Health

Summary

Ms C complained about a number of aspects of the care and treatment provided to her late mother (Mrs A) during two admissions to Queen Elizabeth University Hospital. Ms C complained that the standard of clinical care and treatment provided to her mother was not reasonable. Ms C also complained that the nursing care provided to Mrs A was not reasonable. Ms C's third concern was regarding the board's communication with Mrs A and the family during the admissions.

We took independent advice from a cardiologist and a nursing adviser. We found that the clinical care and treatment provided to Mrs A was reasonable. We found that the medications prescribed were appropriate and that Mrs A was reasonably reviewed. Whilst there was a failure to refer Mrs A to a heart failure nurse when she was discharged, we found that this was picked up at a later out-patient appointment and that an earlier follow up would not have impacted on Mrs A's treatment. We did not uphold this aspect of Ms C's complaint.

With regards to nursing care, we found that, whilst for the most part the nursing care was reasonable, the fluid balance charts were not always complete. We found this to be unreasonable and we upheld this aspect of Ms C's complaint.

Finally, based on the records available, we found that the board's communication with Mrs A and the family was reasonable. We did not uphold 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 complete fluid balance charting.

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

• Nursing staff should complete all care rounding charts, including fluid balance charts, as required.

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 was unhappy that the doctor in the prison health centre decided that his prescription for pregabalin medication (medication used to treat pain from damaged nerves) would be reduced. He was also unhappy that, shortly after this, the decision was made to stop the medication entirely as a result of a failed spot check. The following month the medication was restarted, but on a supervised, reduced dosage. Mr C was concerned about this as he said that this medication was very important in helping him manage pain. He complained to us that the board unreasonably reduced his dose of pregabalin.

We took independent advice from a GP. The adviser explained that the decision to prescribe this medication is a clinical one based on the patient's need and the medical assessment. It is not prescribed based on a patient's request and, in this case, the adviser considered that there had been no clinical failings. The adviser also noted that the decisions had been in line with the relevant policy and were also in line Mr C's medication contract, which said that medication would be stopped if a spot check was failed. We did not uphold this complaint.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr A) at Queen Elizabeth University Hospital.

Mr A attended the board's respiratory clinic over the course of a number of months. The board's consultant respiratory physicians were concerned that Mr A was suffering from mesothelioma (a rare type of cancer that is linked to asbestos exposure). The board arranged for blood tests, a scan, and a biopsy. The results showed no evidence of cancer. However, the consultant remained concerned about this. Mr A's condition deteriorated over the course of the following months, and the consultant said that while a diagnosis of mesothelioma was not proven, it was very likely. The board made arrangements for oxygen therapy for Mr A, however his condition deteriorated and he suffered a cardiac arrest and died.

Mrs C complained that the board failed to give Mr A a firm diagnosis of mesothelioma within a reasonable timeframe. She also raised concerns about a nurse failing to visit after the oxygen for oxygen therapy was delivered to Mrs C and Mr A's house. Mrs C also complained that the board did not communicate the severity of Mr A's illness to his family.

We took independent advice from a consultant respiratory physician and from a nurse. We found that there are recognised difficulties with diagnosing mesothelioma. We found that the board conducted appropriate investigations, but also balanced their concerns about mesothelioma with the possibility that Mr A was suffering from a different condition. We found this to be reasonable. Regarding Mrs C's concerns about nursing staff, we found that there were limited records available to suggest that staff had advised that they would attend. We found that whether nursing staff will follow up in these circumstances is dependent on local arrangements, and that it was reasonable not to arrange a follow-up. In relation to Mrs C's concerns about communication, we found that there were records which suggested that staff had attempted to explain the situation to Mrs C and Mr A. We did not uphold Mrs C's complaints.

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr A) regarding the care and treatment he received at the medical practice. In particular, she complained that the practice did not do more to assist Mr A in obtaining a clear diagnosis and appropriate treatment for his mental health difficulties. This included concerns that Mr A's repeated requests for cognitive behavioural therapy (CBT) were not actioned.

