Health

Summary

C complained about the care and treatment provided to their infant child (A) who was born with a terminal genetic condition. A's family had open access to the children's ward, allowing them to seek medical advice or assistance when needed.

C brought A to the ward as they were unwell. After assessment, A was discharged with advice to return if their condition changed. A's condition deteriorated and they were taken to A&E the next day. When staff were unable to obtain intravenous access (when a needle is inserted into a vein), an intraosseous needle was used (a needle that goes directly into the bone). A complication occurred during the procedure and A was transferred to another health board for specialist care where there were further major complications.

C felt that treatment would have started sooner if A had remained in hospital, avoiding the need for the intraosseous infusion and the subsequent complication. We took independent advice from a consultant paediatrician (specialist in children's medical care). We found that A received a reasonable standard of care and treatment and that the harm that occurred was a recognised complication of the procedure.

We welcomed the board’s review of the case and noted that it had contributed to important learning in relation to the care of children with complex medical needs.

We did not uphold C's complaint.

Summary

C complained that the board failed to reasonably communicate with them about the care and treatment of their parent (A). C said that the board failed to inform them that a lump had been found on A’s breast while A was in hospital. A had been due to go into respite care in a care home but this was delayed. When staff found the lump on A’s breast, A told staff that they did not want it to be treated. This was communicated to A’s GP and respite care home but was not communicated to C. C subsequently learned of the breast lump when A was admitted to another hospital in another board area.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). With regard to the breast lump, we found that an appropriate hand-over was made to the GP for follow-up in the circumstances. In a non-emergency situation, it was reasonable to take time to establish capacity and consent before informing family. Due to time constraints before A’s transfer, this was not fully explored, but the handover was deemed appropriate under the circumstances.

Therefore, we did not uphold the complaint. However, we provided feedback to the board about the need for early assessments of decision-making capacity, re-assessment during admission, and improved engagement with family members where appropriate. We also provided complaints handling feedback.

Summary

C complained on behalf of their friend (A), a care home resident. A became unwell and was in a lot of pain. An Out of Hours GP suspected an internal bleed and arranged for an ambulance to be requested. A call was made to Scottish Ambulance Service (SAS) at 20:20, requesting a ‘one-hour response’ to hospital. The SAS call handler advised that the majority of responses were taking over four hours. An ambulance did not arrive until 02:21, by which time A’s condition had deteriorated and they were too ill to be moved. A was given medication and died in the care home. C complained about the delay in SAS providing an ambulance for A.

In their response to the complaint, SAS explained that they operate a priority-based system of dispatch to ensure that emergency ambulances are available to respond to the most serious and life-threatening cases in the first instance. They operate a welfare call back process when timed admission calls are unable to be met within the requested timeframe. Regular welfare calls were made to A’s care home, during which SAS apologised for the delay, checked on A’s condition, and gave worsening advice to call 999 if A’s condition deteriorated. SAS considered that the final welfare call, which was reviewed by a SAS clinician, was appropriately upgraded to an emergency response.

We took independent advice from a paramedic adviser. We acknowledged that some of the contributory factors which led to the delay in providing an ambulance for A were beyond SAS’s control. There were significant demands on their service and there were also delays in handovers at the receiving hospital. However, our investigation identified a missed opportunity to escalate the request for an ambulance following an earlier welfare call in which symptoms of faster breathing and agitation were reported, indicating a deterioration in A’s condition. Although it was not possible to say whether the outcome for A may have been different had an ambulance been provided sooner, this may have shortened the period of time during which A was in pain and distress. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the unreasonable delay in providing an ambulance for A, and for the failings identified in our investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Clinician escalation/re-triage is mandatory when welfare calls report new or concerning symptoms, especially where serious underlying pathology is suspected.
• Welfare scripts include condition-specific red-flag prompts to improve the detection of deterioration.

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 that their adult child (A) received from the prison healthcare team and particularly a failure to formulate a treatment plan for ongoing symptoms of stomach pain, nausea, diarrhoea and weight loss.

The board noted that numerous tests had been carried out to investigate the cause of A’s symptoms, which had come back negative. They initially mistakenly stated that tests were negative for Irritable Bowel Syndrome (IBS), then later clarified that there is no definitive test for IBS and it is diagnosed by a process of elimination. They said that A had no formal diagnosis of IBS, but received treatment and dietary advice for this possibility. They noted that tests for Inflammatory Bowel Disease (IBD) were negative. As A did not have a diagnosed long-term or chronic condition, the board said a treatment plan was not required and they concluded that A received appropriate care.

We took independent advice from a general practitioner. We found that reasonable and thorough tests were done regarding A’s symptoms but a reasonable care plan was not put in place to address possible IBS. Staff appeared to lack a clear understanding of the difference between IBS and IBD. A had an inflammatory eye condition which is associated with IBD, and there was a failure to note this potential link and consider a referral for a colonoscopy (examination of part of the intestines with a camera on a flexible tube). If a colonoscopy was negative for IBD, this would point towards a diagnosis of IBS and a dietician referral and care plan would be appropriate to support dietary changes. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Awareness should be raised amongst clinical staff regarding the differences between IBS and IBD and the potential links between inflammatory eye disease and IBD. Appropriate care plans should be in place to manage IBS and support dietary changes, especially in a prison setting where prisoners have limited control over their food choices. Complaint responses should be factually accurate. Draft findings should be shared with relevant clinicians to ensure the factual accuracy of any clinical references.

