Health

Summary

Mr C complained about the care that was provided to his wife (Mrs A) at the Princess Royal Maternity Hospital when she was admitted for the induction of labour. Mrs A gave birth to a healthy baby. However, Mr C was concerned that Mrs A did not receive appropriate care prior to being moved to the labour ward. He considered that she was not properly assessed and that as a result, she did not have access to appropriate pain relief.

We took independent midwifery advice. While we found that the initial care Mrs A received was reasonable, the advice we obtained was that following this, there was no evidence that assessments were carried out in line with the relevant guidance, particularly the board's own Latent Phase of Labour guideline. The adviser considered that there had been a failure to recognise that Mrs A had progressed into established labour and that she had missed out on the appropriate level of monitoring as a result. The advice we received also highlighted some issues around the way that Mrs A's pain was managed. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C and Mrs A for the failures identified by this investigation;
• draw the comments of the adviser regarding monitoring to the attention of relevant staff for reflection;
• raise awareness of the Latent Phase of Labour guidelines to ensure that they are applied appropriately; and
• draw the comments of the adviser on planning pain relief alongside the patient to the attention of the relevant staff.

Summary

Mrs C complained to us about the care and treatment her son (Mr A) received at Queen Elizabeth University Hospital before his death.

Mrs C said that the hospital had not been equipped to meet Mr A's needs. We took independent advice from a nursing adviser. We found that there had been a delay in obtaining an appropriate specialist bed for Mr A. There were also problems in relation to Mr A's bed sheets and in obtaining an appropriate hoist for him. We upheld this complaint. However, the board had apologised to Mrs C for these failings and we were satisfied that they had taken reasonable steps to try to prevent these problems from recurring.

Mrs C also complained about the nursing care provided to Mr A. We found that there had been problems with the meals provided to Mr A and with the buzzer being out of his reach. Again, we upheld Mrs C's complaint but we were satisfied that the board had apologised to Mrs C for these failings and had taken steps to prevent them recurring.

Mrs C complained that there had been no explanation as to why Mr A had not been offered dialysis. She said that dialysis had been mentioned to Mr A over several days as a possible procedure, but that this was then postponed. We took independent medical advice on this aspect of Mrs C's complaint. We found that the decision that Mr A did not require dialysis had been reasonable, but that the communication of this to him and his family had been inadequate. Mrs C complained that there had not been a reasonable standard of communication with family members. In regard to this, the adviser was critical of the record-keeping. We upheld these aspects of Mrs C's complaints.

Finally, Mrs C complained that reasonable arrangements were not in place for the storage and security of personal belongings. We upheld this complaint, as we found that there had been some confusion about where Mr A's belongings were being stored in the hospital. In addition, there was no evidence that Mrs C had been informed of the outcome of an investigation into Mr A's missing watch.

Recommendations

We recommended that the board:

• provide us with evidence that steps have been taken to ensure that medical records are maintained appropriately;
• issue a written apology to Mrs C for the failure to communicate adequately with Mr A and his family;
• ensure that there are adequate systems in place in the hospital for the safe storage of patients' belongings; and
• ensure that Mrs C is informed of the outcome of the investigation into Mr A's missing watch.

Summary

Miss C complained about her labour and delivery at the Princess Royal Maternity Hospital. She said that the labour had been very difficult and that she had not been provided with sufficient pain relief. She also said that she felt the communication had not been reasonable, as she did not recall being offered general anaesthetic and she was unaware that she was going to have a forceps delivery.

During our investigation, we took independent advice from two advisers, an obstetrics adviser and an anaesthetics adviser. We found that the pain relief given to Miss C during her labour and delivery had not followed hospital guidelines, and that this possibly resulted in her having sub-standard pain relief. We found this to be unreasonable care and treatment.

We also found that whilst the record of communication was reasonable, the board had previously acknowledged that the communication was not effective and apologised for this. We upheld Miss C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings in care and treatment identified in this investigation;
• feed back the findings of this investigation to relevant staff, highlighting the importance of following guidelines;
• feed back the findings of this investigation to relevant staff, highlighting the importance of effective communication during labour and delivery.

Summary

Mrs C complained that when she phoned the medical practice for an appointment, she was given neither an appointment nor a phone consultation.

We looked at the practice's records and took independent advice from a GP adviser. As there was no audio recording of the phone calls, we could not determine what was said. There was no evidence that Mrs C was not taken seriously when she was unwell, and we found that she saw a GP the day after she phoned the practice. We did not find that practice staff failed to respond to Mrs C's request for a medical consultation in a reasonable manner and therefore we did not uphold Mrs C's complaint.

Summary

Mr C complained about the treatment he received from his GP practice after a fall in which he sustained a head and neck injury. He thought the practice should have referred him to A&E.

We found the treatment Mr C received was reasonable. He attended the practice without an appointment and was seen by a triage nurse who assessed his injury. He was advised to take pain relief. Mr C later called the out-of-hours service and was given a pain-relieving injection and on-going pain relief. When the medication ran out he went back to the practice, was assessed, and was given more medication.

Mr C returned to the practice and told them he wanted to go to A&E. He attended A&E the same day and had an x-ray, which was clear. He was given advice about lying flat and exercise.

We found the treatment the practice provided was reasonable in the circumstances, given Mr C's presenting symptoms. Mr C's injury was assessed in the normal way by a triage nurse. No serious injury was evident. Mr C was, appropriately, advised to seek further advice should his condition deteriorate. When Mr C was assessed in A&E, no significant injury was found. We therefore did not uphold Mr C's complaint.

