Health

Summary

C, an advocacy worker, complained on behalf of their client (A) about the care and treatment provided by the board during a four day admission to hospital. A, a type 1 diabetic (a condition where blood glucose levels are too high because the body cannot make the hormone insulin), was admitted for lower abdominal pain. A received an ultrasound scan on the following day which proved inconclusive. The next day A received a CT scan which showed free fluid, in keeping with a burst ovarian cyst. A was discharged the following day.

C complained that A was discharged, having received no treatment, in pain, and without follow-up referrals. C complained that as a type 1 diabetic, A’s diabetes and food intake had not been correctly managed. The board said that treatment, discharge, and diabetes management were appropriate. The board apologised for not offering meals after breakfast on the day of discharge.

We took independent advice from a gastrointestinal and general surgeon (specialist in the digestive system). We found that A’s nutritional intake had been appropriately restricted due to investigations which were necessary to rule out surgery. A's diabetes had been appropriately managed via an insulin infusion called a sliding scale. We found that no treatment or follow-up care would be indicated for a burst ovarian cyst as this would usually resolve itself. We found that prior to discharge, A’s pain had reduced such that they were able to manage it with paracetamol alone and that discharge was therefore appropriate. Therefore, we did not uphold this part of C's complaint.

C also complained about the quality of complaints handling. We found that although there was a delay in providing a complaint response, this was because a meeting was being organised and that C was appropriately informed of the delays. Post decision correspondence was also delayed. However, this did not breach the Model Complaints Handling Procedure, which does not specify timescales for post decision correspondence. As the board had already increased administrative staff, improved procedures and apologised, we did not uphold this part of C's complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the practice in the months prior to A’s death in hospital. C complained that the practice failed to look at A’s leg and foot pain and that A was only prescribed water tablets. C also said that no home visits were arranged for A, that they were informed that A had a hiatus hernia (when part of the stomach moves up into your chest), and that A’s family did not receive a telephone call back when promised.

We took independent advice from a GP. We found that there was no failure on the part of the practice to look at A’s leg and foot pain or that A was prescribed water tablets. We also considered that there was no need for home visits in the time specified and that A had been diagnosed with a hiatus hernia in hospital. Finally, we considered that the practice had provided a reasonable explanation in relation to not phoning the family back given that A’s family had called an ambulance for A by the time in question, so a telephone consultation was no longer required. Therefore, we did not uphold C's complaint. We did provide feedback to the practice that they may wish to remind staff of the importance of keeping clear documentation for every home visit.

Summary

C had a history of multiple facial trauma and had undergone various procedures over the last decade in relation to their nose and face. C then received further injury which caused damage to their nose.

C complained that the board refused to perform any further investigations or the reconstructive surgery they considered was required. This was despite numerous GP referrals to the ear, nose and throat (ENT) department. C stated that they continued to suffer ongoing pain and symptoms associated with their facial injuries. C complained that the board were acting on the basis of a psychological assessment from a number of years ago, which suggested investigation and treatment could be damaging to C. C strongly objected to the content of this assessment.

We took independent advice from an ENT surgeon. We found that it was reasonable for the board to take into consideration the psychiatric assessment that warned against unnecessary investigations and treatment unless indicated on objective grounds. However, we considered that given the passage of time since that document was produced, and because C had recently been assaulted potentially causing new injury, it was reasonable for C to be reassessed. Therefore, we upheld C's complaint.

We also noted failings in relation to complaint handling and made a recommendation to address this.

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:

• Where a significant period of time has elapsed since a patient was clinically assessed and there is evidence that the patient’s clinical situation has changed, the patient should be offered a clinical reassessment.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement. The board should comply with their complaint handling guidance when investigating and responding to 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.

When it was originally published on 22 March 2023, this case referred to a Medical Practice in the Ayrshire and Arran NHS Board area. This was incorrect, and should have read a Medical Practice in the Fife NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

C complained about the end of life care their late spouse (A) had received from the practice. A had Lewy body dementia (a progressive dementia that results from protein deposits in nerve cells of the brain which affects movement, thinking skills, mood, memory, and behaviour) and was cared for at home by C. When A’s condition deteriorated, C complained that the GP had not visited them at home to assess their decline. C also complained that there had been a delay in initiating their end of life care plan allowing access to appropriate pain relieving medication and to the community palliative care team for support.