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’s parent (A) suffered a number of falls during an admission to hospital where A sustained a head injury and subsequently died. C complained to the board that A’s falls risk was not effectively managed.

The board identified some failings in relation to A’s falls care, including a lack of personalised falls prevention plan and a lack of falls risk signage over A’s bed. However, they noted that staff were fully aware of A’s falls risk and took measures to reduce this, and they did not find that A fell due to a lack of reasonable care.

We took independent advice from an experienced mental health nurse. We found that there was a failure to effectively assess A’s significant falls risk and tailor interventions to their individual needs. We noted that the board did not consider it appropriate for A to have received one-to-one nursing or be moved to a more observable area, however, no evidence was provided of consideration having been given to the risks and benefits of such interventions. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for failing to reasonably manage A’s falls risk. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Falls prevention assessment and planning should be personalised and carried out in line with up-to-date board policies and procedures.

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 given to their late sibling (A) who had a history of schizoaffective disorder. After a change in the consultant responsible for A’s care, A’s diagnosis was changed and their medication withdrawn over an extended period which led to A becoming unwell. They required admittance to hospital on a number of occasions before their death by suicide.

The board carried out a significant adverse event review (SAER) into what happened which identified a number of failures and made a number of recommendations as a result. Later the board issued their complaint response to C’s complaint which detailed the consultant’s position that A’s symptoms were not in keeping with a continuing psychotic illness, and that, this view was shared by the wider clinical team.

We took independent advice from a consultant psychiatrist and a mental health nurse. We found that the decision to change A’s diagnosis was not supported by their presentation, that the various diagnoses were referred to with no explanation and that the consultant involved in A’s care held an incorrect belief that schizoaffective disorder and schizophrenia were, in essence, the same condition and were interchangeable. We also found that NICE guidelines were not always followed appropriately, that there was an over-reliance on remote methods of assessment, that changes were made to medication without having seen or assessed A and that clinicians unreasonably maintained that A did not present with psychotic symptoms when the evidence demonstrates otherwise. Finally, we found that the nursing care was reactive and treatment was crisis led and failed to provide support and strategies for early interventions, that there was a failure to create a community care plan and that there was a lack of multi-disciplinary working, and therefore, a lack of challenging decisions on patient care. As such, we found the care and treatment both in hospital and from the community nursing team to have been unreasonable and we upheld this aspect of the complaint.

We also considered the way in which the board handled C’s complaint. We noted that the board provided a brief complaint response as they considered the SAER had addressed the main issues. We also found that the board’s complaint response directly contradicted the findings of the SAER, as it included the consultant’s view that A did not present with psychotic symptoms. We considered this to be unreasonable. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .
• Appropriate clinical guidelines should be followed when providing treatment to patients.

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

• i) Appropriate clinical guidelines should be followed when providing treatment to patients.
• ii) Clinician’s should have up-to-date accurate knowledge of the descriptions and classifications of conditions within their sphere of expertise.
• iii) Diagnosis reviews should be carried out when appropriate and in line with current disease classifications and treatment guidelines.
• iv) Clear rationale for decisions made to maintain or change a diagnosis should be recorded timeously in clinical records.
• v) Diagnoses should be clear, consistent, and evidenced.
• vi) When decisions are made to change, reduce, and/or withdraw medication there should be clear rationale recorded for this and close assessment of the patient should be carried out.
• vii) The emergence of symptoms or change in presentation should be assessed and considered thoroughly and the preferred diagnosis or treatment plan reviewed and adjusted in light of a patient’s presentation and changing needs.
• Mental health nursing staff should have in place pro-active, person-centred support planning for their patients. Person-centred support plans should be reviewed and updated regularly. Concerns about patient care and safety should be escalated by nursing staff appropriately, either to medical staff or nursing supervisors.
• Appropriate clinical guidelines should be followed when providing treatment to patients.

In relation to complaints handling, we recommended:

• Complaints should be investigated in line with the NHS Model CHP. Complaint responses should be full, factual, clear, and easy to understand. Decisions reached should be evidenced, proportionate, and objective. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 standard of medical care and treatment provided to their late partner (A) by the board in relation to their risk and diagnosis of liver cirrhosis (permanent scarring of the liver which leads to dysfunction) and gastrointestinal haemorrhage.

A was initially under the care of the board’s rheumatology service for psoriatic arthritis, which was treated with medication. The board’s gastroenterology service then began to care for A, and, after testing, found that A had liver cirrhosis with portal hypertension (elevated blood pressure in the portal vein).

After several months, A’s condition began to deteriorate and they attended the medical ambulatory care unit and A&E within a few weeks. A was discharged home both times. A died two days after their contact with A&E.

