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Health

  • Case ref:
    202201027
  • Date:
    May 2023
  • Body:
    A Medical Practice in the Grampian NHS Board area
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about how the practice had managed their lithium prescription (a medication used to treat mood disorders).

We took independent advice from a GP. We found that the practice acted reasonably in requesting that C arrange blood tests every three months to monitor their medication levels. We were also satisfied that the practice had provided reasonable advice about how to ensure C did not run out of medication.

We did not uphold C's complaint.

Related reading

  • Case ref:
    202101272
  • Date:
    May 2023
  • Body:
    Fife NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment their adult child (A) received from the board. A had a complex medical history including a diagnosis of Complex Regional Pain Syndrome (CRPS, a rare condition where persistent and severe pain occurs following an injury). A attended A&E complaining of an elevated heart rate and fatigue. A working diagnosis of sinus tachycardia (a faster than usual heart rhythm) secondary to medication was made. A was discharged home with no further treatment. A couple of months later, A was admitted to A&E following a collapse, racing heart and swelling of their hands and feet. A was admitted to hospital where their condition deteriorated overnight. A's condition continued to deteriorate and they were transferred to the Medical High Dependency Unit (HDU) and the Intensive Care Unit (ICU). Ultimately, it was decided that A should be transferred to a hospital in another health board area where cardiology and advanced cardiac (heart) support would be available. A's condition did not improve and they died a few days later.

C raised a number of complaints with the board regarding the care and treatment A received. The board investigated C's concerns and undertook a Significant Adverse Event Review (SAER). However, C remained dissatisfied with some aspects of A's care.

We took independent advice from an appropriately qualified adviser. We found that when A initially presented at A&E, the clinical staff were aware of their history of CRPS and existing medications, that a full examination was carried out along with blood tests which were normal and that there was no obvious reason to admit A to hospital at that time. We found that the treatment A received during this admission was reasonable and appropriate and that onward referral was unlikely to have changed the outcome for A.

In relation to their second attendance, we noted that A was acutely unwell. We found that appropriate investigations were carried out in a timely manner and that, as A's condition deteriorated, their care was appropriately escalated through the HDU and ICU to transfer to another hospital where specialist equipment was available. We found that where the board had identified areas for improvement in their review of matters, the action they had taken was appropriate. We considered that the board provided A with appropriate treatment and investigations in response to their presenting symptoms and that they escalated A's care appropriately in recognition of the seriousness of their deteriorating condition.

We did not uphold C's complaints.

Related reading

  • Case ref:
    202006731
  • Date:
    May 2023
  • Body:
    Borders NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C, a support and advocacy worker, complained on behalf of their client (A) who was unhappy with the care and treatment they received during the birth of their child (B) and whilst they were a patient on the postpartum ward.

A's labour progressed very quickly, B's heart rate dropped, and decisions were made to deviate from the birthing plan as a result. A was unhappy with decisions that were made, the care received from midwives, and the lack of communication with them about what was happening. A also had concerns about the postpartum care they received, as they required a blood transfusion and felt their concerns were ignored by staff.

The board considered appropriate guidelines were followed and appropriate action and decisions were made in the circumstances. There was a need to deliver B urgently as there was evidence of distress. In relation to the care A received after the birth of B, the board said they did not consider there were any delays in the care provided to A, or the monitoring of their condition. They did identify an issue with documentation and highlighted that there should always be a handwritten contemporaneous record. This was addressed with staff members involved.

We took independent advice from two clinical advisers: a consultant obstetrician (a specialist in pregnancy and childbirth) and a registered midwife. We found that the care and treatment provided to A during labour was reasonable in the circumstances. We also considered the care and treatment provided by midwives on the postnatal ward was reasonable. We noted that there was a debrief in this case however, given the events of the birth, further debriefing at a senior level may have been helpful. We provided the board with feedback on this point.

We found that the care and treatment provided to A during the birth of their child and postnatally was reasonable and required in the circumstances in which B's health was at significant risk. Therefore, we did not uphold C's complaints.

