Health

Summary

Ms C complained about the care and treatment provided to her father (Mr A) following two admissions to Glasgow Royal infirmary. Mr A, who resided in a nursing home, had vascular dementia and visual impairment. Ms C also complained about the time taken by the board to investigate and respond to her complaint.

During our investigation, we obtained independent medical and nursing advice.

Mr A was admitted to hospital after sustaining a fractured hip in a fall. He had surgery the following day and was discharged back to his nursing home several days later. The board accepted there were failings in Mr A's nursing care which had resulted in a failure to identify the infection(s) which Mr A was developing and had led to his premature discharge. The advice we received was that Mr A's surgical treatment was reasonable and he was not able to undertake rehabilitation due to his mental state.

However, we identified a number of failings in Mr A's medical care, nursing care, and in communication with his family. These included failure by staff to ensure they had the relevant information to make an informed decision about Mr A's discharge, as well as failures in record-keeping and nutritional care. We also found that during the assessment, planning and delivery of Mr A's care, there was a failure to fully comply with the Adults With Incapacity Act and the Standards of Care for Dementia in Scotland. We therefore upheld this aspect of Ms C's complaint. The board had apologised for the failings in communication during this admission and said they had introduced a new relatives communication sheet, in relation to which the nursing adviser said there were advantages and disadvantages.

Mr A was readmitted to hospital the following day. While Ms C considered the quality of care Mr A received was generally satisfactory and often good, she was critical of certain aspects of his care and about his subsequent transfer to Lightburn Hospital.

We did not find evidence that the medical treatment Mr A received during this admission was of an unreasonable standard and so did not uphold this aspect of Ms C's complaint. Although we considered that aspects of Mr A's nursing care were carried out to a reasonable standard, we found staff failed to ensure that it was appropriately person-centred. We found failures in complying with the Adults with Incapacity Act and the Standards of Care for Dementia in Scotland and also in the communication with Mr A's family. We therefore upheld Ms C's complaint in this regard.

The board also accepted that the time taken to investigate and respond to Ms C's complaint was unreasonable, and so we upheld this aspect of Ms C's complaint. We considered that the board had provided Ms C with an appropriate apology for this and taken steps to address what had occurred.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings in Mr A's care and treatment;
• feed back the comments of the advisers and the findings of this complaint to the staff involved for reflection and learning;
• report to us on the steps taken to address the failings identified by this investigation in relation to complying with the Standards of Care for Dementia in Scotland, both in relation to patient care and treatment and in communication with relatives/carers;
• feed back to relevant staff the comments of the nursing adviser concerning the use of a relatives communication sheet;
• report to us on the steps taken to address the failings identified by this investigation in relation to complying with the Adults With Incapacity Act (2000), with particular regard to capacity to consent to treatment;
• carry out an audit of early readmissions following discharge from the ward concerned so as to identify any further avoidable failures; and
• provide evidence that the issues identified in relation to complaints handling have been fed back to their complaints lead and shared with complaints staff.

Summary

Mr C, who works for an advocacy service, complained on behalf of Mrs B. Mrs B's husband, Mr A, was a patient at the medical practice. He initially attended with left-sided chest pain that he reported had been present on and off for months. An x-ray was arranged but this was normal. He went on to report neck pain and urinary symptoms. Mr A was later diagnosed with lung cancer which had spread to the vertebrae in his neck. His urinary symptoms were found to be unconnected to this diagnosis.

Mrs B was concerned that the practice had not provided an appropriate level of care to Mr A. She said that his condition could have been diagnosed earlier and made particular reference to a scan which she felt should have been arranged.

After taking independent advice from a GP, we found that Mr A had not been provided with appropriate medical treatment. While we found that a scan could not have been arranged for Mr A by the practice, he should have been referred to the local NHS board's respiratory team after he reported chest pain being present on and off for months, even though the x-ray was normal. The adviser highlighted that this action was supported by the Scottish Referral Guidelines for Suspected Cancer. We found that the other aspects of Mr A's care were reasonable.

Recommendations

We recommended that the practice:

• apologise to Mrs B for the lack of respiratory referral;
• ensure that all relevant staff are familiar with the Scottish Referral Guidelines for Suspected Cancer; and
• ensure this case is discussed at the next appraisal of the doctor who saw Mr A at the relevant consultation.

Summary

Ms C complained that a GP failed to carry out a reasonable assessment when she attended the board's out-of-hours service. The GP carried out an assessment and discharged her, stating that she probably had a non-specific viral illness. Ms C was admitted to hospital approximately 24 hours later and was subsequently diagnosed with a different condition.

