Health

Summary

C complained that the board failed to provide their adult child (A) with adequate care and treatment by discharging them from hospital when they were not medically fit to be discharged, highlighting A’s ongoing incapacity at that time.

A was admitted to hospital following an insulin overdose. Following treatment in an intensive care unit, they were transferred to a general ward. A was discharged after an in-patient stay of several days. A was readmitted to hospital by ambulance transfer the day after their discharge.

We took independent advice from an emergency medicine consultant adviser. We found that it was unreasonable for the board to have discharged A. We found that there were failings in the discharge process which had led to A being discharged with an unaddressed medical condition. Therefore, we upheld the complaint.

We also found that there had been delay in undertaking a psychiatric review. We provided feedback to the board about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A, C, and their family for discharging A from hospital with an unaddressed medical condition leading to their readmission and for the delay in carrying out a psychiatric review. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• In similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and the assessment recorded in the patient’s clinical records.

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

C presented at A&E with a painful left foot. The diagnosis recorded in the medical records was a foot sprain. A few months later, C was diagnosed with a rare degenerative condition and a possible healing fracture in their foot was also noted.

C complained that the doctor at A&E had not physically examined the foot, had not carried out an x-ray and had not taken a medical history. As such, a possible fracture may have been missed and a diagnosis of the degenerative condition was not considered. As a result, C felt that the correct treatment was not offered.

We took independent advice from an emergency medicine adviser. We found that the condition in question is rare and unlikely to be diagnosed in an A&E setting. It was also not clear whether the possible healing fracture had been present at the time. However, it would have been appropriate to carry out a physical examination, to take a medical history and to carry out an x-ray. Overall, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not carrying out a physical examination and not taking a medical history, such that an x-ray was not considered. 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:

• Clinicians should be reminded of the importance of carrying out a thorough physical examination and recording the patient’s medical history.

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

C complained about the care and treatment that their spouse (A) received from the board. A was diagnosed with colorectal cancer (bowel cancer) and underwent colon cancer surgery abroad, before returning to the UK. They were reviewed by the board’s oncology team (cancer specialist team) and it was determined that the cancer had spread and that chemotherapy was required.

Although A initially responded well to chemotherapy, once the chemotherapy course ended, the cancer was found to have spread further. A was not considered fit enough to undergo further chemotherapy and died.

C complained to the board that, following the positive indications, the board failed to communicate clearly with A and their family about their prognosis, treatment and next steps. C raised particular concerns that clinicians were unwilling to give information about the nature and extent of A’s deterioration, the sizes of tumours identified and information about the treatment that could be provided.

C considered that the board failed to provide A with appropriate treatment during their time in hospital and that these failures could have resulted in A not being able to recover sufficiently to undergo further chemotherapy. C was concerned that A suffered a series of issues related to their stoma site (opening in the body) and C complained that these issues were not treated with sufficient urgency or concern.

In response to the complaint, the board provided a detailed account of the care provided to A and their communication with A's family. The board acknowledged that A responded well to chemotherapy but once the first six cycles were complete, the cancer started to grow aggressively and A never regained the fitness required to restart treatment. The board explained that following further review of A, it was established that surgery was not an option for A and gave their view as regards the progression of A's illness and recurrent infections which necessitated admittance to hospital. Additionally, the board clarified their understanding with respect to the communication with A and their family and explained why they considered this to be reasonable in the circumstances.

We took independent advice from a senior clinical oncologist. We found that the assessment and treatment of A’s cancer during the period concerned was reasonable. We considered a period of care during which A experienced difficulties with respect to their stoma site and infections and considered the care provided to be reasonable in the circumstances. We found that whilst there were clearly difficulties with respect to communication between clinicians and the family, medical professionals tried to answer questions about A’s care and there was evidence of appropriate communication with the family.

With respect to the care and treatment provided to A, we found that an appropriate diagnosis was made, with a reasonable treatment plan and follow up testing to monitor the effectiveness of treatment. Despite initial good progress, A's cancer progressed and decisions made about A's treatment, including that A was not fit for surgery, were clear with demonstrable reasoning. A suffered difficulties with infections and complications which, again, were appropriately responded to and treated. Overall, the care and treatment provided to A was reasonable and in line with good practice. As such, we did not uphold the complaint.

With respect to communication with A and their family, the records demonstrated that A and their family asked a lot of questions to help their understanding. There was evidence of frustration on both sides regarding the level and extent of communication and information requested. There may have been opportunity for clinicians to consider and better manage the family’s expectations about the level of detail which could be provided about the treatment and prognosis. However, we found that the level of detail about A’s care and treatment was in line with what would reasonably be expected in the circumstances and we did not uphold this complaint.

