Health

Summary

Ms C complained on behalf of her late father (Mr A) about the failure to provide him with an appropriate scan following his presentation with significant weight loss over a short period of time. Ms C said Mr A had not been contacted about an appointment. Mr A was then phoned by a doctor who took the decision, without seeing Mr A, that a scan was unnecessary. Ms C said she believed that had Mr A been scanned, then the lung cancer he had would have been discovered and treated. Mr A had died suddenly of heart failure, and Ms C believed his heart had been under strain due to the untreated condition.

The board said that Mr A had been phoned on several occasions without success. He had then been written to, offering him an appointment. When the doctor had phoned Mr A it had been to ascertain if a scan was still necessary. The doctor's recollection was that Mr A had not wished to proceed with a scan and that he had stated that he had regained a small amount of weight. The board did not feel that Mr A's medical outcome was affected by the decision not to give him a scan.

We took independent medical advice and found that it would have been appropriate to review Mr A in clinic, given his symptoms. We noted that there was a significant gap between the phone conversation and the doctor writing to Mr A's GP, which meant that there were not appropriate records kept of the phone call. The advice we received was that this was in breach of General Medical Council guidelines on communication with patients. We found that there was evidence that the board made reasonable efforts to contact Mr A about his appointments, and so we did not uphold this aspect of Ms C's complaint. However, we considered it a failing that the doctor was unable to access Mr A's appointment schedule when he phoned him, and as such he could not advise him of the length of time Mr A would wait before his next appointment. We therefore upheld 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 contact Mr A's GP in a reasonable amount of time and for failing to arrange a scan.

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

• The staff involved should reflect on the advice we received in relation to Mr A's need for an appointment for a scan.
• Staff should adhere to reasonable timescales when dictating clinical correspondence. At a minimum, these timescales should be in line with General Medical Council guidance.
• Clinical staff should be able to access the in-patient appointment viewing system to check appointments.

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 raised a number of concerns about the care provided to his mother (Mrs A) at Queen Elizabeth University Hospital. During Mrs A's admission, she was found to have fallen whilst in the bathroom. The nurse who found Mrs A did not identify any immediate signs of injury and noted that Mrs A had not reported loss of consciousness. Nursing staff subsequently carried out observations, and a doctor carried out an examination, noting no injuries. Following the examination, Mr C noticed that the bed sheets by Mrs A's elbow were spotted with blood and he reported this to nursing staff, who arranged for a small wound on Mrs A's arm to be dressed. The following day, Mr C noticed bruising around his mother's hairline and reported this to nursing staff, who had not previously noted this. A scan was then arranged, the results of which indicated that Mrs A had an acute subdural haematoma (bleeding in the space between the brain and the skull). Mrs A was subsequently transferred to a neurosurgical ward, and a procedure to evacuate the subdural haematoma was carried out.

A number of weeks following the fall, the board decided to undertake a significant clinical incident investigation. This took a number of months to be finalised, and it concluded that the assessment of Mrs A's risk of falling was not carried out appropriately and made a number of recommendations. To assess whether the board had taken appropriate steps in response to the failings identified, we took independent advice from a nursing adviser and a medical adviser.

Based on the nursing advice we received we could not conclude that Mrs A would not have fallen had the falls risk assessment been carried out appropriately, and had the appropriate interventions been in place. However, we considered that it was unreasonable that the board did not take the steps that they could reasonably have been expected to take to reduce the risk of Mrs A falling. We upheld this complaint, and we made a recommendation in relation to falls risk assessment.

Mr C was unhappy that nursing and medical staff failed to identify and treat his mother's injuries. In response to Mr C's complaint, the board acknowledged that nursing staff should have observed the bruising to Mrs A's head when delivering personal care and apologised that medical staff also missed this injury. The medical adviser was critical that a top-to-toe examination was not carried out by medical staff following the fall, and was also critical of how the medical examination was documented. We were satisfied that a dressing was appropriately applied to the cut to Mrs A's arm, and that a scan was arranged within a reasonable time after the bruising on her head was noticed. However, we found that the examination following the fall was not reasonable, and we upheld this aspect of the complaint. We made a number of recommendations for improvement.

We were also critical of the way the board handled Mr C's complaint. We found that staff had potentially missed an opportunity to recognise Mr C's complaint at an earlier stage, and we considered that this may have delayed the start of the complaint investigation. We noted a number of other shortcomings in the way the board handled and responded to Mr C's complaint. We upheld this aspect of the complaint and made a recommendation.