We took independent advice from a medical adviser. We found that the assessment carried out by the GP had been appropriate for the symptoms described by Ms C. We also found that it had been reasonable for the GP to consider that Ms C had a non-specific viral illness. Although Ms C said that she had not been asked about her medical history, the GP said that they had asked Ms C about this but had not recorded her response. We found that if the response was negative and not relevant, it would have been reasonable for the GP not to have recorded it. It had also been reasonable not to refer Ms C to hospital and there was no evidence that the delay in diagnosis of Ms C's condition was a result of unreasonable practice by the GP. We did not identify failings by the out-of-hours service and we considered that the care provided by the GP was of a reasonable standard. We therefore did not uphold Ms C's complaint.

Summary

Mr C complained about the board's management of healthcare appointments for his child, who suffers from allergies and diabetes. In particular, Mr C was concerned that the board cancelled an out-of-area appointment for a joint allergy and gastroenterology clinic, on the basis that equivalent local services were available. However, the board did not provide a gastroenterology appointment until about six months later.

The board acknowledged that some of the appointments were outwith the

12-week waiting time target for new out-patient appointments, including a clinical genetics appointment (delayed due to a missed referral), an allergy appointment (provided out-of-area as the child's GP had requested this), and a gastroenterology appointment (which took longer to arrange as it was a joint appointment with gastroenterology and the head of the local allergy service, and was further delayed by a consultant gastroenterologist leaving the board).

After taking independent medical advice, we found that it was reasonable for the board to take the position that an out-of-area referral for allergy and gastroenterology was not required, as there were equivalent services available within Scotland. We found that the delay in the clinical genetics appointment was unreasonable, and while the board had already acknowledged this and addressed the problem, we considered they should also apologise to Mr C. However, we were not critical of the timeframes for the gastroenterology and allergy appointments. While we acknowledged these were outwith the 12-week target, we noted that the target is for 95 percent of cases to meet these timeframes, and in this case we considered the timeframes were reasonable in view of the specific circumstances.

Mr C also said the board gave inaccurate information in their complaint response about what kind of support it was agreed at a clinical meeting the health visitor should provide. We found there were conflicting accounts about exactly what was said at the meeting, but the board's description of this was consistent with the health visitor's role and in keeping with the support actually provided, and we therefore did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to meet the waiting time target for his child's clinical genetics appointment.

Summary

Mrs C complained about the care and treatment she received in relation to her labour at Forth Valley Royal Hospital. Mrs C had a long and difficult labour, and her baby was born with the use of forceps. An episiotomy (a surgical cut of the area between the vagina and anus) was performed and Mrs C suffered a fourth degree tear (a severe tear in the vaginal tissue), which was repaired that day. A few months later, Mrs C was diagnosed with a recto-vaginal fistula (an abnormal connection between the rectum and the vagina) and disrupted anal sphincter (muscle that surrounds the anus), for which she underwent several unsuccessful operations. Nine months later, Mrs C was referred to a specialist at Glasgow Royal Infirmary, who decided that a colostomy bag (a pouch placed over one end of an intestine) was required to allow healing before further procedures to repair the fistula.

We took independent obstetrics and gynaecology advice and surgical advice. In relation to Mrs C's complaint about the standard of obstetric care and treatment provided, we found that the fourth degree tear was properly identified and repaired within a reasonable time, but that the board failed unreasonably to arrange an obstetric review before discharge from Mrs C's first admission to hospital (which also had an adverse effect on communication) and that there was confusion about postnatal appointments and delays.

Regarding the standard of surgical care and treatment provided, while we were satisfied that medical staff managed the fistula in a reasonable way, we found that they failed unreasonably to obtain consent for one of Mrs C's operations. Finally, we were critical that the board failed to respond formally to the surgical aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• ensure that consent is obtained and documented in line with the relevant guidelines;
• raise the failings this investigation identified with the relevant staff;
• inform us of the actions taken to address the complaints handling failings this investigation identified; and
• apologise for the failings this investigation identified.

Summary

Mr C complained that there was an unreasonable delay in diagnosing his skull fracture, that there was a further delay in his being informed of the diagnosis and that there was an unreasonable delay in his being referred to an appropriate specialist.

Mr C declined to provide consent for his medical records to be accessed and his case was therefore discontinued.

Summary

Mrs C, an advocacy and advice worker, complained on behalf of Mr and Mrs A regarding a child protection referral which was raised by a children's physiotherapist in relation to their daughter (Miss B). The physiotherapist raised concerns in the referral that Mr and Mrs A were fabricating injury and illness in Miss B and were refusing to engage with physiotherapy. This was not taken forward by social services as Miss B was subsequently diagnosed with a genetic condition.

We took independent clinical advice from a senior nurse director, who noted that those raising child protection concerns have a duty to be as sure of their grounds for suspicion as is practicable. It was noted that Miss B had indeed sustained an injury but that there appeared to have been a misunderstanding as to the nature of this. It was also noted that while a formal diagnosis of Miss B's illness had not yet been received, there was evidence that she was undergoing genetic testing at the time. The adviser considered that, in both instances, the physiotherapist could reasonably have attempted to clarify matters by speaking to Mr and Mrs A and medical staff.