Summary

Mr C complained about a nurse in the substance misuse clinic within the prison. Specifically, that when he self-referred, the nurse did not provide him with adequate advice, care and treatment for his reported addiction and self-harm issues. Mr C had particular concerns that he had explained to the nurse that he did not wish to be prescribed methadone (a drug used medically as a heroin substitute) as he had had problems with taking it in the past, and that instead he needed a prescription for a different medication used to treat addiction. He said that the nurse had not passed this information to his psychiatrist. Mr C also said that the nurse had not passed on information about his self-harming to the psychiatrist.

During our investigation, we took independent advice from a mental health nurse. We found that there was no evidence that the information Mr C said that the nurse had failed to pass on to the psychiatrist had ever been disclosed to the nurse. However, we found that no proper assessment and care plan had been completed by the nurse when Mr C attended the substance misuse clinic and considered this unreasonable. We also considered that the nurse's record-keeping was insufficient. In view of these failings, we upheld this aspect Mr C's complaint.

Mr C also complained that the board's handling of his complaint had been unreasonable. We identified that, whilst the board's initial complaint response had been sufficient, they did not investigate Mr C's subsequent complaints. We found that this was unreasonable and not in accordance with national complaints handling guidance. Therefore we also upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in relation to record-keeping and lack of evidence regarding proper assessment;
• review their process when a prisoner self-refers to the addictions team to ensure adequate assessment and care planning is carried out where appropriate;
• draw the findings to the attention of the nurse;
• apologise to Mr C for not responding to his additional complaints; and
• draw these findings to the staff involved in the local investigation of Mr C's complaint in order to highlight the importance of investigating and responding to all issues complained about in accordance with national complaints handling guidance.

Summary

Ms C had an operation on a toe of her left foot at Forth Valley Royal Hospital. Ms C's foot was put in a plaster cast and when she returned the following month for it to be changed, a member of staff tried to realign the toe contrary to the instructions in Ms C's medical records. We did not take the complaint further because Ms C decided to pursue an alternative way to remedy her complaint.

Summary

Mr C complained about the care and treatment provided to him by the prison health centre. He said that he was not being provided with appropriate pain relief for a number of complex medical problems and his complaints about these issues had not been properly investigated. Mr C said that the GP he saw in prison changed his prescription from that provided to him in the community. Mr C said his mobility and balance had been severely affected.

We took independent medical advice on Mr C's prescriptions. The adviser said that Mr C was properly reviewed and the changes to his prescriptions were in line with national guidance on the management of chronic pain and the prescribing of pain relief within a prison setting. Mr C had been reviewed and his medication discussed with him. The adviser did not find evidence that Mr C had been significantly affected in the ways he described by the changes to his medication.

Our investigation found that Mr C's complaints were responded to promptly and addressed the issues he raised. There was no evidence that complaint procedures were not properly followed.

Summary

Mr C complained about the way the board dealt with his review application for NHS continuing healthcare for his late mother (Mrs A), who was resident in a care home. He also complained about how the board handled his subsequent complaint.

Mr C's application was rejected by the board on the basis that Mrs A did not meet the criteria as set out in the Scottish Government Guidance Circular CEL 6 (2008), the relevant guidance at the time. By the time the board had referred the application to two clinicians for assessment, Mrs A had died. Their assessments were paper based.

We took independent advice from a consultant in medicine for the elderly. They said it could reasonably be interpreted from the wording of the CEL 6 (2008) guidance that a paper based assessment constituted a clinical opinion. The adviser agreed with the findings of the clinicians that Mrs A had not satisfied the criteria for NHS continuing healthcare. The adviser also said that Mrs A's deteriorating health, her admissions to hospital, and the fact that her care home was unable to meet her care needs did not mean that she met the criteria. We accepted that advice.

However, we found that that there were unacceptable and lengthy delays by the board in reaching a decision on Mr C's application, that their review process was slow and disorganised, and that they had not appeared to have taken Mr C's review application and concerns seriously. We also found that there was a failure to communicate effectively with Mr C during the review process. For this reason, we upheld the complaint.

The board had accepted there had been unacceptable delay in responding to Mr C's complaint, for which they had apologised. However, we considered the board's actions were then aggravated by their failure to obtain a suitable person to carry out an independent review of their decision, having said to Mr C that they would do so, which resulted in yet further unreasonable delay.

Recommendations

We recommended that the board:

• issue Mr C with a formal apology for the failings in relation to delay and their communication with him during the review process;
• issue Mr C with a formal apology for their failure to carry out an appropriate independent review and to handle his complaint in a timely manner;
• provide evidence of the review carried out of their patient experience processes in relation to complaints handling; and
• reflect on the comments of the adviser in relation to the need to identify an independent reviewer.

Summary

Mrs C complained that GPs at the medical practice failed to diagnose cholesteatoma (an uncommon abnormal collection of skin cells inside the ear). Mrs C felt the practice had failed to do this over a number of years.

We took independent advice from a GP adviser. We found there was no evidence that Mrs C's consultations with GPs several years ago were linked to her recent consultations in terms of cholesteatoma diagnosis. We also found that the practice's management of Mrs C's case was reasonable during all consultations, and when they noted that her symptoms were not settling they arranged an urgent review with a hospital specialist. There was no evidence of a delay in the referral and we concluded that the care provided to Mrs C was to a reasonable standard given the circumstances at the time. Therefore we did not uphold Mrs C's complaint.