Health

Summary

C, an advocate, complained on behalf of their client (A) about the care and treatment they received from the board. A had attended the board for a chest x-ray following respiratory symptoms but the x-ray was reported as normal. A had a second chest x-ray a few months later which led to them being diagnosed with lung cancer. On review of the first chest x-ray it was found that this had been abnormal and was reported incorrectly.

The board's response to C's complaint recognised a mistake had been made by the reporting radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). The board advised that the chest x-ray had been outsourced to an external provider for reporting, and they had fed back this incident to the provider and radiologist, which had been investigated accordingly. The board apologised to A and confirmed the event met the criteria for duty of candour (a legal requirement on all health and social care providers in Scotland which seeks to ensure there is openness and transparency with the aggrieved party when something has gone wrong, and which seeks to learn from the incident). The board also advised the incident had been reviewed internally and concluded that the mistake had occurred due to human error, and that it was not considered to be indicative of a wider problem within the organisation.

We took independent advice from a lung cancer physician. We confirmed that A's diagnosis of lung cancer had been delayed by around three months due to the first chest x-ray being incorrectly reported. We found that it was reasonable for A to have expected the abnormality in their chest x-ray to be identified. However, once the mistake had been recognised, the steps taken by the board had been reasonable in alerting the external radiology company to the problem, and in terms of the board's own internal investigation into the matter. Therefore, we upheld this aspect of C's complaint but made no further recommendations due to the appropriate action taken by the board.

C also complained about the board's handling of their complaint. We found that the board had been transparent with A by alerting them to the mistake and that they had reasonably advised A of the incident meeting the criteria for duty of candour. However, we found that the board had failed to explain to A what this meant in terms of their obligations to them as the aggrieved party. It was our view that the board had not reasonably fulfilled their obligations in keeping with the duty of candour guidance. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should ensure they have met their obligations to A in respect of duty of candour. The board should offer to send A a copy of their report on the incident.

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

• Where duty of candour applies, the board should ensure they take all of the necessary steps in keeping with the guidance, and inform the aggrieved party of the organisation's obligations to them in keeping with the legislation, irrespective of whether a complaint has been made or not.

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 their late spouse (A) with reasonable care and treatment during three attendances at A&E and an admission to hospital.

The board said that A complained of pain in their right forearm causing them sleep disturbance. However, there was no indication that imaging scans were required as an emergency. A was already under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) which was appropriate for the muscle injury A had. Therefore, the assessments, plan, and discharge of A at the first two attendances in the emergency department were appropriate on the basis of what was known at the time. During the third attendance at the emergency department, the board said that investigations indicated that A had a raised marker for infection and inflammation which could have been an indication of underlying condition or malignancy. At this point it was identified that an MRI scan should be carried out, but there was no indication that this was required as an emergency. A was admitted to hospital for further investigations.

We took independent advice from a consultant in emergency medicine. We found that appropriate and timely emergency care was provided to A on each of their attendances at A&E. We also noted that a clinical significant event review was carried out. The issues were fully explored and the board had appropriately reviewed and reflected on learning. We considered that A received reasonable care and treatment at A&E and as an inpatient. Therefore, we did not uphold this part of C's complaint.

C also complained about the board's handling of their complaint. C said that the board did not contact them during their complaint investigation. They also highlighted that the board did not address all their concerns. We found that the board failed to address and respond to a significant part of the complaint raised by C until prompted to do so by this office. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to handle their complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• The board's complaints handling system and their investigation should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement. Complaints should be properly assessed in line with the Model Complaints Handling Procedure and all points of complaint should be identified and agreed before the complaint investigation begins.

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, an MSP, complained on behalf of their constituent (B) about the care and treatment of their adult child (A). A had awoken with a cut and bruised face and no memory of how the injuries had been sustained. A attended a minor injuries unit before being sent by taxi to A&E for further assessment. A was assessed and discharged without further treatment or follow-up. A few months later, A died suddenly.

B believed that A had suffered a seizure on both occasions and that A's assessment had been inadequate. B felt staff had failed to consider whether A had suffered a seizure nor had they considered prescribing medication which could have prevented further seizures. B was also unhappy with the way their complaint was handled.

We took independent advice from a consultant in emergency medicine. We found that the examination of A was thorough. However, given the uncertainty over the cause of A's injuries and the symptoms they described, further investigation should have been carried out. We did not find that A's death could have been predicted, or that there was any definitive evidence that A had suffered a seizure. However, given that further investigations were justified and were not carried out, we found that the standard of care provided to A was unreasonable and that the cause of A's injuries was not adequately investigated or followed up. Therefore, we upheld these parts of C's complaint.

In relation to complaint handling, we found the board's investigation to be reasonable. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B 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/information-leaflets.

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

• The board should share this decision with the departments involved for discussion at a team review with a view to identifying any points of learning and improvement.
• The emergency department should review their practices regarding the assessment of causes of head/facial injury and subsequent investigation of underlying conditions.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about how the practice had managed their lithium prescription (a medication used to treat mood disorders).

We took independent advice from a GP. We found that the practice acted reasonably in requesting that C arrange blood tests every three months to monitor their medication levels. We were also satisfied that the practice had provided reasonable advice about how to ensure C did not run out of medication.

We did not uphold C's complaint.

