Health

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.

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs A) by the medical practice. In particular, she complained that the practice delayed taking action which diagnosed Mrs A was suffering from pancreatic cancer. We took independent GP advice and found that the practice had acted promptly in referring Mrs A for specialist intervention and that there were no delays in sending the referrals. The medical records detailed that Mrs A was referred to hospital twice under the two-week cancer pathway. We did not uphold the complaint.

Ms C also raised concerns that the practice had failed to investigate Mrs A's abnormal liver function results taken in 2014. The advice we received was that the test results had not shown any deterioration until September 2015 and at that time the practice had acted reasonably in making an urgent referral to hospital. In view of the advice that the practice's response was reasonable, we did not uphold the complaint.

Ms C was also concerned that the practice had failed to take appropriate action on Mrs A's reported weight loss. The clinical records demonstrated that Mrs A had been referred for dietary advice and attended a dietician clinic, and the advice we received was that the referral had been made at an early stage. We were satisfied, based on the medical records and independent advice we received, that the practice responded appropriately to Mrs A's reported weight loss and we did not uphold the complaint.

Finally, Ms C complained that the practice failed to ensure appropriate palliative care was put in place for Mrs A at home. The advice we received was that, based on the medical records, the practice had not delayed in referring Mrs A to palliative care services and that the practice offered reasonable care. We did not uphold the complaint.

Summary

Mrs C complained to us about the care and treatment her late mother (Mrs A) had received at Biggart Hospital and University Hospital Ayr. Mrs C said that staff at Biggart Hospital had failed to treat her mother's deteriorating condition. We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that there had been prompt recognition of Mrs A's deteriorating condition and that the care and treatment provided to her had been reasonable. We did not uphold this aspect of Mrs C's complaint.

During her treatment Mrs A was transferred from Biggart Hospital to University Hospital Ayr. She was subsequently transferred back to Biggart Hospital. Mrs C complained about the decision to transfer Mrs A back to Biggart Hospital given that she had tested positive for sepsis, MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) and E.coli (bacteria found in the digestive system). We found that Mrs A's condition had improved at the time to the point that it was reasonable to consider her transfer back to Biggart Hospital. We did not uphold this aspect of the complaint.

Mrs C also complained that the communication between Biggart Hospital and University Hospital Ayr was unreasonable. We found that there was no clear documentation of communication between the hospitals about the fact that Mrs A had E.coli and MRSA. We therefore upheld this aspect of the complaint.

Mrs C further complained that Biggart Hospital had prescribed her mother a form of morphine, despite the fact that Mrs A had previously had an adverse reaction to morphine. We found that Mrs A's allergies, drug intolerances and drug interactions could have been better documented, and we made a recommendation in relation to this. However, we found that it had been reasonable to give Mrs A small doses of morphine, as the effect on her was being monitored. We did not uphold this complaint.

Finally, Mrs C complained about the medication Mrs A received at University Hospital Ayr. We found that it had been reasonable to try alternative medications given that Mrs A was able to tolerate them. In addition, nursing staff had observed Mrs A for adverse side effects. That said, Mrs A had not been given her routine medication when she was admitted to University Hospital Ayr and the reasons for this had not been adequately recorded. 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 the lack of clear documentation and communication.

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

• The policy on communication between hospitals regarding patient transfer should be reviewed.
• The computer system for recording allergy information should be reviewed.
• A review policy around prescribing medication on admission, including who is responsible for this if the admitting team are too busy, should be produced.

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 had a family history of DVT (deep venous thrombosis, a blood clot in a vein). During her pregnancy she suffered cramps and pain in her calves. She therefore underwent a scan of her right leg. This scan was clear but because she continued to complain of pain, Mrs C underwent a further scan. Mrs C said that the scan was of her left leg, although the board said it was of her right leg. After Mrs C gave birth, a further scan confirmed a pulmonary embolism (a clot in the blood vessel that transports blood to the heart and the lungs) and a DVT in her left leg.

Mrs C complained to the board that despite her many complaints, they did not refer her to haematology (the specialism concerned with the study of blood and blood-related disorders) and that they failed to properly carry out the second scan. In response, the board said that Mrs C should have been reviewed by a senior doctor and probably referred back for a further scan. However, Mrs C still felt that the scan had been carried out incorrectly.

We obtained independent haematology advice and found that although scans were a good diagnostic tool for DVT of the upper leg, they were not as reliable for the calf. We found that an examination had not shown evidence of a clot in Mrs C's lower leg. Furthermore, the scan about which Mrs C complained had been carried out in a reasonable way and Mrs C had been reviewed on three occasions during the five days after this scan. Despite the board's own conclusion, we found that the management and care received by Mrs C following her scan was reasonable. We therefore did not uphold Mrs C's complaint.

Summary

Mrs C complained about the care and treatment provided to her husband (Mr A) during hospital admissions to the Royal Infirmary of Edinburgh (RIE), Liberton Hospital, the Western General Hospital and Ellen's Glen House in the months prior to Mr A's death. Mrs C also complained about communication and the board's complaints handling.

The board arranged a meeting for Mrs C with staff from the hospitals involved, and provided several written responses to her complaints, including an independent clinical review of some of the complaints. The board acknowledged a number of failings, including that significant decisions to complete a 'do not attempt cardiopulmonary resuscitation' (DNACPR) form and a 'verification of expected death' form were not discussed with her or Mr A, that the nursing documentation from Ellen's Glen House was completed to a poor standard, and that all of the medical records from Mr A's admission to RIE had been lost. However, Mrs C was not satisfied with the board's response.