Related reading

  • Report no:
    202101928
  • Date:
    May 2023
  • Body:
    A Medical Practice in the Ayrshire and Arran NHS Board area
  • Sector:
    Health

The complainant (C) complained to my office about the care and treatment provided to their late parent (A) by their GP practice (the Practice) after A presented at the Practice in August 2019, with shortness of breath and chest pain. A was subsequently diagnosed with severe Chronic Obstructive Pulmonary Disease (COPD, a lung condition that causes breathing difficulties) and lung cancer. A very sadly died in late 2020.

C complained that the Practice failed to provide reasonable care and treatment to A when they presented with chest pain. In particular that the Practice did not perceive A’s condition as being serious and urgent and the significant deterioration in A’s health was not investigated.

In responding to the complaint, the Practice considered that A’s symptoms were taken seriously and that appropriate investigations were undertaken including excluding cardiac causes for their symptoms.

I sought independent advice on this complaint from a GP (the Adviser). I found that:

  • The Scottish Referral Guidelines for Suspected Cancer (the Guidelines), in particular, the section relating to lung cancer, should have been taken into account by the clinicians at the Practice from the outset when treating A.
  • There was a failure by the Practice to recognise the seriousness of the symptoms A presented and to refer them urgently as required under the Guidelines. I considered this was a significant failing in care.
  • While a referral was made to the respiratory physicians, I was extremely critical that this was not made on an urgent basis.
  • While the Practice subsequently conducted a Significant Event Analysis (SEA), it was limited and did not fully address what had occurred in A’s case. There was no mention of the Guidelines in the SEA report. I was particularly critical of this.

Taking account of the evidence and the advice received, I upheld the complaint. I also considered there was a failure by the Practice to provide C with a full and informed response in relation to certain aspects of their complaint and in particular to take into account the Guidelines.

 

Redress and Recommendations 

The Ombudsman's recommendations are set out below:

What we are asking the Practice to do for C:

Complaint number

What we found

What the organisation should do

What we need to see

(a)

Under (a) we found:

  • There was a failure to recognise the significance of A’s symptoms when they presented at the Practice between August 2019 and September 2020, to make an urgent referral.
  • The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer.
  • There was a failure by the Practice to fully address the issues raised when responding to C’s complaint and evidence of a lack of learning from the complaint by the Practice as a whole.

Apologise to C for the failings identified.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

 

A copy or record of the apology.

By: 26 June 2023

We are asking the Practice to improve the way they do things:

Complaint number

What we found

What should change

What we need to see

(a)

Under complaint (a) we found:

  • There was a failure to recognise the significance of A’s symptoms when they presented at the Practice between August 2019 and September 2020, to make an urgent referral.

Patient symptoms should be appropriately identified and managed.

Symptoms or features suggestive of cancer should result in the appropriate referral being made in line with relevant guidance.

Evidence that this decision has been shared and discussed with relevant staff in a supportive manner. This could include minutes of discussions at a staff meeting or copies of internal memos/emails.

Evidence that training needs in relation to the application of relevant guidance have been identified and addressed.

Evidence of how the findings of this case have been used as a reflective training tool for relevant staff.

By: 24 July 2023
(a) The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer.

Local and Significant adverse event reviews should be reflective and learning processes that considers events against relevant standards and guidelines, to ensure failings are identified and any appropriate learning and practice improvements are made.

Evidence that the Practice have reviewed their systems and processes for reviewing significant events to ensure it is a fully reflective and learning process that supports the staff involved to identify learning and improvement.

By: 24 August 2023

We are asking the Practice to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see

(a)

Under complaint (a) we found:

  • There was a failure by the Practice to fully address the issues raised when responding to C’s complaint and evidence of a lack of learning from the complaint by the Practice as a whole.
  • The complaint response contained out of date contact details for the SPSO, including the address.

Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedures | SPSO. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning.

Learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g., a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Practice’s complaint handling process is clearly signposted on its website and that information, including documentation (e.g., complaint leaflet and/ or template complaint response letter have been updated) in accordance with the model complaints handling procedure.

Evidence that the website and documents properly signpost to the SPSO, including the current SPSO contact details.

Evidence that relevant staff have or are scheduled to have appropriate complaint handling training.

By: 24 July 2023

 

Feedback

Points to note

The Practice, when making an urgent cancer suspected referral, could have requested consideration of a CT scan. This would have allowed for A to be considered for a CT scan after their first chest x-ray was carried out. I encourage the Practice to share this and reflect on it for the future.