In response, the practice said that although a GP had not visited A at home in their final weeks, a number of GPs had been in constant liaison with the district nursing team about their care and prescribing appropriate medications. They noted that their duty doctor had not been aware of, or could refer into, the palliative care team but following liaison with the district nursing team, this was progressed and A had received assistance thereafter.

We took independent advice from a GP. We found that the practice had not provided a reasonable standard of end of life care to A. We considered they should have carried out an earlier assessment of A’s palliative and end of life needs to inform better care planning, that there was an unreasonable delay in providing A with appropriate pain relieving medication, and noted that staff lacked awareness of the community palliative care team and the referral process. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of end of life care. 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 experiencing a reported deterioration in their condition should be appropriately assessed in accordance with relevant national guidelines.
• Patients receiving end of life care should have their response to pain relieving medication appropriately assessed and any required changes promptly administered.

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 reasonable care and treatment to their late parent (A). A was admitted and discharged from hospital on two separate occasions. A died shortly after their third admission to hospital.

We took independent advice from a consultant in geriatric medicine and general medicine (a specialist in care of the elderly).

We found that while some aspects of A’s care were reasonable, particularly in relation to cardiac (heart) care, given the complexity and combination of A’s conditions, age and frailty, A should not have been discharged the day after their first admission. A should have remained in hospital given that a deterioration in their condition was very likely to occur, and as they also required further detailed assessment of their mobility. It was determined that A’s combination of problems would have required inpatient care even for a previously healthy patient and the acute exacerbation of A’s conditions would have been profound and life threatening.

We also found that there was a lack of detailed assessment of A’s mobility difficulties prior to being discharged. We found that the board failed to take account of the evidence in A’s records that they had struggled with their mobility and had needed supervision and support. We noted that an assessment of A’s mobility had been part of the medical plan at the time of their first admission. Given the severity of A’s illness, age, and the difficulty with walking, there should have been a specific and detailed assessment of A’s mobility prior to their discharge. We also found that the board failed to provide a full response to C’s complaint.

Taking account of the evidence and the advice we received, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in discharging A from the hospital the day after their admission, for failing to carry out a full and detailed assessment of A’s mobility prior to their discharge and for the failure to provide C with a full and informed response in relation to their complaint. 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:

• In similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and in line with recognised guidelines.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate.

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 reasonable care and dental treatment to them over a period of several months. During clinical examinations, C raised concerns about experiencing pain from a particular tooth.

We took independent advice from a dentist. We found that while treatment provided by the dental practice was, in general, reasonable, there were some missed opportunities to further investigate the condition of the tooth in question. Further investigations would have been appropriate to help determine whether the tooth was the actual cause of the pain. We found that further information obtained at subsequent appointments would have helped confirm that C’s pain was the result of a localised infection. The board accepted that in retrospect, the pain was due to the tooth that was ultimately extracted. Given the missed opportunities to further investigate the condition of the tooth in question, develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the missed opportunities to further investigate the condition of the tooth in question, for the failure to develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort. 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:

• Dentists should act in line with the Scottish Dental Clinical Effectiveness Programme's Management of Acute Dental Problems.

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 refer them for an x-ray following a fall, which contributed to a delay in diagnosing fractured vertebrae.

C attended A&E following their injury and then attended the practice a few days later (first consultation). C then had a GP telephone appointment the next day due to ongoing pain (second consultation), and subsequently attended the practice again in person some weeks later (third consultation). C complained that their symptoms were not fully investigated and an obvious bend in their neck was overlooked.

We took independent medical advice from a GP. We found that the practice’s actions at the first and second consultations were reasonable in relying on the outcome of the recent A&E assessment, and that an onward referral for x-ray imaging was not indicated at that point. We found, however, that C’s ongoing pain should have been considered persistent by the time of the third consultation, and that their spinal tenderness should have been regarded as significant. We found that these symptoms should have been regarded as ‘red flag’ symptoms (possibly indicative of a more serious pathology), and should have triggered onward referral for imaging assessment.