We took independent medical advice from a GP, who considered that the practice arranged appropriate referrals for Mr A to mental health services. They noted that the specialists involved in these clinics had shown reluctance to give a specific diagnosis. They observed from one of the clinic letters that a psychiatrist had suggested a CBT approach and, while this did not appear to have progressed, they said it was not the role of a GP to follow up treatment plans arranged by a separate specialty. The adviser concluded that the care provided to Mr A by the practice was reasonable. We accepted this advice and did not uphold this aspect of complaint.

As Mr A had moved to a new GP practice, the practice were only able to access his electronic records and not any older paper records. Ms C also raised concerns that the complaint was not fully investigated as all medical records were not accessed. The practice considered that they had enough information to respond to the complaint and the adviser agreed that sufficient records were accessible to enable a response to the concerns and queries raised. We concluded that the practice's investigation was reasonable and proportionate to the issues raised and we did not uphold this aspect of the complaint. We noted that the practice had failed to provide details of our office in their complaint response, but they acknowledged this and we were satisfied that this had since been appropriately addressed through the revision of their complaints handling procedure.

Summary

Mrs C complained to us about the care and treatment provided to her late husband (Mr A) at the Victoria Infirmary. Mr A had been referred to the board for investigation of macroscopic (visible) haematuria (blood in urine). Mr A had subsequently died from cancer of the bladder.

Mrs C complained that a discharge letter inappropriately referred to Mr A as having been treated for microscopic (non-visible) haematuria. We found that the letter did incorrectly say that Mr A had undergone a cystoscopy (a procedure to look inside the bladder using a thin camera) for microscopic haematuria instead of macroscopic haematuria. The board said that this had been due to a typing error. We upheld the complaint and recommended that the board apologise to Mrs C for this. However, we noted that the investigations that had been carried out where appropriate for a man presenting with macroscopic haematuria and that this typing error had not impacted on Mr A's care.

Mrs C also complained that the board failed to carry out a CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) at the time that Mr A underwent the cystoscopy. We took independent advice from a consultant urologist and we found that there had been no requirement at that time for the board to carry out a CT scan. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board's response to her complaint had incorrectly stated that there had been no subsequent contact between Mr A's GP practice and the hospital after Mr A's cystoscopy. Mrs C provided evidence which showed that the GP practice had phoned the hospital after Mr A's cystoscopy to report that there was still blood in Mr A's urine. We found that, in line with the relevant guidance, this should have prompted the board to request a CT scan at that time. However, we found that even if a CT scan had been carried out, it was unlikely that Mr A's outcome would have been significantly different. Due to the evidence we saw that there had been contact between the GP and the hospital, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the incorrect information on the discharge letter which inappropriately referred to microscopic haematuria. Also apologise for incorrectly stating in the complaints response that there was no subsequent contact from Mr A's GP practice after the cystoscopy. These apologies should be in line with 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 a GP surgery contacts a hospital with additional information, it should be recorded and acted on.

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 the board unreasonably failed to provide him with appropriate dental treatment when he was held on remand in prison. He said that the board failed to x-ray his tooth and should have tried to save his tooth, rather than only offering tooth extraction. Mr C was concerned that the board advised him that, as an untried prisoner, he did not qualify for the same dental treatment as a convicted prisoner or a person who was not in prison.

We took independent advice from a dental practitioner. The adviser said that the board should have carried out an x-ray of Mr C's tooth as part of his dental treatment. They said that the board failed to discuss the risks and benefits of all treatment options with Mr C and record the discussion in the dental records. The adviser also said that the board should have offered to provide root canal treatment for Mr C's affected tooth, in accordance with the NHS Guidance. As a result of these failings, Mr C suffered intermittent pain from his affected tooth for a considerable period.