Summary

C complained about medical treatment provided to their late spouse (A) following their transfer to a community hospital from a regional hospital, where A had been treated for a heart attack. C raised concern about several aspects of the care provided, including the frequency of medical reviews and communication with A’s family about their condition.

We took independent advice from a consultant in care of the elderly. We found that A had been suffering from hypernatraemia (high sodium levels in the blood) at the time of their hospital transfer and that this condition required careful monitoring of A’s fluid balance, planned daily medical reviews and frequent blood tests. Despite this, we noted that A had not been medically reviewed daily at the community hospital. Weekend medical cover was provided by an out-of-hours GP service, which would only attend if required. Given this, we found that the decision to transfer A to this hospital had been unreasonable.

We also found that the frequency of blood tests carried out was insufficient and that no medical review was carried out despite rising sodium levels in A’s blood. We noted that A had not received intravenous fluids over a period of three days despite their oral intake documented as poor and that, when intravenous fluids had been administered, the particular type of fluids given had been inappropriate to treat hypernatraemia and may have worsened A’s condition. However, it was not possible to say how this might have affected A's outcome given the generally poor prognosis associated with the condition and A’s significant comorbidities. For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A’s treatment. 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:

• Robust handover procedures should be in place so that staff taking over responsibility for patient care following transfer to community hospitals are clear about ongoing treatment and review requirements.
• Patients should only be transferred to community hospitals when it is clear that the required level of care can safely be provided following transfer.
• In patients presenting with conditions causing electrolyte imbalances, such as hypernatraemia, medical and nursing staff should be clear on (i) the frequency and the means by which such patients require to be reviewed including the frequency of blood tests and; (ii) the appropriate intravenous fluids to be used to manage such conditions.

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.

Please note the events this complaint refers to may have occurred some time ago due to a delay in publication. We publish our findings to share learning and inform improvement.

Summary

C complained that the board failed to provide appropriate care for their parent (A) when they were admitted to A&E. A had a cut on their leg which was not treated because the board said they had not been made aware of it. C said that this was not acceptable, noting that patients are not always able to make staff aware of their symptoms.

We reviewed the medical records and took independent advice from a consultant in emergency and retrieval medicine. We noted that the explanations provided by the board as to why they were not aware of the wound, and did not treat it at the time, did not tally with the information in the medical records, where it was noted that A had been admitted with a cut to the knee. We progressed the complaint to investigation and asked the board to comment on the initial findings and suggested a resolution approach would be welcome. The board responded, stating they wished to move to resolution and would meet the outcomes asked for. We accepted this outcome.

Summary

C complained about the orthopaedic care (conditions involving the musculoskeletal system) and treatment that they received from the board. C had a wrist injury and underwent an initial operation and a second operation three years later. C complained that the reason for the second operation was because the first operation carried out had been ineffective and that mistakes had been made.

C also complained that they had been allocated two community health index (CHI) numbers which had unreasonably impacted on the care and treatment that they received from orthopaedics.

We took independent advice from a consultant orthopaedic surgeon and a consultant radiologist. We found that the orthopaedic care and treatment C received was reasonable and we did not uphold this complaint.

We also found no evidence that the issue of CHI numbers had impacted on C’s care and treatment regarding their two operations. We did not uphold this complaint.

Summary

C complained about the treatment they received from the board following a knee injury. C’s injury had occurred when level 3 of the Scottish Government’s COVID-19 lockdown measures were in place, which limited travel between local authorities to essential travel only. C’s accident had occurred outwith their own local authority area. C complained that the A&E staff repeatedly asked them about their local accommodation and travel arrangements. C reported that they were only admitted to hospital for one night, and they were obliged to make their own travel arrangements for their discharge the next day despite experiencing severe pain.

The board said that C had been timeously assessed and treated at the A&E, with orthopaedics (specialists in the musculoskeletal system) taking over their care due to the diagnosis of a displaced fracture with foot drop. C’s injury had been immobilised with a knee brace and they were assessed using crutches by physiotherapy prior to discharge the next day, with the plan being for C to travel back to their own health board area to arrange further care and treatment of their injury. C was given an immediate discharge letter to pass to the receiving clinical team and a prescription for pain killers.

