board conducted an adverse event review of Mr A's admission. They acknowledged some failings, including that Mr A was missed on the ward round, that some of the nursing documentation was not fully completed, and that the family should have been told sooner how serious Mr A's condition was. The board apologised to Mr A's family, discussed the learning from the complaint with staff and agreed a new process for ward rounds to ensure that patients who are being moved are not missed. The board also met with Ms C to discuss the complaint, but Ms C found the meeting unhelpful and brought her complaint to us.

After taking independent medical and nursing advice, we upheld Ms C's complaints about medical care and communication.

While we found there were some omissions in nursing documentation, we found that the overall standard of nursing was reasonable. We found the administration of the medication was appropriate, as this was given as needed, using a scoring system to assess Mr A's symptoms. While we noted that Ms C disagreed with many points of the board's response to her complaint, we did not find failings in their complaints handling. However, we made some suggestions regarding how the board could improve their complaints handling practice by inviting people who request a meeting to confirm the issues they want addressed in advance of the meeting.

Recommendations

We recommended that the board:

• demonstrate to us what steps they have taken to reassure themselves that the new system for ensuring consultant reviews of incoming patients on the acute medical unit is effective.

Summary

Ms C complained that a dentist failed to carry out reasonable investigations to find the cause of her dental pain over the course of a year. She also complained that the dentist broke the root of her tooth and left it in her gum during the extraction of her tooth. We took independent advice from a dental surgeon and found that the dentist took reasonable steps to identify the cause of Ms C's dental pain, and that the delay was due to the time she had to wait for an appointment with a specialist. We did not uphold this aspect of the complaint. Whilst the adviser considered the tooth extraction was carried out properly, they felt that Ms C should have been advised that the likelihood of her tooth fracturing during the extraction was high, and offered a referral to a specialist to carry it out. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Ms C with a written apology for failing to tell her that the risk of fracturing her tooth was high, and for not offering her a referral to a specialist to carry out the extraction. The apology should meet the standards set out in the SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

Summary

Ms C complained that her dentist failed to give her appropriate treatment. In particular, she complained that the dentist may have fractured the root of her tooth during root canal treatment.

During our investigation we took independent advice from a dental surgeon. The adviser said that a root canal was the appropriate treatment for Ms C's tooth, and found that the root canal had been carried out appropriately, with Ms C's root fracture happening over a year later. We, therefore, did not uphold the complaint.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received at Monklands Hospital. Mrs A attended the A&E department at the hospital and was diagnosed with a urinary tract infection. She was sent home with antibiotics and instructions to return if she still felt unwell. Mrs A returned the next day and was admitted for further investigations. Scans showed Mrs A had a large mass in her pelvis, hydronephrosis (an obstructed kidney) and pulmonary emboli (blood clots in her lungs). She was treated by urology doctors for the kidney problems, and then by gynaecologists for the mass in her pelvis, which was found to be cancerous. Mrs A was offered surgery roughly two weeks after her admission, but it was not possible to remove the cancer. Mrs A was given palliative care and died in hospital.

Mr C complained that Mrs A was not admitted when she first attended hospital, and that it took too long to diagnose Mrs A's cancer and offer her surgery. Mr C was concerned that gynaecologists did not review Mrs A until a week after her admission, and then waited for the multi-disciplinary team meeting around a week after that before making a decision about treatment.

The board responded to Mr C's complaint in writing and offered to meet with him if he wished. They explained that they considered the treatment provided was appropriate.

After taking independent emergency medicine and gynaecology advice, we did not uphold Mr C's complaints. We found that the treatment provided when Mrs A first attended hospital was appropriate, and that it was reasonable to offer antibiotics first with instructions to return if her symptoms continued. We also found the time-frame for diagnosing and treating her cancer was reasonable. While Mrs A was not reviewed by gynaecologists until a week after admission, gynaecologists discussed her condition with the doctors caring for her, and requested further tests to diagnose the mass, which were carried out before the gynaecology review. We also found that it was appropriate to wait for the multi-disciplinary team meeting before deciding on treatment, given the complexity of Mrs A's case.

Summary

Mr C raised concerns about the care and treatment the board provided to his late sister (Mrs A) at Wishaw General Hospital. These concerns extended to medical care, nursing care, and communication with Mrs A's family.

