Health

Summary

C complained about the care and treatment their late spouse (A) received for a bowel perforation. A died in hospital following a cardiac arrest. C complained that the conservative, non-surgical approach taken to A’s treatment led to a deterioration in their condition, leaving them unfit for surgery.

C also complained about the standard of A’s medical records, which made it unclear whether clinical advice and treatments had been followed.

Furthermore, C complained that the board’s complaint response contradicted information given at the time, particularly regarding the healing of the abdominal leak and plans for discharge. Instead, the board’s response stated that the treatment had failed, A’s condition was non-survivable, and the leak persisted. Given this, C questioned the board’s decision to attempt cardiopulmonary resuscitation and the lack of palliative care for A.

We took independent advice from a consultant surgeon. We found that there were aspects of A’s care which were reasonably managed including timely administration of intravenous antibiotics and a CT scan on admission. However, we found that there was a lack of urgency and clarity following the CT scan, and an absence of documented clinical reasoning such as treatment purpose, an escalation plan, and consideration of palliative care. High dependency care was not provided early despite signs of deterioration.

Communication with A and C was inadequate, with no documented discussions about the severity of A’s condition or care decisions. We also found failings in fluid resuscitation and monitoring, with delayed reviews of A’s response to treatment. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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:

• Patients should receive reasonable surgical care at a level appropriate to their condition. In particular, patients should receive timely assessment and have a clear management plan in place. This should include appropriate monitoring, planned follow-up reviews, and repeat tests and investigations to assess the response to treatment. Fluid resuscitation should be adequate and fluid balance carefully monitored. Medical records should be comprehensive and completed in line with local and professional standards. Communication with a patient and their family about their care and treatment should be timely and transparent.

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 spouse (A). The first of C’s complaints was that the board had failed to reasonably and accurately record and report an alleged incident between A and a member of staff. They also complained about the board’s investigation, and future references in records to the incident. We identified a number of failings including that the incident referred to was not reliably recorded on the board’s incident reporting system, that the board did not properly investigate C’s concerns, and that medical record correction notices issued were inaccurate and inconsistent. We upheld the complaint.

C also complained about the care and treatment that A had received. We took independent advice from a psychiatrist. We found that the care and treatment was of a reasonable standard. We did not uphold this aspect of C’s complaint.

Finally, C complained about the board’s handling of their complaints. While acknowledging that the complaints were numerous and complicated, we were of the view that the board could have taken action at an earlier point to define the complaints. They also could have investigated to a higher standard and responded more promptly. We therefore upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for their failings in relation to recording and reporting of, future references to, and investigation into, the alleged incident; and for failings in relation to complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Place a new medical record correction notice in A’s records that accurately identifies the incorrect entries and corrects these.

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

• Where a patient raises concerns about accuracy of medical records, this should be properly investigated and responded to.

In relation to complaints handling, we recommended:

• Complaints should be responded to timeously and investigations should accurately identity failings.

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 that the board’s mental health services did not communicate information regarding C's adult child (A) reasonably. A, who had experienced various mental health issues, was taken to hospital after taking an unknown quantity of tablets. C and another family member were concerned about A's mental health. A did not wish to remain in the hospital and clinicians assessed that A had capacity to make this decision. A few days later, A agreed to go to the hospital for a mental health assessment. The board referred A to the community mental health team (CMHT) and did not admit them to hospital. A few weeks later, A took their own life.

C complained about the board's actions in the lead up to A's death. The board’s complaint response indicated that they had no concerns about the actions taken in relation to A's care. A significant adverse event review (SAER) concluded that communication between agencies (including within the board) could have been improved and an action plan based on the SAER recommendations was developed. The board acknowledged that A had died while in their care and apologised for this. C remained dissatisfied and raised their complaints with SPSO.

We took independent advice from a consultant psychiatrist. We found that, as the SAER concluded, there were failures in communication involving the mental health team, including failures to update risk assessments, failures to use the electronic case notes system and inconsistency in referral criteria across CMHTs. We concluded that the board did not take a partnership approach when communicating with Ass family and did not adequately take into account their concerns when assessing risk. Therefore, we upheld C's complaint.

