Health

Summary

Mrs C complained that staff at Glenrothes Hospital failed to provide her father (Mr A) with appropriate medical care and treatment, particularly regarding dehydration, confusion and breathlessness. She also complained that there were unreasonable failures to provide adequate nursing care, and that staff failed to communicate appropriately with her and her family. She said that their concerns were ignored. The family had concerns about Mr A returning home. Mrs C said that Mr A had been given inadequate physiotherapy and that, despite his poor condition, staff insisted upon completing an assessment at home. Mrs C said that after she complained about these matters she did not receive a response until three months later and she was not kept informed about what was happening.

In replying to the complaint, the board agreed that there had been some delay for which they apologised. In relation to the family's concerns about Mr A's confusion, the board said that medical staff could have treated Mr A's dehydration more aggressively by giving him intravenous fluids but that although the family had concerns, they did not consider there to have been a problem. Similarly, they considered that after Mr A reached his physiotherapy goals there was no need for further input. The board did not consider that they had undertaken an inappropriate home assessment, nor did they think that they had failed to discuss matters reasonably with the family during Mr A's admission to the hospital.

We took independent advice from a nurse, a GP and a mental health nurse. We found that Mr A's dehydration could have been treated earlier, perhaps by earlier admission to another hospital for intravenous fluids, but that this would not necessarily have prevented the deterioration in his overall health. We upheld this aspect of the complaint.

We also found that not all the records had been completed fully regarding Mr A's nursing care, particularly those concerning his fluid balances. We found that Mr A had had a surprising result during cognition tests and that this had not been monitored. We upheld this aspect of the complaint.

We found that the family were kept appropriately up-to-date regarding Mr A's condition and that where the family had concerns, these were noted and taken into account as far as was possible. We did not uphold the aspect of the complaint regarding communication.

We found no evidence that Mr A had been given insufficient physiotherapy as he had achieved the goals that had been set for him and we did not uphold this part of the complaint.

We did not find evidence that a home assessment had been carried out unreasonably, or that the decision to return Mr A home was unreasonable. While the family were not in agreement, this had been what Mr A wanted. As such, we did not uphold this part of the complaint.

Finally, we found that the board had not responded to the complaint in a timely manner, nevertheless, the family had been kept updated about the delay. On balance, 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 failing to monitor Mr A's fluids and cognition properly. 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:

• Nursing staff should complete all care rounding charts as required to ensure that the fluid levels of patients is properly recorded.
• When there has been a surprisingly low cognition score, cognitive functioning should be kept under review.

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 an appointment she had attended with a psychiatrist to explore her possible learning difficulties. In particular, she complained that she had not properly consented to discussing the matters raised with her, that the questions asked of her were unreasonable given the stated purpose of the meeting, and that her privacy was ignored as these questions were asked in front of others.

We took independent advice from a mental health adviser and found that while the psychiatrist had acted reasonably in the matter of consent, they should have enquired further about Ms C's understanding of the appointment. We found that the questions asked were not unreasonable, but it should have been made clear to Ms C that she could decline to answer. We did not uphold these aspects of the complaint, but made a recommendation to address this.

In relation to Ms C's privacy concerns, we found that she should not have been asked any personal questions in the presence of others. We, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should send Ms C a written apology.

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

• It should be made clear to patients that if they are unhappy with a line of questioning, they can ask for it to be stopped.
• Records of appointments should show, as far as is possible, an assessment of whether or not a patient has understood consent issues.

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 to the board about the care and treatment provided to her mother (Mrs A) during an admission at University Hospital Ayr. Mrs A was admitted to hospital after her GP noted that she had low sodium levels. During the admission, Mrs A received treatment for heart failure and low sodium. Her condition did not improve and she died a number of days later. Ms C complained to the board about communication with the family, the nursing care provided to Mrs A, the medical treatment provided to Mrs A and the board's failure to respond to a claim for lost property.

In response to Ms C's complaint, the board arranged two meetings with the family to discuss their concerns. The board acknowledged that communication was poor and that nursing care could have been more compassionate, and apologies were offered for these shortcomings. Ms C remained dissatisfied and brought her complaint to us.

In the course of our investigation, we took independent advice from a medical adviser and a nursing adviser. The medical adviser found that Mrs A was very unwell and said that staff should have informed the family of this from the time of Mrs A's admission, not just at the time of her deterioration. The nursing adviser did not find evidence that nursing staff had advised the family of the seriousness of Mrs A's condition, although they could not confirm if nursing staff had recognised this themselves. We noted that the board had identified a number of points of learning and improvement in relation to communication, and we asked the board to provide evidence that appropriate action had been taken. We upheld this complaint and made further recommendations based on the advisers' comments.

We also investigated Ms C's concerns about nursing care. The nursing adviser noted a number of gaps in the fluid balance and clinical risk assessment recording, but otherwise found that the records were generally of an acceptable standard. However, the nursing adviser was critical that nursing staff did not escalate Mrs A's condition to medical staff earlier in the admission, given the family were raising concerns about her condition. The nursing adviser concluded that, on balance, the nursing care fell below a reasonable standard. We upheld the complaint and made a number of recommendations.

Ms C also raised concern about the medical care provided to Mrs A. The adviser noted that Mrs A was very unwell at the time of admission and her condition was complex to treat. The adviser was critical that there was not a proactive plan to manage Mrs A after the day of admission, and noted that the assessments by medical staff were more superficial than they would have expected to see. The medical adviser said that the most important aspect of Mrs A's care was to assess her response to treatment and make sure her sodium level was rising in a safe manner. The adviser noted that this did not happen, and concluded that the care was unreasonable in this case. We upheld this complaint and made a number of recommendations.

Finally, Ms C said that a number of items of Mrs A's jewellery had gone missing on the ward, and complained that the board had failed to respond timeously to a claim for lost property. The board acknowledged that the belongings procedure had not been followed in this case and apologised to Ms C for the delay in responding to the claim. We upheld the complaint and asked the board to supply us with evidence that their review of the lost property claim results in learning and improvement to ensure that the correct procedure is followed in the future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and her family for the specific failings in medical assessment and treatment and the failings in nursing care. 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:

• Systems should be in place for senior nursing staff to monitor nursing communication sheets on an ongoing basis. Systems should also be in place to monitor feedback received from a range of sources about communication with relatives and significant others.
• Nursing staff should recognise when a patient's condition is deteriorating and take appropriate steps to respond.
• Medical staff should make a detailed plan of treatment for patients with heart failure and low sodium levels. Medical staff should also be proactive in providing treatment and monitoring the response to the 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 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.