There were conflicting accounts as to whether Mr and Mrs A were refusing to engage with all physiotherapy, or just the physiotherapist in question. However, it was clear that relations between Mr and Mrs A and the physiotherapist were already difficult and the adviser considered that the board might reasonably have taken earlier steps to offer Miss B the opportunity to see a different therapist. The adviser also noted that the physiotherapist did not inform Mr and Mrs A about the referral, despite there being no record of any decision having been taken that this would not have been in Miss B's best interests. We therefore concluded that the physiotherapist did not act in line with the board's child protection procedures. We therefore upheld this complaint.

Mrs C also complained about a delay in providing Mr and Mrs A with copies of their children's medical records when they requested access to these. We noted that there had been a lengthy delay which the board had acknowledged and apologised for. However, while the board had undertaken to review their process to avoid a similar future delay, we noted that no action appeared to have been taken in this regard until after we sent an enquiry to them. We were critical that the board had not progressed action they had promised to take in response to a complaint. We therefore upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs A for the failings this investigation has identified;
• inform us of the steps they have taken to ensure that staff adhere to their child protection procedures, particularly in relation to the involvement of parents/carers;
• take steps to ensure that staff are aware of the importance of taking any action reasonably available to them to clarify the validity of any child protection concerns they have;
• apologise to Mr and Mrs A for the delay in taking forward the promised action to look at their process for responding to requests for access to medical records; and
• inform Mr and Mrs A of the outcome of their policy review and, particularly, any process changes that have been made to prevent a recurrence of the problems they experienced obtaining access to their children's medical records.

Summary

Mr C complained to us about the care and treatment provided to his wife (Mrs A) by the medical practice. He complained that the practice failed to provide Mrs A with appropriate treatment when she presented with lower back pain, and that they failed to appropriately examine her at her consultations. Mr C felt that the back pain was a symptom of the cancer Mrs A was later found to have and which led to her death. Mr C further complained that Mrs A had been provided with inappropriate inhalers for a number of years.

In investigating this complaint, we took independent advice from a GP adviser. We found that whilst Mrs A had presented with lower back pain for a number of months, there were no symptoms at that time which would have alerted her GP to the possibility of her having cancer. When Mrs A reported new symptoms, these were found to be due to abdominal cancer. We found that the management of Mrs A's original symptoms, which was primarily with painkillers, was reasonable. We also found that Mrs A was reasonably examined by GPs at the practice based on her reported symptoms. We therefore did not uphold this aspect of Mr C's complaint.

With regard to the inhalers Mrs A had been prescribed, we found that as Mrs A had never been formally diagnosed with an illness that would require regular use of inhalers, it was not reasonable that she had been prescribed these on a long-term basis. Whilst we did not find there to have been adverse effects as a result of this failing, we upheld Mr C's complaint. The practice acknowledged that the monitoring of Mrs A's inhaler use could have been better and told us they had undertaken a review of their system regarding this.

Recommendations

We recommended that the practice:

• apologise for the failings identified in this investigation;
• draw the comments of the adviser regarding prescription of inhalers to the attention of the relevant staff; and
• update this office on the action taken following the practice's review of their systems for recalling patients who are on regular inhalers.

Summary

Mrs C complained about several aspects of the nursing care that had been provided to her mother (Mrs A) at Western Isles Hospital and about the nursing staff's communication with the family.

We took independent nursing advice. We found that while some aspects of nursing care were reasonable, the board had already carried out their own review which had identified a number of failings with care and communication and apologised for these. We found that there had been poor practice in relation to the use of a hoist when lifting Mrs A. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• provide a further apology, for the inappropriate use of the hoist by staff on the ward; and
• provide Mrs C with a copy of the completed case review showing the action taken to address the concerns raised.

Summary

Mrs C, who had a history of osteoporosis, fell whilst in Ninewells Hospital. She complained that despite being in a great deal of pain, her back was not x-rayed.

On her discharge, Mrs C complained to the board but they advised that as she had been checked after her fall by increasingly senior doctors who found no bony tenderness, an x-ray had not been required and she had been discharged with appropriate advice. Mrs C learned from a subsequent x-ray that she had suffered a fracture to her spine.

We took independent advice from a consultant in acute medicine. We found that Mrs C had been appropriately assessed and examined after her fall. She had no bony tenderness which would have indicated that an x-ray was required. We also found that even if Mrs C had been x-rayed at the time and a fracture had been found, she would have been given no additional or different medication and her treatment would have remained the same. This was because she was already taking medication for a previous fracture.

We did not uphold the complaint.