Summary

C complained about the care and treatment their adult child (A) received from the board. A had a complex medical history including a diagnosis of Complex Regional Pain Syndrome (CRPS, a rare condition where persistent and severe pain occurs following an injury). A attended A&E complaining of an elevated heart rate and fatigue. A working diagnosis of sinus tachycardia (a faster than usual heart rhythm) secondary to medication was made. A was discharged home with no further treatment. A couple of months later, A was admitted to A&E following a collapse, racing heart and swelling of their hands and feet. A was admitted to hospital where their condition deteriorated overnight. A's condition continued to deteriorate and they were transferred to the Medical High Dependency Unit (HDU) and the Intensive Care Unit (ICU). Ultimately, it was decided that A should be transferred to a hospital in another health board area where cardiology and advanced cardiac (heart) support would be available. A's condition did not improve and they died a few days later.

C raised a number of complaints with the board regarding the care and treatment A received. The board investigated C's concerns and undertook a Significant Adverse Event Review (SAER). However, C remained dissatisfied with some aspects of A's care.

We took independent advice from an appropriately qualified adviser. We found that when A initially presented at A&E, the clinical staff were aware of their history of CRPS and existing medications, that a full examination was carried out along with blood tests which were normal and that there was no obvious reason to admit A to hospital at that time. We found that the treatment A received during this admission was reasonable and appropriate and that onward referral was unlikely to have changed the outcome for A.

In relation to their second attendance, we noted that A was acutely unwell. We found that appropriate investigations were carried out in a timely manner and that, as A's condition deteriorated, their care was appropriately escalated through the HDU and ICU to transfer to another hospital where specialist equipment was available. We found that where the board had identified areas for improvement in their review of matters, the action they had taken was appropriate. We considered that the board provided A with appropriate treatment and investigations in response to their presenting symptoms and that they escalated A's care appropriately in recognition of the seriousness of their deteriorating condition.

We did not uphold C's complaints.

Summary

C, a support and advocacy worker, complained on behalf of their client (A) who was unhappy with the care and treatment they received during the birth of their child (B) and whilst they were a patient on the postpartum ward.

A's labour progressed very quickly, B's heart rate dropped, and decisions were made to deviate from the birthing plan as a result. A was unhappy with decisions that were made, the care received from midwives, and the lack of communication with them about what was happening. A also had concerns about the postpartum care they received, as they required a blood transfusion and felt their concerns were ignored by staff.

The board considered appropriate guidelines were followed and appropriate action and decisions were made in the circumstances. There was a need to deliver B urgently as there was evidence of distress. In relation to the care A received after the birth of B, the board said they did not consider there were any delays in the care provided to A, or the monitoring of their condition. They did identify an issue with documentation and highlighted that there should always be a handwritten contemporaneous record. This was addressed with staff members involved.

We took independent advice from two clinical advisers: a consultant obstetrician (a specialist in pregnancy and childbirth) and a registered midwife. We found that the care and treatment provided to A during labour was reasonable in the circumstances. We also considered the care and treatment provided by midwives on the postnatal ward was reasonable. We noted that there was a debrief in this case however, given the events of the birth, further debriefing at a senior level may have been helpful. We provided the board with feedback on this point.

We found that the care and treatment provided to A during the birth of their child and postnatally was reasonable and required in the circumstances in which B's health was at significant risk. Therefore, we did not uphold C's complaints.

Summary

C complained on behalf of their spouse (A) about the care provided by the practice. A developed a wound in their left leg and received several courses of antibiotics and wound treatment but the wound deteriorated. A was referred to a vascular specialist several weeks after they first attended the practice. A was later admitted to hospital and died.

We took independent advice from a practice nurse adviser. We found that there were particular concerns about the lack of robust record keeping. The required wound assessment was not carried out or repeated at least every seven days as required. There was no record of the rationale behind the dressings used. There was no record of leg ulcer assessment being carried out and no documentation to support why this was the case until the referral. We found that the use of inadine (a type of surgical dressing) was inappropriate and that the choices for other wound dressings chosen were not detailed. We also found that the ongoing referral was not made in a timely manner.

Therefore, we upheld the 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/information-leaflets.

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

• Patients requiring wound care should be managed in accordance with relevant guidance and timely referrals made. In particular, the wound should be appropriately assessed, documented and reviewed, appropriate wound swabs taken and appropriate dressings applied and checked.

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 practice failed to provide a face to face appointment to their late spouse (A) which contributed to a delay in onward referral, and ultimately delayed diagnosis of amyloidosis (a condition in which amyloid proteins build up on organs like heart, kidney and liver).

A had multiple telephone consultations with their GP over the year, presenting with varying symptoms. C complained that the frequency with which A presented should have prompted a face to face appointment. The practice response stated that it was not common practice to offer face to face assessment during the COVID-19 pandemic and that A had not requested a face to face appointment

We took independent medical advice from a GP adviser. We found that the practice’s failure to offer a face to face appointment was not reasonable. The frequency with which A presented and the symptoms that they described should have been identified as ‘red flags’ which triggered a face to face appointment and onward referral for specialist investigation, regardless of COVID-19 restrictions in place at the time. Therefore, we upheld this complaint.

We noted that the practice had already reflected extensively on their management of A, demonstrated learning and things that they would do differently in future, and offered apology to C. As such, we made no further recommendations.