During our consideration of the complaint, we gave the board the opportunity to comment on the adviser's views on the SAER Action Plan. The board reviewed and rewrote the SAER Action Plan and the proposed actions now relate directly to the recommendations in the report. However, we also noted that the board do not have the resources to undertake the proposed actions due to funding decisions. We noted that the revised SAER Action Plan could have included alternative actions that were not reliant on funding decisions. We have taken all of the above into consideration when making our recommendations.

Recommendations

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

• Board staff are mindful of the importance of communication with the family members of neurodiverse patients and adequately take the concerns of family members into account when assessing risk.
• The board develop a contingency plan to address failings in communication through training and team development of relevant staff that does not rely on external new funding, which could include building in awareness-raising and training within the development of revised CMHTs; and developing “Neurodiversity champions” within each team as sources of greater expertise to spread information and awareness.

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 dental care and treatment that they received. C underwent root canal treatment (RCT) on their lower right tooth. C said that this was not performed appropriately and that they should have been referred earlier to an endodontist (a dentist with special training to treat problems affecting the inside of the tooth). C was also concerned that the dentist had caused injury to the inferior alveolar nerve (a nerve that runs through the lower jaw, providing sensation to the lower teeth, gum, lip and chin), left a gap in their tooth and caused a dent to another tooth.

We took independent advice from a dentist. We did not find conclusive evidence that the dentist caused injury to the inferior alveolar nerve or a dent to C's tooth. We noted that the dentist did refer C to the endodontist but we did not find conclusive evidence that this should have happened sooner. However, we concluded that the dentist did not follow current guidance on endodontic practice. There was no evidence of the use of special tests or periapical radiographs (an x-ray that shows the entire tooth, from the crown to the root tip and surrounding bone) taken before the RCT was performed. As such, it was not possible to determine the case complexity. The dentist also used incorrect solution to irrigate the tooth canal and used an old method for assessing the quality of the radiograph imaging taken. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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:

• The dentist should take the following actions. Read through the Professional duty of candour from the General Dental Council and make reflective notes. Read through A Guide to Good Endodontic Practice and make some reflective notes. Read through Section 5.4.1 of Guidance Notes for Dental Practitioners on the Safe Use of X-ray equipment (Second Edition, 2020) and make some reflective notes. Read the following article (https://www.dentalprotection.org/uk/articles/tempted-to-change-the-records) from Dental Protection and make some reflective notes. Undertake a CPD course on Endodontics (e.g. Turas online courses from British Endodontic Society) https://learn.nes.nhs.scot/59573

In relation to complaints handling, we recommended:

• The dental practice’s complaints procedure should be revised to ensure it aligns with SPSO’s Model Complaints Handling Procedure: www.spso.org.uk/the-model-complaints-handling-procedures. If further assistance is required with this, the dentist / practice can contact the SPSO’s Improvement, Standards and Engagement Team: https://www.spso.org.uk/training or NHS Lothian.

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 that the board failed to communicate appropriately with their partner (A) regarding charges for treatment. A is a non-UK resident and was charged for non-urgent treatment at hospital following an accident. C complained that A was not informed of the financial liabilities they would incur prior to their treatment, despite having confirmed that they were a non-UK resident and having repeatedly tried to ascertain this information. According to the relevant guidance, any liability to charging should be explained from the outset and patients should be asked to sign an undertaking that they agree to this, ideally before treatment commences.

In their response to the complaint, the board said that the correct process had been followed, and that the variation to the standard processing of A’s case was due to the local address information that was initially recorded. The board confirmed that further training and advice would be provided for clinical teams to ensure that they are fully aware of the guidance and how to advise potentially liable patients appropriately.

We found no evidence that the guidance was followed in A’s case. We considered it a failing on the board’s part that A’s overseas address was not recorded at their initial presentation, noting that their overseas status was documented in the records at that time. We also found that there was a missed opportunity to follow up on matters when A’s relative contacted the Private and Overseas Financial Team with an enquiry a few days after A’s initial presentation at the hospital. Therefore, we upheld C's complaint.

We acknowledged that the board had taken significant steps to improve their service following C’s complaint. A's insurer had also settled the outstanding sum. Therefore, we made no financial recommendation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings we have identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies. We note that the board do not intend to pursue A for any outstanding treatment charges not covered by A’s insurer. For A's records, and for the avoidance of any doubt, we request that the board’s apology letter includes a statement confirming that no outstanding sums are owed to the board.