After taking independent medical and nursing advice, we upheld Mrs C's complaints. We found some additional failings in medical and nursing care, including that Mr A was discharged from RIE when he was not fit to be discharged, and that nursing staff did not contact the family or carry out a neurological assessment when Mr A suffered a minor head injury. In relation to Mr A's missing medical records, we were advised that the board's actions in relation to the management of files were relevant but not sufficient.

We also found failings in the board's complaints handling. On several occasions the board agreed to take action, but did not follow through on this, and the independent clinical review provided to Mrs C included inaccurate findings, which were contradicted by the board's later responses. However, in making our decision we acknowledged that the board devoted considerable time and effort to addressing the numerous points Mrs C raised, including meeting with her and writing detailed responses to her concerns.

Recommendations

We recommended that the board:

• feed back our findings to the RIE doctor who discharged Mr A, for reflection and learning;
• confirm that the consultant who put in place the DNACPR without informing Mrs C has discussed this complaint at an annual appraisal;
• demonstrate that there are robust auditing processes in place at Liberton Hospital and Ellen's Glen House, to ensure decisions about DNACPR and nurse verification of death decisions are discussed with patients and/or families;
• discuss the nursing adviser's comments in relation to the treatment of Mr A's head wound with relevant nursing staff, for reflection and learning;
• demonstrate they have taken the action identified in their improvement plan to improve record-keeping (introduction of transfer letters and discussion of the process of filing notes at a quality meeting);
• review training needs of relevant staff in relation to information governance;
• update the management of misfiled and missing records procedure to include reporting responsibilities of staff;
• apologise to Mrs C for the additional failings our investigation found;
• review their systems for tracking actions agreed with a complainant, to ensure they follow up on these; and
• confirm that the failings in the independent clinical review have been fed back to the relevant doctor for reflection and learning as part of their next annual appraisal.

Summary

Mr C complained about statements made by a GP at an adult protection case meeting held in relation to the care of his wife (Mrs A). Mrs A suffered from an illness that affected her ability to care for herself and was in hospital at the time of the meeting, which was organised to discuss the possibility of discharging her home.

We took independent advice from a GP adviser. The adviser noted that Mrs A was a patient who did not have capacity to make decisions about her care, which meant that the GP was responsible for deciding on the appropriate medical treatment to safeguard or promote the physical or mental health of Mrs A. The adviser considered that the statements made by the GP were supported by the medical records and were, therefore, accurate. The adviser explained that an adult protection meeting is a forum in which care providers share information and that in this context, it was appropriate for the GP to share their concerns with the meeting. We did not uphold this complaint.

Mr C also raised concerns about a letter the GP had sent to him following the meeting. In particular, Mr C felt that the letter inferred that he had mistreated Mrs A. We found that the letter from the GP sought to explain the GP's reasons for the statements made in the previous meeting. The adviser did not consider that the letter inferred that Mr C had mistreated Mrs A, and overall felt that the letter was appropriate. We therefore did not uphold this aspect of Mr C's complaint.

Finally, Mr C expressed concern that the practice had not communicated with him reasonably in relation to arranging a meeting to discuss his complaint to them. We found that Mr C had spoken to the practice manager about a meeting, yet we noted that this did not take place. We considered that both Mr C and the practice manager had different expectations about who would take the next step to arrange a meeting. It was not possible for us to determine what was said and agreed in this conversation, and for this reason we did not uphold this aspect of Mr C's complaint.

We also considered how the practice had handled Mr C's complaint. Although we were satisfied with many aspects of the complaints handling, we found that the practice's complaint correspondence did not provide information about the support available through the Patient Advice and Support Service (PASS), and did not provide information about how to contact us should Mr C remain dissatisfied. We therefore made a recommendation in relation to this.

Recommendations

We recommended that the practice:

• take steps to ensure that complaints are acknowledged and handled in accordance with the practice's complaints procedure.

Summary

Mrs C complained that one of the board's clinicians failed to provide her late daughter (Ms A) with appropriate treatment.

Ms A suffered from epilepsy and cerebral palsy. The clinician prescribed a particular medication for Ms A due to an increase in her seizures. Over the following months Ms A attended A&E at a number of points due to seizures and was seen by the board's A&E clinicians. Approximately 18 months later Ms A was taken to hospital where it was identified that she was suffering from end stage renal failure, and she later died.

Mrs C said that she raised concerns about the prescription of the particular medication to Ms A, which she linked to Ms A's death. She said the board should have further monitored Ms A. The board considered that the care and treatment had been appropriate, and said that there was no link between the medication and Ms A's deterioration.

After obtaining independent medical advice we did not uphold Mrs C's complaint concerning the board's clinician. We found that the board's clinician had followed national guidance regarding the medication and that the decision to prescribe this was reasonable in the circumstances. We found no link between this medication and Ms A's outcome.

While we did not uphold the complaint Mrs C brought to our office, we found evidence that clinicians within the board had not acted on high blood pressure readings taken from Ms A on two A&E attendances. We made a number of recommendations to the board regarding this issue.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise for failing to act on Ms A's high blood pressure readings.

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

• The board should ensure that staff are aware of guidance that recordings of high blood pressure should be acted upon.
• The board should ensure that the circumstances of this case have been fully considered for wider learning at a significant review level.

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.