Health

Summary

Mr C complained about the care and treatment provided to his late wife (Mrs A) at Golden Jubilee National Hospital. Mrs A had been diagnosed with bladder cancer by another health board, but before being able to receive treatment for the cancer had suffered a heart attack. She was referred to the hospital for cardiac surgery. Mrs A was to receive treatment for the bladder cancer after having cardiac surgery. However, by the time she had recovered sufficiently from the cardiac surgery, the cancer had progressed and curative treatment was no longer possible. Mr C said that there had been unreasonable delays in Mrs A undergoing cardiac surgery, that informed consent had not been obtained for Mrs A's cardiac surgery, and that there had been unreasonable failings in communication between the specialists treating Mrs A.

We took independent advice from a cardiac surgeon. The adviser commented that the hospital could have considered treating Mrs A as an in-patient at an earlier point, as this may have been a more holistic approach given her co-existing cancer diagnosis. However, we found that although Mrs A's cardiac surgery had been postponed several times, it was still carried out in a reasonable and appropriate timeframe from a cardiac point of view.

Mr C had been concerned that staff at the hospital were aware that Mrs A would not be able to undergo treatment for her bladder cancer and therefore her consent to undergo cardiac treatment, which had been based on her understanding that without it she would not be able to have her bladder cancer treated, was not fully informed. Our investigation found that throughout Mrs A's patient journey at the hospital, all staff had been working under the impression that her bladder cancer was operable. We did not uphold this aspect of Mr C's complaint.

We found that after Mrs A's cardiac surgery, staff at the hospital failed to send a discharge letter to the other health board to inform them that the surgery had been successfully carried out. We found this to be unreasonable. We upheld this aspect of Mr C's complaint, but considered that the hospital had already taken steps to address this issue and therefore made no further recommendations.

Recommendations

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

• Treatment for patients that require heart treatment prior to cancer treatment should be planned holistically.

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, a prisoner, complained about how her complaints were being responded to by the board. The board had written to Ms C informing her that the volume of complaints, comments and feedback she was submitting was putting a disproportionate strain on their resources and impacting on their ability to assist other people. They asked Ms C to adjust her behaviour. They said they were taking action under their Unacceptable Actions Policy and would be limiting the responses they gave to her complaints, focusing only on those they deemed most significant and which had not been resolved at the time.

Ms C continued to submit complaints.

We found that the board's policies on restricting contact were confusing and that clearer information could have been given to Ms C regarding the board's expectations and what they would do to manage Ms C's behaviour if she continued to submit high volumes of complaints. For that reason we upheld the complaint and made a recommendation to address it. We did not recommend an apology for Ms C as, although there had been a lack of clarity on the board's part, Ms C was well aware of the impact her actions were having on the board and did not take the opportunity to modify her behaviour.

Recommendations

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

• The board should have a clearer policy for unreasonable or unacceptable actions, to enable them to efficiently manage unreasonable actions.

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 daughter (Miss A) about the care provided to her at Forth Valley Royal Hospital following an ultrasound scan which confirmed that she had lost her baby. Ms C was concerned that a sonographer, rather than a midwife, had told Miss A that the baby had died, and that she then had to wait for 45 minutes to see the doctor and midwife. She was also concerned that her daughter was not given a full explanation of the medication she would receive and of the process which would lead to the birth of her baby. She felt that the level of support and information provided to her daughter was inadequate. Ms C was also unhappy with what happened when her daughter returned to the hospital two days later to give birth to her stillborn baby. She felt that the support provided by the midwife was poor and this meant that her daughter eventually gave birth without the midwife being present. She was also concerned about the level of pain relief provided, documentation which suggested the baby would be cremated when this was not the intention of the family, and that the time of the birth was misreported in the records.

