Health

Summary

Mr C complained about the care and treatment received by his sister (Mrs A) at University Hospital Ayr. Mrs A was referred to the hospital for a respiratory opinion with a chronic cough. Mr C felt that there were delays in carrying out investigations and a lack of communication with Mrs A about her condition. Mr C also raised concerns about the board's complaints handling.

During our investigation we took independent medical advice from a consultant in respiratory medicine. We found that there were delays in Mrs A receiving follow-up respiratory appointments and that there was a failure to communicate appropriately with Mrs A about her diagnosis and treatment. We upheld this aspect of the complaint.

We also found that the board failed to provide a reasonable response to Mr C's complaint, therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mr A for the failings identified in this report.
• Apologise to Mr C for not addressing all of his concerns in their handling of his complaint.

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

• Patients should receive follow up clinical appointments within a reasonable timescale.
• Patients should have a clear understanding of respiratory consultants' views about their condition and the impact the resultsof tests may have on their diagnosis or 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 complained about the care and treatment his late wife (Mrs A) received at Crosshouse Hospital. Mrs A had been a patient there for 12 days when she was discharged home. Mrs A was readmitted to the hospital later the same day and died shortly thereafter.

We obtained independent medical advice and we found that although Mrs A was in an orthopaedic ward during her admission, she should have been admitted to a medical or rheumatology ward, or transferred to one as soon as possible after her admission. There was also a lack of a senior review of Mrs A by a consultant and a failure of early input from rheumatology, general medicine and microbiology. We found that the choice of antibiotics prescribed to Mrs A was a deficiency in her treatment, although we found no evidence that the antibiotics contributed to her decline. Furthermore, we found that there was a failure to act promptly on test results that showed Mrs A had E.coli. We also found that there were failures in communication with Mr C and Mrs A. While we found failings in Mrs A's treatment, we accepted that there were certain features that had masked the serious nature of her illness and that there was no significant error to blame for Mrs A's outcome. Given the failings identified, we upheld this part of Mr C's complaint.

Mr C was also dissatisfied that despite a post-mortem being carried out, Mrs A's death was recorded as unascertained. We found it was reasonable to record Mrs A's death as being unascertained given the advice we received that a post-mortem does not always provide a definite cause of death. We did not uphold this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a written apology to Mr C for the failings in the care and treatment provided to Mrs A.

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

• The board should ensure that staff reflect on and learn from the findings of this investigation. In particular there should be reflection on the admission to an inappropriate ward, the antibiotic medication prescribed, the lack of early input from appropriate departments, the lack of senior review by a consultant, the lack of prompt action on test results and the poor communication.

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 there had been a delay in transferring her mother (Mrs A) from Uist and Barra Hospital to Western Isles Hospital. Mrs A had a stroke and after the emergency services were called, she was taken by ambulance to Uist and Barra Hospital. The Scottish Ambulance Service had been called prior to her admission, and a plane to transfer Mrs A to Western Isles Hospital then left the mainland. Because of adverse weather, the plane was unable to land at the nearby airport and as a result, the transfer could not take place that evening.

In response to Ms C's complaint, the board explained that there is a four and a half hour window to assess a patient who is suspected of having had a stroke and judge the potential benefit of thrombolysis (clot busting) treatment. The board said that the delay in transfer was caused by bad weather, which meant that the cut-off time for potential treatment with thrombolysis medication had passed.

We took independent advice from a specialist in emergency medicine. They did not find evidence of a delay in contacting the ambulance service regarding air transfer and said that the decision whether it was safe to fly or not, and the assessment of the likelihood of being able to land, rested with the aircraft captain. The adviser said that once it became apparent that the plane was unable to land, the opportunity to get Mrs A to Western Isles Hospital, complete a CT scan and consider the possibility of thrombolysis in under four and a half hours had passed. Whilst the adviser considered that the care surrounding the transfer was reasonable, they considered that the doctor's records should have been more detailed. We did not uphold this complaint, but we made a recommendation.

Ms C also raised concern about the communication during the transfer process. We found that the board had apologised for any upset and distress Ms C's family experienced. Having considered the evidence available, the adviser concluded that the communication was reasonable. We did not uphold this complaint.

Recommendations

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

• Medical staff should maintain sufficiently detailed medical records in accordance with General Medical Council Good Medical Practice 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

Mr C complained that his GP practice unreasonably failed to arrange a scan of his shoulder and that they failed to refer him to an external psychology service. Mr C also had concerns that the practice failed to consult with him following a review of his medication, and that they failed to act on a letter sent to them by a consultant neurologist regarding changes to his medication. Mr C also complained that the practice failed to provide adequate responses to his letters and that they failed to apply the correct complaints handling procedure.