The adviser explained that the board were correct in their view that Mr C did not qualify for the same dental treatment as a convicted prisoner or a person who was not in prison. This was because the NHS Guidance indicated that an untried prisoner was entitled to some, but not all, of the NHS treatments available to a convicted prisoner or someone who was not in prison. However, we were concerned that it appeared that the board were not aware of the full range of treatment available to prisoners on remand. Given the failings identified, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for:
• failing to x-ray his tooth
• failing to discuss the risks and benefits of all treatment options with Mr C and record this discussion in the dental records
• failing to offer root canal treatment, in accordance with NHS Guidance.
• 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:

• In circumstances such as Mr C's, the board should x-ray patients' teeth.
• The risks and benefits of all treatment options should be discussed with patients and these discussions should be recorded in the dental records.
• Root canal treatment should be offered in cases such as Mr C's, in accordance with the NHS 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, an advocacy and support worker, complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's daughter (Miss A) in the final months of Miss A's life. Miss A had Fanconi anaemia (a genetic disease that can lead to bone marrow failure and cancer) and had a complex medical history of complications following a bone marrow transplant. Miss A received treatment at the Beatson West of Scotland Cancer Centre over a number of admissions. She was treated for numerous health issues, including a bowel condition.

Ms C raised concerns that staff failed to inform the family of the severity of Miss A's bowel condition. We took independent advice from a consultant haematologist and from a registered nurse. We were unable to find evidence that staff had discussed with Miss A, or Ms B, the severity of Miss A's bowel condition. We concluded that communication with the family was poor and we upheld this complaint.

Ms C also complained that the board did not provide a reasonable standard of treatment during Miss A's final admission. We found that the treatment provided for Miss A was in line with the relevant guidance, but the advice we received was that no consideration appeared to have been given to the fact that Miss A was dying and needed palliative therapy to keep her comfortable. We found that this was unreasonable and we upheld this complaint.

Ms C also raised concern that the board did not make reasonable transport arrangements when Miss A was discharged on one occasion when she became unwell in the car of a volunteer driver. We found that Miss A was noted to be well prior to discharge, and that it seemed that she became suddenly unwell during the journey. We were satisfied that the transport arrangements in place were reasonable and we did not uphold this complaint.

Finally, Ms C complained that the board refused to admit Miss A on one occasion when Ms B called the hospital in the early hours of the morning. The advice we received noted that Miss A was advised to attend the clinic later that day, but to call back if she became more unwell. The adviser did not find evidence that admission was requested and considered that the board's advice in this situation was reasonable. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to communicate with Ms B and Miss A reasonably about the severity of Miss A's bowel condition and for the failure to provide palliative care and support to Miss A at the end of her life. 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 be provided with any information on their condition that they want or need to know in a way that they can understand. This should be communicated in a way that is considerate to those close to the patient. Staff should be sensitive and responsive in giving patients and families information and support. Communication with patients and their family members should be documented.
• Patients who are approaching the end of their life should receive high-quality treatment and care that supports them to live as well as possible until they die, and they should be supported to die with dignity.

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 on behalf of her aunt (Mrs A) about the clinical treatment she received when she attended the emergency department at the Queen Elizabeth University Hospital following a fall. Ms C complained that the board failed to investigate and treat Mrs A's head injury and that the board unreasonably failed to diagnose a shoulder injury.

We took independent advice from a consultant in emergency medicine. We found that the board had not identified that Mrs A had fractured her shoulder. Prior to our investigation, the board had apologised for this and had taken action to address the error. We also found that, although an error had occurred in relation to identifying Mrs A's shoulder injury, overall the care and treatment she had received had been reasonable. In view of the failing to identify the shoulder injury, we upheld the complaint. However, as the board had accepted this failing and had already taken action to address this, we made no further recommendations.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) when he attended the out-of-hours primary care emergency centre at the Victoria Ambulatory Care Hospital. He was discharged home but a few days later was admitted to the emergency department of Queen Elizabeth University Hospital, where he was treated for a severe chest infection with possible underlying heart problems. After some hours Mr A's condition was considered to be near to death and it was indicated that he was suffering from aortic stenosis (a narrowing of the left ventricle of the heart, which can cause problems such as heart failure) and fluid on his lungs. Mr A was later transferred to the medical high dependency unit where he was reviewed and underwent numerous tests. He was then transferred to the intensive care unit, where he later died.