We took independent advice from a midwifery adviser. We found that it was appropriate for the sonographer to report the ultrasound findings to Miss A. We noted the subsequent delay in seeing a doctor or midwife, but we did not consider that this delay was unreasonable for the hospital at that time. We were satisfied that the records showed that Miss A was provided with a reasonable level of support and advice and that she was given the opportunity to ask any questions she had at that time about medication or the birth process. Following her attendance at hospital two days later, we were satisfied that the level of support provided to Miss A was reasonable. We noted the issues with the form suggesting cremation, but we also noted that the board had agreed to review this literature when they responded to Ms C's complaint. As we were satisfied that the level of care and support provided was reasonable, we did not uphold these complaints. However, we did highlight to the board the importance of ensuring that their record-keeping is accurate as we did note a discrepancy in the times recorded in the midwifery records.

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) at Forth Valley Royal Hospital.

Mr A was referred to the board and diagnosed with prostate cancer. At a multi-disciplinary team (MDT) meeting, a decision was made to adopt a watchful waiting approach (an approach used in prostate cancer management in men with few symptoms). Mr A attended an appointment approximately six months later, then another twelve months after that. At that point, it was found that Mr A's prostate specific antigen (an indicator of prostate cancer or other prostate conditions) had risen. Following a further MDT meeting, he was seen by an oncologist who felt that he was suitable for radical radiotherapy. In the following months, Mr A's condition deteriorated and he died.

Mr C complained that staff failed to provide Mr A with appropriate clinical treatment. He questioned the decision to place Mr A on watchful waiting programme, and the level of review he received. The board partially upheld Mr C's complaint on the basis that communication could have been better. In particular, they acknowledged that it would have been appropriate for Mr A to have been seen by a consultant at the time the decision was made to put him on watchful waiting. The board advised that they had taken action as a result of Mr C's complaint, and that patients would be seen by a consultant following a decision to place them on watchful waiting.

We took independent advice from a consultant urological surgeon and an oncologist. We found that the board followed guidelines and reviewed Mr A at reasonable intervals once watchful waiting was decided on. However, we found that the watchful waiting decision should not have been made without clinical assessment by a consultant, which may have led to a decision to offer radiotherapy. We noted that Mr A's cancer followed a path that was significantly worse than could have been expected, and that a decision to offer radiotherapy would not necessarily have prevented this. On balance, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to arrange a review with a consultant for Mr A when the decision was made to take a watchful waiting approach. The apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

Summary

Mrs C complained about the care and treatment provided to her daughter by staff at the Victoria Hospital. Mrs C complained that when they arrived at the hospital, the nurse was unwelcoming and did not acknowledge how ill her daughter was. Mrs C also said that throughout the admission, nursing staff did not carry out appropriate observations. Mrs C went on to complain that when her daughter was assessed by medical staff, she was not thoroughly examined and a diagnosis of viral infection was made without full consideration of her symptoms and condition.

We took independent advice from a paediatric nurse and a paediatrician. We found that nursing staff did not provide Mrs C's daughter with appropriate nursing care, with failings identified in taking observations, record-keeping, and using the Children's Early Warning Score chart (CEWS chart - a set of patient observations to assist in the early detection and treatment of serious cases and support staff in making clinical assessments). We found that national guidance on children with fever was not appropriately followed by nursing staff. We also found that, whilst the examinations carried out by clinical staff were appropriate, they did not give enough consideration to the possibility of a serious illness. We upheld both aspects of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide her daughter with appropriate nursing care and clinical treatment. The apology 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:

• Paediatric nursing staff should be knowledgeable and proficient in undertaking nursing assessments, observations, and using CEWS, and be able to act quickly on these observations.
• Parents/guardians should be given written information on warning symptoms and how further healthcare can be accessed if a child who had suffered from fever symptoms is discharged without diagnosis.
• Clinical staff should give consideration to the possibility that a child that has symptoms of a viral infection may have a more serious illness, and should be aware of the National Institute for Health and Care Excellence Fever guidelines.

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 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.