We took independent advice from an orthopaedic consultant. We fond that the board’s treatment of C was reasonable, both in terms of the type of injury they had sustained, and in keeping with the guidance in place at the time for management of orthopaedic injuries during the pandemic. We considered it was appropriate for A&E staff to enquire about C’s travel and accommodation arrangements to help inform their plan of care. They also commented that without lockdown measures in place, C’s injury would have required transfer to a specialist centre for surgical reconstruction. However the guidance at the time had been appropriately followed by the board for non-operative management of the injury with later reconstruction. Therefore, we did not uphold C’s complaint.

Summary

C complained about the maternity care they received from the board when they gave birth to their twins. C was suspected to have COVID-19 and this was confirmed the day after delivery.

C complained that they were placed in a room that wasn’t equipped for labour and that they were pushed towards a vaginal delivery, rather than a planned caesarean section. The board explained that the labour room was set up with equipment stored outside the room for infection control purposes. C also complained that they weren’t provided with appropriate postnatal care.

We took independent advice from a midwife. We found that the records supported reasonable decision making surrounding the delivery method and that appropriate discussions had taken place with C in this regard. We also considered that the records evidenced a reasonable standard of postnatal care and that the decision to store equipment outside the room was reasonable. Therefore, we did not uphold this part of C's complaint.

C was unable to see their babies in the neonatal intensive care unit (NICU) until after their COVID-19 isolation period ended. C complained that it wasn’t explained to them why they weren’t allowed skin to skin contact before the babies were taken away to the NICU. C also complained that there was no clear process in place for them to see their babies and that staff were initially unable to tell them when this would happen. The board acknowledged that C did not receive an explanation as to why skin to skin contact was not allowed. We noted that the board had asked staff to reflect on C’s negative experience of communication and we were satisfied they had demonstrated learning from this.

We found that the restrictions in place for visiting the NICU were reasonable, that there were clear processes and guidelines in place to support this, and that the records showed this was appropriately communicated to C. Therefore, we did not uphold this part of C's complaint. We provided complaint handling feedback to the board as we noted some inaccuracies in their responses to C.

Summary

C, a support and advocacy worker, complained on behalf of their client (A) that the board failed to ensure clinicians provided a surgical assessment and procedure to A within a reasonable time frame. A had been referred to the board’s neurosurgical department (specialists in surgery on the nervous system, especially the brain and spinal cord) following an injury to their back but decided to undergo a surgical procedure privately following delays from the board. A continued to experience pain and felt that the board's delay had led to an adverse outcome from the surgery.

We took independent advice from a consultant neurosurgeon. We found that the board unreasonably delayed the clinical assessment and treatment of A. We also found that there was an unreasonable delay to A being given a clinic appointment and that communication around the treatment time guarantee process could have been better. However, we could not say with any certainty that the delay led directly to an adverse outcome for A. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to progress their treatment within a reasonable timescale. 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:

• Consideration as to how to better manage patients’ expectations in terms of their treatment time guarantee calculation and how the treatment booking process works.
• Make improvements to the clinic booking process to ensure patients are seen within national waiting time targets.

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.

Please note the events this complaint refers to may have occurred some time ago due to a delay in publication. We publish our findings to share learning and inform improvement.

Summary

C complained on behalf of their partner (A). A had a telephone consultation with the practice and reported haemoptysis (coughing up blood) and a fever. A also reported that they had taken a lateral flow test for COVID-19 which was negative. A did not take a PCR test for COVID-19 prior to contacting the practice. The practice considered it was likely that A had COVID-19 and advised that they self-isolate for ten days after symptoms started. A's condition deteriorated and several weeks later they were admitted to hospital and diagnosed with bacterial pneumonia.

C complained that the practice did not offer A a face to face appointment and subsequently failed to correctly diagnose their condition of bacterial pneumonia, instead focussing on COVID-19 as being the cause of A's illness.

The practice considered that they had been following the guidelines in place at the time and had correctly signposted A to the COVID-19 Hub for further assessment. We took independent advice from a GP. We found that there was no evidence in the clinical record that A had been signposted to the COVID-19 Hub and that haemoptysis was never listed as one of the common symptoms of COVID-19 infection. We found there was a failure to offer A a face to face appointment, particularly given they had reported haemoptysis.

We welcomed that during our investigation the practice reflected further and accepted that A's complaint of haemoptysis merited further clinical consideration and assessment. Given that the practice have taken appropriate and sufficient action to learn and improve from this complaint, we did not recommended that they take any further action. However, we recommended that they apologise to C and A for not offering A a face to face appointment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for not offering a face to face appointment which may have led to bacterial pneumonia being considered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.