Recommendations

What we asked the organisation to do in this case:

• Send Mr C a written apology for failing to carry out a reasonable assessment of Mrs A following her fall.

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

• Junior medical staff should be trained on how to carry out appropriate assessments for patients who have fallen.
• The member of medical staff who assessed Mrs A should reflect and learn from the adviser's comments on record-keeping.

In relation to complaints handling, we recommended:

• Complaints should be handled in accordance with the proper procedure.

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 that the board unreasonably failed to diagnose and treat the cause of her back pain. She had suffered chronic back pain since being involved in a motorbike accident a number of years previously. Ms C said that she had not been provided with a satisfactory resolution and explanation for her ongoing pain and she felt that the care and treatment she had received had been inadequate. Ms C said her mobility had been affected, and she continued to require to take strong pain medication.

We obtained independent medical advice from a trauma and orthopaedic consultant and a consultant neurologist. The advice we received was that both the orthopaedic and neurology care and treatment provided to Ms C was consistent and appropriate. The advisers did not identify failings in Ms C's care and treatment. We did not uphold Ms C's complaint.

Summary

Ms C complained on behalf of her late mother (Mrs A) about the care and treatment she received from the board. Specifically, Ms C complained about a consultant geriatrician's assessment of Mrs A's condition, as well as their communication with Mrs A and her family about her condition and treatment options. Ms C also complained that an out-of-hours doctor failed to communicate appropriately about Mrs A's condition and treatment options.

During our investigation we took independent medical advice from a consultant geriatrician and from a general practitioner. We found that the out-of-hours doctor's communication was reasonable. We also found that the consultant geriatrician's assessment of Mrs A's condition was reasonable. As a result, we did not uphold these aspects of Ms C's complaint. We did find that there were failings in how the consultant geriatrician communicated with Mrs A and her family. We, therefore, upheld this aspect of Ms C's complaint and made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing to Ms C and Mrs A for failing to communicate appropriately about Mrs A's condition and treatment options. The apology should comply with the SPSO guidelines on making an apology.

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

• Consultants should attempt to communicate with patients during their assessments, in order to respect the patient's dignity.
• Patients or family members should be told of their right to a second opinion, or be given the opportunity for a further discussion with the clinician, if they feel dissatisfied with a clinician's assessment.

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 late mother (Mrs A) about the care and treatment she received from her GP practice. Ms C considered that Mrs A's medication was changed inappropriately, that Mrs A was not given appropriate treatment for her symptoms and there was a failure to communicate reasonably with Mrs A and her family about her condition. Ms C also complained about the handling of her complaint.

During our investigation we took independent GP advice. We found that Mrs A's practice gave appropriate treatment for her symptoms, but delayed in making an urgent referral to a consultant geriatrician and a routine referral to a dietician. They also delayed in issuing Mrs A with a prescription. In light of these delays, we upheld this aspect of Ms C's complaint and made recommendations to address this.

We found that it was reasonable that Mrs A's medication was changed, and did not consider that there were failings in communication by the practice. We considered the handling of Ms C's complaint to be reasonable and, therefore, we did not uphold these aspects of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in referring Mrs A to the consultant geriatrician and for the delay in issuing her the prescription. The apology should comply with the SPSO guidelines on making an apology.

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

• The GP should review their clinical management plans, following house visits, to ensure their prescribing is complete.

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 her husband (Mr A) received when he was admitted to prison. In particular, Mrs C complained that, on admission, the health centre's handling of Mr A's medication was unreasonable. She also complained that there was an unreasonable delay in treating Mr A's stomach condition.

The board explained to Mrs C that Mr A was uncooperative and would not engage with the admission process when nursing staff tried to take his medical history. They advised that Mr A would have been asked to confirm his GP detail's so that his prescribed medications could be checked.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to issue the medication to him following the doctor's consultation on 7 September 2016.

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 provided to her husband (Mr A) from Lochhead Day Hospital, which is a specialist assessment unit for people with known or suspected dementia. Mrs C complained that she was not adequately consulted about the decision to discharge Mr A. Mrs C also complained that no alternative day time care was offered to Mr A following his discharge.

During our investigation we took independent medical advice from a psychiatric nursing adviser.

The adviser considered that it was reasonable that Mr A was discharged from Lochhead Day Hospital, due to safety concerns. We did not uphold this aspect of Mrs C's complaint. However, the adviser considered that there was an unreasonable failure to involve Mrs C in agreeing a follow-up plan for Mr A's care before his formal discharge. Therefore, we upheld this aspect of Mrs C's complaint and we made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to involve her in agreeing a clear and effective follow-up plan for Mr A's care before his discharge.