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

• All relevant staff are familiar with how to input patient details on the MPI screen. All staff are aware of the Private and Overseas Finance Team contact details.

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 nursing care provided to their late parent (A) during their admission to hospital. A arrived at the emergency department before being admitted to a ward. While in hospital, A lost weight and had difficulty eating. Due to delirium, A’s mobility was poor and they experienced a number of falls whilst in hospital. This resulted in a broken hip requiring surgery.

In response to the complaint, the board agreed that there had been multiple failings in relation to the management of A’s diet and reduction in weight. When mobilising A, it was explained that staff did so in accordance with physiotherapy assessments and a number of measures were put in place to prevent A from falls. However, the board acknowledged that due to staffing levels, A did not receive the level of care that they should have.

We took independent advice from a nursing adviser. We found that basic nursing care could not be evidenced in A’s case due to a lack of individualised care planning and delivery. We found that the care provided to A was inadequate and inconsistent and was not provided to the standard required. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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:

• Nursing documentation should be completed to standard required.
• Patients should receive appropriate nursing care.

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 that the board failed to provide them with reasonable care and treatment. C had a cancer diagnosis and was concerned about the length of time taken to arrange their surgery.

We took independent advice from a consultant clinical oncologist (specialist in the diagnosis and treatment of cancer). We found that it was reasonable for C's treatment plan to change and the delays in arranging a date for surgery were unavoidable due to capacity issues. Therefore, we did not uphold this part of C's complaint.

C also complained that the board's communication was unreasonable. We found that the board’s complaint response contained inaccurate information. In particular, it indicated that a provisional date for surgery was offered to C when this was not the case. Therefore, we upheld this part of C's complaint. However, we made no recommendations based on appropriate action already taken by the board.

Summary

C complained that the board failed to reasonably investigate and/or diagnose the cause of their symptoms of significant weight loss, intense abdominal pain, vomiting, altered bowel habit and nausea. C also complained that they were discharged from the board’s gastroenterology service (specialists in the diagnosis and treatment of disorders of the stomach and intestines) despite these ongoing symptoms. C said that they were left with no option but to obtain private care and treatment in England where they were diagnosed as suffering from mesenteric ischaemia (restricted blood flow to the intestines). C underwent surgery to correct this privately. While this resulted in significant improvements in C’s health, C complained that this course of action should not have been necessary and that there were cost implications.

In their complaints response, the board acknowledged and apologised for issues with delays in providing investigations, and failings with respect to communication. However, they considered the clinical decisions made in relation to the investigation and management of C’s case were appropriate.

We took independent advice from a consultant gastroenterologist and a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the board should have considered a diagnosis of mesenteric ischaemia as a strong possibility based on C’s presenting symptoms. Furthermore, when a CT scan was undertaken there was a failure to report the narrowing of the blood vessels supplying the gut. We found that the decision to discharge C from the gastroenterology service was unreasonable given their ongoing persistent symptoms and, of particular concern, their ongoing weight loss. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Calculate and reimburse C in relation to their private treatment (including the cost of travel to and from London for C after their discharge from the gastroenterology service) on production of appropriate receipts. The calculation should be based on what the treatment / surgery would have cost the NHS (rather than the full cost of the treatment) and what proportion of that C had to pay. The payment should be made by the date indicated; if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from the initial date to the date of payment.

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

• Care should be taken when discharging patients with ongoing and persistent symptoms and, in particular, who have ongoing weight loss when there is no clear explanation or diagnosis established.
• Where a patient presents with post-prandial abdominal pain and weight loss with no apparent cause despite extensive investigation there should be a high index of suspicion of mesenteric ischaemia as a strong possibility being the diagnosis, there should be interdisciplinary working between a multi-disciplinary team (the investigating team and radiology) so as to reduce the risk of missing mesenteric ischaemia as a diagnosis and there should be a specific review for evidence of any mesenteric blood vessel atherome on CT scans carried out.