Mr C required a cortisone injection in his shoulder and he requested that a scan be performed prior to receiving the injection. We took independent advice from a GP adviser and found that giving a scan prior to a cortisone injection is not standard practice in Scotland, therefore it was reasonable that the GP did not request this. We did not uphold this complaint.

We found the standard procedure would be for a clinician to make a referral to external services, such as an external psychology service, and that a GP would not usually make such a referral. We, therefore, saw no evidence of failure on the part of the practice in this regard, and did not uphold this aspect of Mr C's complaint.

We found that changes to Mr C's medication were discussed with him by his consultant, and that the GP correctly followed the consultant's instructions to amend the prescription. We found that when Mr C enquired with the practice about this change, they correctly advised him to make an appointment with his GP to discuss the review of his medication. We did not uphold this complaint.

We found no evidence that the practice had failed to respond to Mr C's queries in a reasonable manner, and we did not uphold this complaint. However, we did find that the practice failed to follow the correct complaints procedure, and that they provided Mr C with the incorrect complaints procedure. The practice acknowledged this mistake, and we upheld this aspect of the complaint. We asked that the practice send us a copy of their new complaints handling procedure and evidence that all relevant staff have received training on this.

Recommendations

In relation to complaints handling, we recommended:

• Information about the complaints procedure should be accessible and made easily available to patients by providing leaflets in the practice and information on their website.

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 orthopaedic care and treatment provided to her by the board. She complained that she was given facet joint injections (injections of anaesthetic to relieve pain) into her spine without being examined by the consultant first, and that at her review appointment she again was not physically examined despite having ongoing pain. Mrs C was also concerned that she was not referred for an MRI scan or CT scan by the orthopaedic consultant. She also complained that the orthopaedic consultant failed to communicate reasonably with her after her review appointment, and that they did not refer her to the pain clinic when they said they would.

We took independent advice from an orthopaedic consultant. We found that it was reasonable that Mrs C was not referred for an MRI or CT scan, as this was in line with national guidance. However, we found that it was unreasonable that Mrs C was not physically examined before the anaesthetic injections were administered, or when she was reviewed at a later appointment. On balance, we upheld Mrs C's complaint about care and treatment.

We found that the communication from the orthopaedic adviser to Mrs C after her review appointment was reasonable and did not uphold this aspect of the complaint. However, we found that there was an unreasonable delay in referring her to the pain clinic and we upheld this aspect of the complaint.

Mrs C also complained about the board's response to her complaint. We found that when Mrs C initially made her complaint, she made it to the complaints department as well as to the individual clinician. Therefore, we considered there had been some confusion regarding who would respond to her complaint. We also found that there had been delays in the response being issued and that Mrs C had not been kept reasonably aware of these delays. The board confirmed that they had already taken action to address this failing. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in care and treatment, and complaints handling. 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:

• Orthopaedic consultants should carry out physical examinations before administering facet joint injections, and at review appointments if the patient is complaining of ongoing pain.
• When patients are informed that a referral will be made, this should be done promptly.

In relation to complaints handling, we recommended:

• When a complaint has been made directly to a clinician as well as to the complaints and feedback team, efforts should be made to clarify who will be investigating and responding.

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 her contact with NHS 24 when she phoned them about her late mother (Mrs A). Specifically, Ms C said that NHS 24 unreasonably delayed in answering her call and in assessing Mrs A's condition. Ms C also said that NHS 24 failed to take appropriate action in response to Mrs A's symptoms, as they did not immediately call an ambulance for Mrs A, even though she had a history of sepsis.

During our investigation we took independent advice from an out-of-hours practitioner. We found that there was no unreasonable delay in answering Ms C's call, or in assessing Mrs A's condition. We found that sepsis cannot be diagnosed over the phone. We considered that NHS 24 took appropriate clinical action in response to Mrs A's symptoms, by arranging an urgent out-of-hours GP visit. We did not uphold Ms C's complaint.

Summary

Ms C complained about the care provided to her father-in-law (Mr A) during a call to NHS 24. Mr A reported that he had been suffering with a cold and cough for five days with symptoms including dizziness, pain in the chest area and a fever. He had also been sick and, while he could drink water, he had not taken his medications. The NHS 24 call handler took details from Mr A and passed these on to a pharmacist. The pharmacist recommended that he buy a medicine to help suppress his cough and allow him to take his other medication. Mr A was also advised on what to do should his condition worsen.

Mr A had further contact with the out-of-hours services the following day. He was later admitted to hospital and died as a result of sepsis (blood infection). Ms C complained about Mr A's first call with NHS 24 as she felt that he had not received appropriate advice or care.

