Health

Summary

Mr C complained about the care his late wife (Mrs A) received from nursing staff during two admissions to Forth Valley Royal Hospital. On the first occasion she was admitted with sepsis (a blood infection) and on the second occasion she was admitted with a hip fracture. In particular, Mr C complained that the board failed to carry out appropriate falls risk assessments, failed to appropriately manage Mrs A's medication and delayed in obtaining a review for Mrs A following a fall. Mr C also complained that it took an unreasonable amount of time for him to be able to speak to a senior staff member about his concerns.

During our investigation we took independent advice from a nursing adviser. The adviser considered that the overall care in relation to falls assessments, monitoring, care and falls prevention was unreasonable. They also found significant failings in how Mrs A's medication was managed.

The board accepted that it took an unreasonable amount of time for Mr C to speak to a senior staff member about his concerns. They also accepted that there was a delay in having Mrs A reviewed following her fall. The board also accepted that there were significant failings in how Mrs A's medication was managed. The board identified learning as a result of the complaint.

In light of the independent medical advice we received, we upheld all of Mr C's complaints. Although the board had taken steps to address the complaint, we made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a formal apology to Mr C for the unreasonable level of care provided to Mrs A in relation to falls assessments, monitoring and care.

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

• The board should ensure that patients at very high risk of falls should be considered for referral to a falls co-ordinator or falls specialist.
• The board should ensure that in future situations similar to Mrs A's a medical review is requested sooner.

In relation to complaints handling, we recommended:

• The board should ensure that senior charge nurses, and other frontline staff, have the skills and confidence to undertake early resolution of complaints.

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 raised concerns about an investigation relating to events at Stratheden Hospital. Following our enquiries, Mrs C met with representatives of the Health and Social Care Partnership, who agreed to explore her complaints further. We therefore did not continue our investigation.

Summary

Mr C complained to us about the care and treatment provided to him by the board in relation to treatment for his leg problems, and their communication with him. Mr C said that after a course of foam sclerotherapy (a procedure where medicine is injected into the blood vessels, making them shrink) for varicose veins in his legs, he was in a lot of discomfort. He said that he was told at a scan a month later that he had deep vein thrombosis (a condition when a blood clot forms in a vein located deep inside the body) but that he was not given appropriate treatment for this. He also said that he had been told contradictory things regarding the clot in his leg.

During our investigation, we took independent medical advice from a consultant vascular surgeon. We found that although the treatment that was given to Mr C was reasonable, there were two occasions on which follow-up scans should have been arranged but were not. We upheld this aspect of Mr C's complaint. We also found that the board had acknowledged that communication with Mr C had been poor, and that the lack of documentation of communication evidenced this. We upheld this aspect of Mr C's complaint.

Mr C also complained to us about the board's complaints handling, specifically that it took a long time for them to issue their final response to his complaint. The board accepted that they had failed to respond to Mr C's complaint in a timely manner and we therefore upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise to Mr C for failing to provide him with appropriate follow-up appointments after his scans.
• The board should apologise to Mr C for failing to communicate appropriately with him about the causes of his leg pain.
• The board should apologise to Mr C for failing to respond to his complaint in a timely manner.

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

• Follow-ups should be arranged for two weeks after a duplex scan shows a clot in the gastrocnemius vein.
• Details of appointments should be clearly recorded.
• Communication could be supplemented by a printed leaflet.

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 provided to him by the board in relation to a hip replacement procedure he had undergone at Borders General Hospital. Specifically, Mr C complained that during the operation, board staff had failed to correctly place the replacement, which resulted in several years of pain and a further operation to correct the replacement. Mr C also complained that there were unreasonable delays in investigating the cause of his ongoing pain after the original hip replacement surgery.

During our investigation we took independent advice from a consultant orthopaedic surgeon. We found that there was no evidence to suggest that Mr C's hip replacement had been incorrectly placed at the first operation. Therefore we did not uphold this aspect of Mr C's complaint. Additionally, whilst we recognised the long time that Mr C was in pain for and the many appointments he had with orthopaedic services, we found that appropriate tests and investigations were carried out at each stage and opinions of other clinicians were sought. We did not uphold this aspect of Mr C's complaint.

Mr C further complained that the board failed to address all of the issues he raised in his complaint to them. On review of the complaints documentation, we found that the board had provided Mr C with a thorough response to his complaint and that they had provided further clarification both verbally and in a letter when Mr C requested this. Therefore, we did not uphold this aspect of Mr C's complaint.

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.