Instead, C was referred for physiotherapy following the third consultation. C subsequently contacted the practice on a fourth occasion to request that this referral be expedited. A GP received this message and concluded that C did not meet the criteria for an urgent referral. The GP did so without taking a history and/or examining C. We found that it was unreasonable to make this decision without evidence. If an examination had been arranged following this fourth contact by C, it may have given rise to an x-ray referral.

We concluded that the practice unreasonably missed opportunities to refer C for an x-ray at the third consultation, as well as at the time of C’s subsequent contact regarding the physiotherapy referral. On balance, we upheld this complaint. We noted the practice had already reflected extensively on their management of C and identified things they would do differently in future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to refer them for further investigation following the third consultation, and for concluding that they did not meet urgent referral criteria without taking a history or examining C. 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 should be referred on for appropriate investigation when they present with red flag symptoms. The practice should ensure that they follow relevant guidelines and that they are aware of and alert to red flag symptoms.

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 end of life care that their partner (A) received at home from district nursing services during the final weeks of their life.

C complained that the nurses did not listen to their concerns about A’s deteriorating condition, that A’s condition was not adequately assessed and managed, and that they were not included in discussions about A’s care. C considered that there were missed opportunities to admit A for earlier hospice care.

We took independent advice from an advanced nursing practitioner. We found that the care provided to A was generally in line with recognised practice for end of life care, with review and prompt action around pain control and symptom management. However, we found that there were significant gaps in communication and clinical assessment which impacted on the care delivered to A.

While the nurses recorded C’s reported changes in A’s condition, this did not appear to have prompted any specific action or investigations. We found that there was a lack of clinical examination, and a failure to check and act upon C’s reports of excessive fluid in A’s legs. The board acknowledged that there was a failure to monitor A’s baseline observations when they began to deteriorate, and we found it concerning that this did not happen. The board also accepted that communication with A and C could have been better managed and they committed to raising this with staff. As A’s main carer, we noted that C’s views should have been central to care planning and to ensuring that the care being provided remained suitable as A’s condition changed. We found that there was an unreasonable failure to act upon C’s concerns and consider whether a need for hospice care was indicated. We therefore 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 receiving end of life care at home should be appropriately assessed and monitored in line with their symptoms and any deterioration acted on. Patients and their carers should be communicated with effectively and their views appropriately taken into account.

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 to the board about the treatment that they received from the board when they attended A&E on the advice of their GP. C had informed the GP that their back pain of three months had worsened over the week.

C reported concerns about the on-call doctor’s manner toward them. C also complained about the assessment and clinical decisions made, particularly that they were sent home despite experiencing a significant level of pain. C was later diagnosed with Cauda Equina Syndrome (CES, a collection of neurological symptoms caused by compression of the nerves at the end of the spinal cord) and required emergency surgery.

Summary

C complained that the board failed to provide appropriate care for their parent (A).

C said that the lack of care resulted in A falling from their bed, while the bedrails were in place. As a result, A fractured their hip. C said that staff had been made aware that A was confused a very disorientated at the time.

We asked the board to provide an explanation as to how A was able to fall from the bed if bedrails were in place. The information provided by the board showed that A had been found trying to get out of bed on two previous occasions. This led us to question what interventions were put in place to try and prevent a fall from happening and why this appears not to have been successful.

We took independent advice from a nursing adviser. We found that the lack of a proper assessment of A’s mental capacity and their previous attempts to climb out of bed contributed to the fall incident and that this was a significant oversight. Additionally, we found that the board failed to maintain accurate and appropriate records, particularly in relation to the 4AT (Rapid Clinical Test for Delirium Detection), on the two occasions that A was found trying to get out of bed, and the fall itself. We therefore 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:

• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant nursing and midwifery standards.
• Patients should be appropriately reassessed when there is a change in their behaviour and, if bedrails are in use, consideration given to carrying out a reassessment of their use.
• Patients over 65 should be assessed in line with the board’s admission procedures including a 4AT so that a full assessment of the patient risk is achieved.

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.