Related reading

  • Report no:
    202100560
  • Date:
    May 2023
  • Body:
    A Medical Practice in the Lanarkshire NHS Board area
  • Sector:
    Health

The complainant (C), a representative of the Patient Advice and Support Service, complained to my office on behalf of A about the treatment A’s spouse (B) received from their GP practice (the Practice) between July and October 2020. B developed cellulitis (a bacterial infection of the skin) on one of their legs. Although B was treated with multiple courses of antibiotics, the infection did not improve. Following an allergic reaction to the antibiotics, B chose not to receive further treatment. Sadly, B’s condition deteriorated and B died.

C complained that the Practice prescribed five courses of antibiotics without seeing B and considered that a GP should have reviewed B face-to-face when the infection did not resolve. A complained that B was not told of the risks of refusing antibiotic treatment. A also considered that the Practice should have carried out blood and skin tests to ensure that an effective antibiotic was prescribed and that the Practice should have referred B to hospital for intravenous antibiotics when B’s condition did not improve.

The Practice detailed the contact they had with B and said that skin conditions such as cellulitis are treated by their Advanced Nurse Practitioners (ANPs) and that they considered the treatment offered to B had been appropriate. The Practice said that they would not recommend the referral of B to hospital due to the COVID-19 restrictions in place at the time.

I sought independent advice from a GP (the Adviser). The Adviser told me B should have been closely monitored and specialist advice should have been sought early on in B’s care pathway. The Adviser told me B should have been seen face-to-face at the first appointment and a doctor should have been involved after the first course of antibiotics failed to work and in line with NICE accredited guidelines, specialist input should have been sought after a second course of antibiotics failed to improve B’s condition and admission for intravenous antibiotics considered.

The Adviser also told me there were no restrictions in place preventing patients from being admitted to hospital should their condition require this between July and October 2020. The Adviser gave their view that the failings they had identified had contributed to B’s death.

In light of the evidence I have seen and the advice I received, I found that: the Practice did not provide reasonable care and treatment to B between July and October 2020. As such, I upheld C’s complaint.

 

Redress and Recommendations 

The Ombudsman's recommendations are set out below:

What we are asking the Practice to do for A:

Rec. number

What we found

Outcome needed

What we need to see
1.

Under (a) we found that the care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable. In particular that:

  • B should have been seen face-to-face at their first appointment and by a GP after the first course of antibiotics failed to work.
  • Swabs should have been taken when there was no improvement.
  • Specialist input should have been sought after B’s condition failed to improve.
  • A Significant Event Analysis or similar reflective review should have been carried out.
  • The Practice’s complaint response was unreasonable.

Apologise to A for the failings identified.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

A copy or record of the apology.

By: 21 June 2023

We are asking the Practice to improve the way they do things:

Rec. number

What we found

Outcome needed

What we need to see
2. The care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable.

Patients presenting with symptoms suggesting cellulitis should be appropriately assessed including a face-to-face assessment and being appropriately monitored.

If their condition does not improve treatment should be escalated in line with relevant guidance.

Evidence that the Practice have:

  1. Critically reviewed their guidance and training needs on the management of cellulitis for all relevant staff to ensure achievement of the outcomes needed.
  2. Ensured relevant guidelines are appropriately referred to and reflected.

Confirmation should be provided of the review and the changes implemented as a result of this review; how the guidance has been updated and disseminated, and how the training needs of staff have been addressed.

By: 16 August 2023, with a progress update by 5 July 2023.
3. A Significant Event Analysis or similar reflective review should have been held. Where there has been a significant adverse event a reflective review should be considered, and either a clear reason recorded as to why it was not carried out, or held, ensuring that events are considered against relevant standards and guidelines and that failings, and good practice, are identified and any appropriate learning and practice improvements made.

Evidence that the Practice have systems and processes in place for reflective review of significant adverse events that support staff involved to identify learning and improvement

By: 16 August 2023

 We are asking the Practice to improve their complaints handling:

Rec. number

What we found

Outcome needed

What we need to see
4.

The Practice’s complaint response was unreasonable.

There is no evidence to support the Practice’s recording that the complaint was acknowledged or that the complaint was responded to within 20 working days in line with the Model Complaints Handling Procedure.