Mrs C complained to the board and when she remained unhappy with their response she brought her complaints to us. Mrs C complained to us that:

the assessment of Mr A at the out-of-hours service was unreasonable

the care and treatment provided to Mr A at Queen Elizabeth University Hospital was unreasonable

the communication with herself, Mr A, and the family during Mr A's admission was poor

the board failed to respond fully to her complaints.

We took independent advice from a nurse practitioner and from consultants in emergency medicine and cardiology. We found that Mr A had been reasonably and appropriately assessed at the out-of-hours service and we did not uphold this aspect of the complaint.

We found that it would have been better if Mr A had been seen and assessed by the cardiologist shortly after his admission to Queen Elizabeth University Hospital, rather than the cardiologist only speaking to the emergency medicine team on the phone, which is what had happened. A face-to-face assessment would have allowed for a better assessment, and for a discussion with Mr A and Mrs C about Mr A's symptoms, treatment and prognosis. We also found that opportunities were missed to keep Mrs C updated on Mr A's condition. As such, we upheld Mrs C's complaints about the care and treatment provided to Mr A, and about the communication with the family.

With regards to the board's complaints handling, we found that the board addressed all of the concerns that were raised with them. We were satisfied that the responses were provided promptly and with appropriate detail. We did not uphold Mrs C's complaint about the board's complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise that a cardiologist did not see Mr A sooner. The apology should meet the standards set out in the SPSO guidelines on an apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for missing opportunities to keep Mrs C fully updated on Mr A's condition.

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

• In cases of aortic stenosis, a cardiologist should assess and physically examine the patient as soon as possible.
• Relatives should be updated on their family member's condition and care.

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 his care and treatment over two admissions to the Royal Alexandra Hospital was inadequate.

Mr C had suffered from two separate incidences of a collapsed lung in quick succession. During the first admission, Mr C disputed the board's position that it had been reasonable to discharge him. During the second admission Mr C's condition worsened. An x-ray was requested and preparations were made for inserting a chest drain. There was then significant deterioration in Mr C's condition. The board accepted that Mr C could have died due to this deterioration. The board said that they did not believe a critical incident review (CIR) was appropriate in the circumstances. They said that Mr C had been suffering from a complex condition and that it was this, rather than any failings by staff, which had contributed to the deterioration. Mr C disputed this, and he disputed the standard of the nursing care he received. Mr C said his deterioration had not been noticed because he was not being monitored properly.

We took independent medical and nursing advice. The medical adviser said that the decision to discharge Mr C following his first admission was appropriate and was supported by the medical evidence. However, the adviser found that during Mr C's second admission there had been a failure by medical staff to identify that a chest drain had not been correctly inserted, which had contributed to his deterioration. It would therefore have been appropriate to conduct an CIR. The medical adviser noted that Mr C's condition could have deteriorated very quickly and it could not be assumed that the severity of Mr C's condition and deterioration was due to an absence of clinical observation. The nursing advice we received found that, aside from some acknowledged failings, the overall standard of care was reasonable. The board had accepted the nursing failings and had taken action to address them.

We found that the board should have conducted a CIR into Mr C's deterioration during his second admission, as this could have identified useful learning for staff. We also found that the board should provide evidence that it had followed through with the work it had committed to in order to address the nursing failings it had accepted had taken place. On balance, we upheld Mr C's complaint that the care and treatment provided to him across the two admissions had been inadequate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failings in his care, and for failing to carry out a critical incident review. This apology should comply with SPSO guidelines on making an apology.

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

• The board should review Mr C's second admission and his subsequent deterioration with the clinical staff involved. This review should include what action was taken to review the x-ray taken and the action taken on Mr C's subsequent deterioration. This review should also include evidence of the resultant learning or improvements.

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.