Mrs A had previously been involved in a road traffic accident, but had been discharged and was recovering. She attended Wishaw General Hospital after feeling unwell, and was admitted. She deteriorated the next day, but recovered. She experienced a further deterioration approximately ten days later. Her condition did not improve over the following days, and Mrs A died approximately four weeks later.

Mr C raised a number of specific concerns regarding the board's identification of sepsis (a blood infection), their actions regarding providing Mrs A with a cannula (a thin tube inserted into a vein or body cavity to administer medication or drain off fluid), and staff not transferring her to the intensive care unit when her condition deteriorated. He also raised concerns about nursing care, including management of Mrs A's wounds by nursing staff.

We took independent advice from a consultant in acute medicine and from a nursing adviser. Regarding medical care, we found that Mrs A should have been treated more aggressively for sepsis, and that there was some delay in relation to a cannula. We also found that Mrs A had been given a penicillin based antibiotic, though she was recorded as having an allergy. However, there was no evidence in the record that this impacted on her outcome. Regarding nursing care, we had concerns about wound care, and the general condition of the nursing records. Regarding communication with Mrs A's family, we found there was insufficient evidence of this in the records, given the seriousness of Mrs A's condition.

We upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in medical and nursing care provided to Mrs A, and for the poor level of communication with her family. 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 aware of the recognition and management of sepsis.
• Staff should be confident in managing situations where vascular access becomes difficult.
• The microbiology or infection team could be involved in the management of complex cases.
• Staff should communicate adequately with a patient's family and should make sure that communication with the family is appropriately documented.

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 medical and nursing treatment she received over a series of hospital admissions to Wishaw General Hospital. Ms C suffered from problems with the discs in her spine and had required spinal surgery on more than one occasion. Ms C said that she had been subjected to lengthy delays during each admission and that there had been an absence of medical review. Ms C said her nursing care had been unprofessional and had resulted in some humiliating incidents. Ms C also complained that she had not been referred for physiotherapy. Ms C further complained that the board's communication with another health board regarding her care was unreasonable.

We took independent medical advice from a consultant neurosurgeon, a nursing adviser and a physiotherapist. We found that Ms C had received inadequate treatment and that there were delays in her receiving scans. This meant that the outcome of a surgery Ms C had to treat cauda equina (a disorder that affects the nerves) was not as good as it might have been. The board had accepted this and had taken appropriate action to improve the diagnosis of cauda equina. We found that, during the later admissions, Ms C had suffered from extended trolley waits in the A&E department before being reviewed by an appropriate specialist. We found it to be unreasonable that Ms C had been left for long periods of time without being seen by medical staff due to failures in communication between the on-call team and Ms C's original consultant. We recommended that the board implement a protocol to cover the re-admission of patients with recurrent problems, so that staff are aware of when they need to refer the patient to the original consultant who had been responsible for treating them. We found that Ms C was, on occasion, denied access to the radiography department due to capacity issues. We considered this inappropriate and said the board should alter their procedures to allow for urgent scanning in spinal cases.

We found that the board had correctly acknowledged the failures in Ms C's nursing care across all of her admissions. We found that, whilst some of the failings were significant, they were due to poor judgement by individual staff members rather than procedural failings. We noted that the board had made reasonable efforts since Ms C's experience to improve and monitor standards of nursing care.

We found that Ms C should have been referred for physiotherapy treatment. We did not agree with the board's view that treatment was not appropriate for Ms C and found that the failure to commence physiotherapy could have delayed her recovery.

We did not find that the communication between the board and another health board regarding Ms C's care was unreasonable and we did not identify any significant failings in this regard. We did not uphold Ms C's complaint about communication between health boards.

We found that Ms C had received an unreasonable standard of medical and nursing care during her admissions to hospital. The board had accepted this and made the appropriate changes to address the failings she experienced in most areas. We found, however, that on the basis of the advice we had received, there were still areas where the board needed to improve and we therefore upheld Ms C's complaints about her care and treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing for failing to provide physiotherapy. 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:

• A protocol should be developed to ensure that scans for patients with suspected cauda equina are not delayed.
• A protocol should be developed so that when patients are re-admitted with a recurrent problem, staff are clear when care should be transferred to a patient's original consultant.
• The general assessment of when physiotherapy is justified should be reviewed.

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.