Health

Summary

Miss C complained that a psychiatrist failed to reach a reasonable diagnosis on the basis of her circumstances and medical history. In particular, Miss C raised concerns that the psychiatrist did not appropriately address her reported history of abuse in reaching the diagnosis. Miss C also questioned whether the psychiatrist considered other factors that would have impacted on her presentation at the psychiatric consultation. Miss C said a different diagnosis should have been reached and that the psychiatrist did not engage appropriately with her spiritual beliefs. Miss C questioned whether the diagnosis was based on an appropriate level of assessment.

The board said the psychiatrist was appropriately concerned that Miss C was suffering from psychiatric illness.

After receiving independent psychiatric advice, we did not uphold Miss C's complaint. We found the psychiatrist appropriately considered Miss C's history and other factors impacting on her presentation at the consultation. We found that the psychiatrist conducted an appropriate assessment and that the diagnosis reached was reasonable in the circumstances.

Summary

Miss C complained that a GP with whom she had been discussing rape and sexual assault unreasonably referred her to a psychiatrist. In particular, Miss C raised concerns that the medical practice had been dismissive of her history and circumstances. She also raised concerns that the practice referred her unreasonably on the basis of previous psychiatric history. She said that the referral should have been to another specialist.

The practice said that the GP referred her to the psychiatrist as it was clinically indicated to do so. They also said the referral was not based on Miss C's previous psychiatric history, but on the GP's concerns about Miss C. The practice also understood that Miss C was in contact with a rape counselling service.

After receiving independent medical advice, we did not uphold Miss C's complaint. We found the referral was reasonable based on the clinical signs recorded in the medical records, which may have been consistent with certain mental health conditions. We also found that the GP considered appropriately the reported history of abuse in making the referral.

Summary

Mrs C complained about a GP's consultation with her husband (Mr A). In particular she felt that that the GP had not taken into account that Mr A had cancer, had unreasonably missed the fact that Mr A had a deep venous thrombosis (DVT) and had inappropriately prescribed quinine. We took independent advice from a medical adviser and concluded that the GP had acted reasonably. In particular, they had taken account of Mr A's cancer, the DVT which Mr A had could not have been detected at the time and the prescription was appropriate.

Summary

Mr C complained on behalf of his constituent (Ms B) who had concerns about the treatment her mother (Mrs A) received at the New Victoria Hospital. Ms B had taken her mother to the hospital after suffering a head wound which would not stop bleeding. Staff at the hospital felt that Mrs A required treatment at the A&E department at the Queen Elizabeth University Hospital and requested an urgent ambulance. There was a 90 minute delay in the arrival of the ambulance and Ms B felt that staff should have stressed the urgency of the situation or provided additional treatment while waiting for the ambulance.

We obtained independent nursing advice which stated that the staff had appropriately assessed that Mrs A required transfer to the A&E department, kept her under observation during the wait for the ambulance and made a further attempt to establish when the ambulance would arrive. However, had the situation deteriorated then there was no indication of what action the staff would have taken and we have asked the board to provide Ms B with explanations which may have given her some reassurance. We did not uphold the complaint.

Summary

[When this report was first published on 19 October 2016, the Southern General Hospital was incorrectly named as the hospital being complained about. This should have said Victoria Infirmary.  This was due to an administrative error for which we apologise.]

Mrs C complained about the care and treatment her late mother (Mrs A) received at the Southern General Hospital. Mrs A died following an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). During the procedure biopsies (tissue samples) were taken, which later led to a bleed.

Following Mrs A's death, the Crown Office and Procurator Fiscal (COPFS) investigated and concluded that they would not refer the death to a Fatal Accident Inquiry.

Mrs C complained to the board at this point, saying she was advised to do this once the COPFS had finished their investigation. The NHS complaints procedure places a 12-month time-limit for considering complaints. The board said that as they had fully cooperated with the COPFS inquiry, there would be no further information to offer and they would not extend the timescale.

We used our discretion to investigate the complaint. We took independent advice from three clinical advisers. The nursing adviser noted that a SEWS (Scottish Early Warning System - a set of patient observations to assist in the early detection and treatment of serious cases and support staff in making clinical assessments) chart was missing. The gastroenterology adviser noted the recording on some of the drug charts was inadequate. The third adviser was a physician and while they noted these omissions in the medical notes, they did not find evidence that the care Mrs A received was unreasonable. While we noted some clinicians would not have biopsied Mrs A, considering her other health conditions, we found this was a degree of professional judgement and the decision to biopsy Mrs A was not unreasonable.