We took independent advice from four advisers who are consultants in rheumatology, gastroenterology, general medical and emergency medicine. We found that the standard of rheumatology, general medical and emergency medicine was reasonable. However, we found that the standard of gastroenterology was not reasonable in that A’s signs of deterioration were not taken seriously enough by the gastroenterology service including that the signs of abnormalities were not reasonably investigated, that A’s portal hypertension should have been identified following an endoscopy and that A should have been referred to a liver transplant unit. We found that the multidisciplinary team meetings unreasonably failed to pick up A’s clear deterioration and arrange appropriate investigations and treatment, and discussions were brief and decisions were deferred. We found that keeping A in the specialist nurse led clinic when they were diagnosed with liver cirrhosis and portal hypertension, and deemed suitable for a transplant, was unreasonable. Finally, we found that there were record keeping failings including clinic letters that failed to contain important information about A’s diagnosis and condition and we found that an urgent referral for a gastroscopy should have been considered sooner. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of medical care and 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:

• Patients with liver disease should be managed and receive treatment in line with the relevant guidelines. Additionally, patients with advanced liver disease should have a clear management plan and be reviewed by a consultant or medical staff when their condition deteriorates. Nurse led clinics should have a clear protocol on when to refer patients for a consultant or medical review. Finally, Multidisciplinary team meetings should have sufficient time to review patients and blood results over time, and further investigations, treatment etc. should be acted on fully and within a reasonable time. This includes referrals to liver transplant unit within a reasonable time.

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 on behalf of their sibling (A) in relation to the care and treatment that the board provided to A after presenting at an out of hours service with symptoms including epigastric pain, vomiting and shaking. A was sent home with treatment for dyspepsia (indigestion) but died shortly afterwards from acute haemorrhagic pancreatitis.

C complained that the board did not adequately take into account A’s full presentation and relevant background information in considering a treatment plan.

We took independent advice from an experienced emergency medicine adviser. Overall, we found that the care and treatment that A received was unreasonable because A’s physiological observations showed a significant degree of abnormality, and the board did not have appropriate systems in place to identify the deteriorating patient in the acute community setting. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that it was not recognised that the physiological observations documented in A’s notes were abnormal when they were seen in the OOHS. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• The board should ensure that there are systems in place that identify the deteriorating patient in the acute community setting inline with SIGN 167 Care of deteriorating patients.

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 on behalf of their partner (A) about the care and treatment that A received from the board during their two admissions to hospital for suspected pulmonary embolus (when a blood clot blocks a blood vessel in the lungs). A had a stroke during their second admission.

We took independent advice from a consultant in general medicine. For A’s first admission, we found that the triage nurse who took A’s bloods, clearly documented that a D-Dimer (a test to detect blood clots) had been done and the results were available on the board’s system before A was discharged but it was not noted or considered. We found that A’s D-Dimer result should have been considered and doing so could have led to an earlier diagnosis of A’s pulmonary embolus. We found this aspect of A’s care unreasonable and we upheld this aspect of the complaint.

For A’s second admission, we found that the treatment of A’s blood clots with medication appeared to be in accordance with relevant guidance which was reasonable. We did not uphold this aspect of the complaint.

We noted that the board advised C in their complaint response that they would take A’s case forward to their adverse events review group for further consideration and that 16 months later, there had been no indication that a significant adverse events review had taken place, which appeared unreasonable. In addition, we found that in their complaint response, the board should have provided C with an explanation of what happened when A was readmitted to hospital, and the nature of A’s stroke, as well as more detailed description of when the adverse events review group’s decision would be made and if this would be communicated to C.

Recommendations

What we asked the organisation to do in this case:

• For the board’s staff in the CAU to read notes made by triage staff when patients are passed on to them.
• The board should carry out SAERs in a timely manner.

In relation to complaints handling, we recommended:

• For the board to provide C with a written explanation of what happened when A was readmitted and the nature of A’s stroke. For staff to address all aspects of a complaint in the complaint response. For the board to obtain statements from key staff during their investigations. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses

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 broke their leg and underwent an operation. Following a scan the next day, C was told that the results were fine and that they could be discharged home. However, a few days later, C was contacted and told that a further review of the scan indicated that they would require further surgery, and this was performed by another surgeon a few days later.

C complained to the board about several aspects of their treatment. The board apologised that C was told two different things about their scan results and explained that there was an anomaly in the image that wasn’t seen at first, but was noticed on further review. C remained dissatisfied and raised their complaints with the SPSO.

We took independent advice from an adviser specialising in orthopaedic surgery. We found that a note of a discussion between clinicians in C’s medical record does not accord with another clinician’s later view, and that the board’s position that the discussion was wrongly recorded was the most likely explanation of what occurred. This meant that, from C’s perspective, the board had unreasonably reached different conclusions following the two reviews of the scan. Given these circumstances, the complaint was upheld.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for giving them incorrect information about the scan, for the inaccurate clinical record, and for the incorrect explanation in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Medical records should accurately record discussion outcomes.

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.