There was a failure to investigate and respond to all the concerns raised by C and provide an appropriate response that recognised the significance of the events for A and the impact of B’s death.

The response was undated.

The Practice’s complaint handling monitoring and governance system should ensure that:

  1. Complaints are properly investigated and responded to in line with the NHS Scotland Model Complaints Handling Procedure.
  2. Failings and good practice are identified, and learning from complaints is used to drive service development and improvement.
  3. Complaint responses recognise and acknowledge the significance and human impact of the events complained about, particularly when a death has occurred.

Complaint responses are clearly dated and records reflect when and how they are shared.

Evidence that the findings on the Practice’s complaint handling have been fed back in a supportive manner to relevant staff and that they have reflected on the findings of this investigation. (For instance, a copy of a meeting note or summary of a discussion.)

By: 19 July 2023

 

 

Related reading

  • Case ref:
    202202672
  • Date:
    April 2023
  • Body:
    A Medical Practice in the Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained on behalf of their spouse (A) about the care provided by the practice. A developed a wound in their left leg and received several courses of antibiotics and wound treatment but the wound deteriorated. A was referred to a vascular specialist several weeks after they first attended the practice. A was later admitted to hospital and died.

We took independent advice from a practice nurse adviser. We found that there were particular concerns about the lack of robust record keeping. The required wound assessment was not carried out or repeated at least every seven days as required. There was no record of the rationale behind the dressings used. There was no record of leg ulcer assessment being carried out and no documentation to support why this was the case until the referral. We found that the use of inadine (a type of surgical dressing) was inappropriate and that the choices for other wound dressings chosen were not detailed. We also found that the ongoing referral was not made in a timely manner.

Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • Patients requiring wound care should be managed in accordance with relevant guidance and timely referrals made. In particular, the wound should be appropriately assessed, documented and reviewed, appropriate wound swabs taken and appropriate dressings applied and checked.

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.

Related reading

  • Case ref:
    202110925
  • Date:
    April 2023
  • Body:
    A Medical Practice in the Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained that the practice failed to provide a face to face appointment to their late spouse (A) which contributed to a delay in onward referral, and ultimately delayed diagnosis of amyloidosis (a condition in which amyloid proteins build up on organs like heart, kidney and liver).

A had multiple telephone consultations with their GP over the year, presenting with varying symptoms. C complained that the frequency with which A presented should have prompted a face to face appointment. The practice response stated that it was not common practice to offer face to face assessment during the COVID-19 pandemic and that A had not requested a face to face appointment

We took independent medical advice from a GP adviser. We found that the practice’s failure to offer a face to face appointment was not reasonable. The frequency with which A presented and the symptoms that they described should have been identified as ‘red flags’ which triggered a face to face appointment and onward referral for specialist investigation, regardless of COVID-19 restrictions in place at the time. Therefore, we upheld this complaint.

We noted that the practice had already reflected extensively on their management of A, demonstrated learning and things that they would do differently in future, and offered apology to C. As such, we made no further recommendations.

Related reading

  • Case ref:
    202111275
  • Date:
    April 2023
  • Body:
    Highland NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Communication / staff attitude / dignity / confidentiality

Summary

C complained about the level of supervision that their spouse (A) was provided with while they were detained in hospital under the Mental Health (Care and Treatment) (Scotland) Act 2003. A was diagnosed with bipolar affective disorder (a condition that affects a person's mood) and was noted to be disinhibited. A later told C that A had entered a patient’s room and had sexual intercourse with them. C acknowledged that this could not be corroborated by the board, but considered that the board had failed to address their concerns regarding the known issues of A’s disinhibited behaviour and them entering other patient’s rooms.

On the basis that there was no available evidence to establish the circumstances surrounding the alleged incident and whether there was any failure by ward staff to monitor A at that time, our consideration of this complaint was limited to reviewing whether the observation arrangements in place were reasonable and appropriate for minimising the risk of such an incident.

We took independent advice from a psychiatry adviser. We found that appropriate risk assessments were carried out throughout A’s admission. We were satisfied that A was given a level of supervision that was in-keeping with national guidance and their assessed risks at that time. In the circumstances, we did not uphold this complaint.