We took independent advice from a practitioner experienced in out-of-hours services. The advice we received was that the care and treatment recommended were reasonable on the basis of the information that was available to the call handler and the pharmacist. The adviser considered that appropriate safety advice had been provided by NHS 24 on what to do if Mr A's condition should worsen. No failings were identified in the way that Mr A was managed by NHS 24 and therefore we did not uphold Ms C's complaint.

Summary

Mr C complained to us about the failure of staff at the Royal Infirmary of Edinburgh to identify that he had sustained a fracture of his spine after a fall at home. It was only when Mr C attended an appointment with a clinician six months later that he was told about the fracture. Mr C wanted to know why the fracture was not identified sooner as this would have allowed him to receive additional treatment.

We took independent advice on Mr C's complaint from an adviser in emergency department medicine and an adviser in radiology. We found that the imaging which was carried out when Mr C attended the hospital immediately after his fall showed subtle signs of a fracture of Mr C's spine. However, this was with the benefit of hindsight. We concluded that, due to the subtle findings which were evident, it was not unreasonable for the staff who reviewed the imaging at that time not to have identified the fracture. We did not uphold the complaint.

Summary

Miss C complained to us that, when she attended her local opticians, she reported symptoms of flashing lights in her left eye. The optometrist said there was nothing to worry about and did not offer her a follow-up appointment. When she saw another optometrist six months later, she was urgently referred to the eye hospital where it was discovered she was blind in her left eye. Miss C said that the first optometrist should have taken her concerns seriously.

We took independent advice from an adviser in optometry and concluded that the first optometrist had provided a reasonable standard of care. This optometrist had seen Miss C on two occasions. At the first appointment there was no record that Miss C had reported flashes in her left eye. Her vision had deteriorated from her last annual check-up, however there was nothing to suggest that Miss C should have been referred to a hospital specialist at that time.

At the second appointment two months later, it was noted that Miss C had reported flashes in her left eye and was worried about going blind. The optometrist offered to perform a dilated examination (detailed eye examination following administration of eye drops) but Miss C declined the offer. The adviser noted that although there was no explanation as to what the optometrist felt was the cause of the flashes, there was no clinical evidence of additional problems or a need for a specialist referral. We did not uphold the complaint. However, we found that the first optometrist should have arranged for Miss C to attend an earlier recall for the recent onset of flashes in line with the local referral protocol. This would have resulted in an earlier check-up, which would have been in advance of Miss C's appointment with the second optometrist. We offered some feedback on this to the opticians.

Summary

Mr C complained that the time his son (child A) had to wait to have treatment by the child and adolescent mental health services (CAMHS) was unreasonable. Mr C also complained that the board failed to take into account all of child A's circumstances before reaching a decision to refuse a referral to CAMHS a number of years earlier. Mr C also raised concerns about the board's handling of his complaint.

During our investigation we took independent advice from a CAMHS nurse. We found that whilst waiting times for CAMHS are long nationally, the government's waiting time target is for treatment to begin within 18 weeks of referral. In this case, child A had waited eight months from referral to treatment. We found this to be unreasonable. The board told us that families are encouraged to go back to the referrer whilst they are waiting for treatment if they are worried about a deterioration in a child's condition. However, we found no evidence that this had been communicated to Mr C or child A and we were critical of this. We upheld this aspect of Mr C's complaint.

In relation to Mr C's complaint about the board refusing a referral for his son to CAMHS at an earlier date, we found that the referral letter did not mention any mental health concerns. We found the letter only mentioned issues such as family relations and behavioural problems, which would not normally be treated by CAMHS. We therefore found that it was reasonable for the board not to have accepted a CAMHS referral for child A at that time. We did not uphold this aspect of Mr C's complaint.

We found that the board's handling of Mr C's complaint had been unreasonable. Whilst we considered the board to have taken reasonable steps to ensure patients are aware of the complaints process, we found that the board had failed to meet the 20 working day target for the full response to Mr C's complaint as set out by the Scottish Government's 'Can I help you?' guidance. The board stated that they considered the 20 working days to start running from when they had received child A's consent to investigate. However, this contradicts the guidelines around complaints handling. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• provide information on what steps they are taking to meet government waiting time targets for CAMHS;
• give consideration to how they can ensure families are aware that, if they have concerns about increased risk or deterioration of symptoms whilst a child is waiting for treatment from CAMHS, they can go back to the referrer;
• apologise to Mr C for the failings in complaints handling identified by this investigation; and
• feed back the findings on complaints handling to the relevant staff.