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

• At the point of discharge from a day hospital or clinic, secondary care services should work with primary care services and partner agencies to ensure that there is a clearly formulated plan in place for follow-up care. Relatives and carers should be involved in this in a meaningful way.

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 on behalf of his wife (Mrs A) about the care provided by mental health services at Dr Gray's Hospital. Specifically, Mr C complained about the way in which a psychiatrist and a community psychiatric nurse (CPN) handled a request for a letter for Mrs A to be excused from attending court as a witness and that they had discharged her from the service without notifying her or offering alternative support.

We took independent advice from a consultant psychiatrist and a mental health adviser. We were critical that the psychiatrist had not made a record of a phone conversation that took place with Mr C at the time to evidence the advice and support offered. This was contrary to national guidance in relation to record-keeping which we were critical of and we made recommendations in relation to this. We also found that the board had acknowledged and apologised that their psychiatrist and CPN had not properly communicated with Mrs A regarding her discharge from the service. The board said that they had taken action to remind staff to share all important communication with patients. We considered that the psychiatrist had not documented adequate reasons supporting why Mrs A was discharged, nor had they offered her the option of another consultation or seeing a different clinician. We also found that it would have been more appropriate for the CPN to have written to Mrs A and explained the options available to her in terms of continuing or not continuing the service. We upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for failing to keep appropriate records.
• Apologise to Mrs A for failing to offer her the option of a further consultation or follow-up appointment with a different clinician prior to being discharged.

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

• The findings of this report should be shown to the doctor involved to ensure that in the future timely and adequate records are maintained.

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, who works for an advocacy service, complained on behalf of her client (Ms A). Ms A had been referred to the community psychiatric nursing service. After a number of attendances, Ms A was referred to a psychiatrist as she felt she was not improving. An appointment was made for her which Ms A did not attend as she said she was not informed of it. As a consequence of non-attendance, Ms A was removed from the list and told she would have to approach her GP should she wish to see a psychiatrist. Later, Ms A attended a day hospital and saw a community psychiatric nurse (CPN) who Ms A felt was judgemental. She said that she was told there was nothing wrong with her.

Ms C complained to the board and was told that Ms A had been informed of her appointment with the psychiatrist, and that it had been reasonable to remove her from the list because of her failure to attend. They also said that the CPN concerned had treated her reasonably and there was no evidence that she had been told there was nothing wrong and that Ms A had misunderstood. Nevertheless, they sincerely apologised for any distress Ms A had been caused and said that this was unintentional.

We took independent advice from a mental health adviser and we found that there was no evidence in Ms A's clinical records to show that she had been told of her appointment or been sent an appointment letter. We concluded that it was unreasonable, therefore, to have removed her from the psychiatrist's appointment list. However, contrary to Ms A's belief, we also found that the CPN was not responsible for this breakdown in communication. We further found that the CPN had treated Ms A appropriately and reasonably, identifying her presenting symptoms and drawing up a plan to deal with them. However, it was not the CPN's usual role to diagnose psychiatric illness and they did not do so. We, therefore, did not uphold the complaint. However, we made a number of recommendations in relation to the board's communication failure.

Recommendations

What we asked the organisation to do in this case:

• Send a written apology to Ms A for failing to advise her about a psychiatric appointment.
• Review Ms A to consider whether or not a further appointment is appropriate, if Ms A so wishes.

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

• The community psychiatric nurse involved should be reminded of the necessity to keep accurate records.
• The process required to issue appointment letters should be fit for purpose.
• Adequate follow-up should be in place for similar situations.

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 underwent an operation to her thumb. Over a year later it had still not healed despite two further attempts to revise the scar and after a review by a second opinion. Ms C complained that the clinician concerned with her treatment then refused to treat her further, saying that the cause of the failure to heal was self-harming. Ms C further complained a second clinician refused to provide surgery to her knee even though imagery showed that it was suffering from degeneration.

Ms C raised her concerns with the board who took the view, overall, that Ms C had been treated appropriately, in accordance with guidance, and that the conclusions and decisions about her thumb had been reasonable.

We took independent clinical advice and found that the clinician involved had done all they could with regard to Ms C's thumb in an effort to get it to heal. They had investigated the circumstances to establish the reasons why it had failed to heal and it was not unreasonable to conclude that the recurrent breakdown of the scar was self-inflicted. With regard to Ms C's knee problems, the board had followed current national guidance not to offer surgery in such cases. We therefore did not uphold Ms C's complaint.