Related reading

  • Case ref:
    202103830
  • Date:
    April 2023
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment that they received from the board. C was diagnosed with an ovarian cyst and admitted to hospital for a laparoscopy (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin) to remove the cyst. During the procedure, no cyst was found. However, an unusual mass was identified but not removed. An MRI scan was arranged to further investigate the findings of the laparoscopy.

C was discharged from hospital but became unwell. C attended the A&E with severe vomiting and diarrhoea and was admitted to hospital that same day.

An MRI scan was carried out and the results indicated that the previously identified mass was a haematoma (a collection of blood) and C was discharged home with antibiotics.

C became unwell again and attended a hospital in England where they were diagnosed with Clostridium Difficile Infection (CDI, a bacterial infection of the large intestine, a common healthcare associated infection). A CT scan also identified a cyst.

C commented that clinicians were surprised that C had not been screened for CDI when they previously attended hospital, having presented with diarrhoea several days after a laparoscopy. The clinicians also reportedly questioned why C’s haematoma was not removed when it was diagnosed given the likelihood of infection.

C complained that the board misdiagnosed their haematoma and failed to screen them for CDI, resulting in unnecessary complications and illness.

The board, in their response to C’s complaint, explained that there was no clinical indication that C was experiencing ongoing diarrhoea, and were satisfied that they did not therefore screen for CDI. The board said that having reviewed the care provided to C during their admission, they were satisfied that, whilst C suffered complications, the care provided was appropriate and reasonable

We took independent advice from a general surgeon adviser. We found that C presented with a history of diarrhoea prior to admission and that this was not identified or flagged to relevant clinicians on their admission to hospital. Given C's history prior to admission, C should have been screened for CDI and therefore, we upheld this aspect of the complaint.

With respect to the C’s diagnosis and treatment, we found that the conservative management plan which was adopted was reasonable in the circumstances. Whilst we identified some aspects of the clinical review undertaken of C’s condition which could have been better, they did not negatively impact on C’s outcome and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • That the board ensure that they implement, or have implemented, all of the recommendations of the Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in health and social care settings in Scotland.
  • That the board review their practices and ensure that all staff are operating in line with the Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in health and social care settings in Scotland.

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.

Related reading

  • Case ref:
    202102676
  • Date:
    April 2023
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment provided by the board when they were admitted to hospital. C said that they had collapsed at home and were told on admission to hospital that they had an abscess on the muscle connecting their back and hip, which was treated with antibiotics. C said that their leg continued to swell and bruise and that the pain continued to get worse, resulting in their legs giving way on a number of occasions whilst in hospital.

C complained that the board failed to appropriately diagnose, assess and treat them and failed to arrange appropriate follow up care on discharge. C also complained about the communication from the board throughout their stay in hospital. In particular, C said that the board failed to adequately explain the treatment or care that they were provided with.

C also questioned the board’s conclusion that their further admission to another hospital was not due to the issues that they experienced at the original hospital, but due to an INR issue (International Normalised Ratio: a test which measures the time for the blood to clot when taking Warfarin). C said that this is not what they were told by the hospital.

We took independent advice from a registered consultant physician. We found that there was a failure to provide appropriate follow up for C on discharge, including on-going pain management. There were also record keeping failures during C’s admission to hospital, such as timings of C’s review and ability to identify involved clinicians. We found that the diagnosis, assessment, treatment and follow-up care with regards to C’s leg was not reasonable, and upheld this aspect of the complaint.

We found that the board’s communication with C was unreasonable, specifically that there is a lack of evidence of adequate communication about diagnosis and treatment and also in relation to pain management and follow-up care. We upheld this aspect of the complaint.

We also found failings in the board’s handling of the complaint, such as limited information being available to demonstrate that there had been a local investigation into the complaint. The board’s response to the investigation questions posed by the SPSO was also limited. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

  • Adequate medical records should be maintained including signed entries and the times of reviews in line with relevant guidelines. There should be clear documentation of relevant clinical subjective and objective findings to support the process of clinical reasoning and care planning.
  • Patients should be discharged with appropriate follow up arrangements in place including for pain management where relevant and discharge documentation should be completed so that full discharge information is provided.

In relation to complaints handling, we recommended:

  • The board's complaint handling, monitoring and governance system should ensure that failings and good practice are identified and that learning from complaints is used to drive service development and improvement. The board should ensure that full responses are provided when responding to SPSO enquiries.

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.

Related reading

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