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 the board provided to their elderly parent (A). A was an active and independent adult who tripped in the community and was admitted to hospital. In hospital, A developed a grade 4 (most severe) sacral (lower back) pressure sore. The board treated A’s pressure sore using Negative Pressure Wound Therapy (NPWT). A deteriorated while in hospital and died approximately twenty weeks after they were admitted.

C raised concerns about the medical and nursing care that the board provided to A. In particular, C was concerned about how the board handled A’s deterioration in hospital, that there were missed opportunities to discharge A from hospital and A’s end of life care.

The board said that A’s mobility was limited due to pain after admission and that there were no missed opportunities to discharge A. The board apologised for delays in obtaining pressure-relieving equipment for A and that discussions with A regarding the commencement of NPWT were not fully recorded. The board shared an improvement plan regarding the care of pressure sores.

We took independent advice from a consultant geriatrician (medicine of the elderly) and a registered nurse. We found that the medical care provided to A was reasonable. We did not uphold this point of C’s complaint. We found that A’s pressure sore was avoidable. We also found that the board failed to provide reasonable nursing care and treatment to A, failed to reasonably assess and treat A’s wounds, failed to reasonably use NPWT in A’s case and failed to complete a significant adverse event review and follow duty of candour procedures in response to A’s avoidable pressure sore. Therefore, we upheld this point of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failures in nursing care identified in this 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:

• Negative Pressure Wound Therapy should only be applied where appropriate and in accordance with manufacturers guidance, board policy and Health Improvement Scotland Guidance.
• Where failings occur, they should be acknowledged and appropriate action should be taken in line with relevant legislation, policies and procedures (particularly duty of candour and adverse event policy).
• Nursing staff should make sure patient’s physical needs are assessed and responded to.
• Patients should receive appropriate and timely wound care in line with the patient’s presentation. In particular:
• Assessments should be completed holistically and on a timely basis, including any required referrals, and should appropriately document the progression/deterioration of a wound;
• Treatment of the would should be appropriate using the correct products for the type of wound; and
• Patients should receive appropriate treatment for pressure damage in line with relevant guidance.

In relation to complaints handling, we recommended:

• Cases involving a death, the circumstances of which are the subject of concern to, or complaint by, the nearest relatives of the deceased about the medical treatment given to the deceased with a suggestion that the medical treatment may have contributed to the death of the patient should be referred to the Procurator Fiscal, in accordance with relevant guidance.

Summary

C complained on behalf of their client (B) about the care provided to B's late parent (A) during their admissions to hospital. A was admitted and discharged from the hospital. A was readmitted a few days later following a fall at their home. A suffered significant injury including spinal and sacral fractures. A remained in hospital for treatment but died a few weeks later. C's concerns related to the clinical and nursing care provided to A during their admissions, particularly in relation to the assessment of A’s cognitive function and capacity, their falls risk, and overall assessments carried out with respect to their condition and deterioration.

In response to the complaint, the board acknowledged that protocols on completion of falls and bed rail risk assessments were not followed and that in the day prior to A’s death, guidance on the timeliness and extent of observations which should have been carried out were not followed, and that the care fell below the expected standard. The board confirmed that appropriate documentation with respect to the assessment of A’s capacity was completed during their admission. C was dissatisfied with the board’s response.

We took independent advice from a consultant geriatrician and a registered nurse. With respect to A’s clinical care, we found that documentation used to assess A’s capacity was not completed to a reasonable standard and we upheld this complaint. We found that the clinical treatment of A during the two days immediately prior to their death was reasonable and we did not uphold this aspect of the complaint.

We considered the nursing care provided to A during the two admissions. We found that the care regarding falls management was unreasonable as appropriate documentation and assessments were not completed correctly or in a timely manner. We also found that there was a lack of evidence of the monitoring of A’s condition which would have made clinical assessment of A’s condition and deterioration more difficult. We found that the level of care and record keeping was unreasonable and upheld the complaint for each admission.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failures identified the decision. 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:

• Relevant staff are aware of National Standards with respect to falls prevention; the requirements to complete and update Falls Risks Assessments and that these are carried out accurately and in a timely manner. Assessments, evaluations, and intervention should be completed in line with guidance.
• Relevant staff are familiar with the adult with incapacity process and the importance of delirium screening tools with patients where delirium is observed and evident.