We did, however, uphold Mrs C's complaint about the board's response to her complaint to them and made recommendations to address the failings. We found that, given the serious nature of Mrs C's concerns and the fact that the board were not previously aware of the content of the COPFS report, it would have been good practice for the board to investigate Mrs C's concerns to identify potential learning and give her the opportunity to discuss her concerns. Additionally, the board have a duty to advise complainants that if they will not extend their timescales, the complainant has the right to come to SPSO. This did not happen in this case.

Recommendations

We recommended that the board:

• apologise to Mrs C for the fact that a SEWS sheet was missing from the clinical records;
• apologise to Mrs C for the fact that drug charts were incomplete and ensure all relevant staff are aware of the necessary record-keeping flowing from the guidelines on anti-coagulation in endoscopy;
• apologise to Mrs C for not advising her of her right to refer her complaint to the SPSO for consideration;
• share the learning from this complaint with relevant staff; and
• reflect on the impact on Mrs C of their refusal to consider investigating her complaint and advise us of the outcome of their reflection.

Summary

Mr C complained about a lack of measures taken by the mental health team based within the prison after he reported thoughts of harming himself or others. Several days later, Mr C caused damage to his arm and hand requiring surgical treatment at hospital.

We took independent advice from a mental health adviser. We found that a team approach should have been taken towards assessing and making a joint decision on Mr C's risk of harming in light of historic factors which do not appear to have been considered after he reported concerning thoughts.

We concluded that Mr C should have been managed under ACT 2 Care arrangements (a strategy for the care of individuals assessed to be at risk of self-harm or suicide) until such time that a multi-disciplinary team decided that his level of risk no longer needed such measures to be in place.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• ensure all relevant staff in the health centre team at the prison are aware of the ACT 2 Care approach to self-harm where 'at risk' prisoners should be subject to the individualised risk management arrangements; and
• share these findings with the staff involved in Mr C's care.

Summary

Ms C, who works for an advice and support agency, complained on behalf of Mrs A. Mrs A underwent a mastectomy procedure at the Victoria Infirmary. She was discharged two days later by a consultant. Mrs A's wound did not heal as expected and she had out-patient treatment to address this. When the treatment was ineffective it was decided that she should undergo a further procedure to explore, wash out and re-close the wound. This surgery was carried out by the consultant who had discharged Mrs A previously. Mrs A was unhappy with the actions of the consultant and complained.

After taking advice from a consultant breast surgeon, we did not uphold this complaint. The advice we received was that adequate and appropriate treatment had been provided by the consultant.

Summary

Mr C complained to us about the medical care and treatment provided to his late mother (Mrs A) in the Southern General Hospital before her death. We took independent advice on Mr C's complaint from a consultant in general and elderly medicine. We found that there had been a number of failings in the medical care provided to Mrs A. There were delays by medical staff in attending when her condition deteriorated. She should also have been seen by a more experienced doctor when nursing staff raised concerns about her condition. In addition, there were failings in relation to communication with Mrs A's family. Although we upheld this complaint, we were satisfied that the board had acknowledged that aspects of Mrs A's care were not adequate and had apologised for this. The board had also carried out a significant incident review and had made recommendations to address the failings.

Mr C also complained that Mrs A did not receive a reasonable standard of nursing care. We took independent advice on this aspect of Mr C's complaint from a nursing adviser. We also found that there had been a number of failings in relation to the nursing care provided and upheld this complaint. However, these failings had been identified by the board and they had made recommendations to ensure there was learning and improvement. They had also apologised to the family for the failings.

Finally, Mr C complained that there had been a delay in moving Mrs A to a critical care unit. We upheld this complaint as we found that Mrs A should have been moved to the critical care unit at an earlier stage and that the delay in doing so had been unreasonable. Although the board had introduced new criteria for medical referrals to the critical care unit, they did not have a written policy in relation to this.

Recommendations

We recommended that the board:

• provide evidence that the recommendations from their significant incident review have been implemented;
• provide evidence that they have considered what the role of a first year trainee doctor should be in cases where there has been a serious deterioration in a patient;
• formalise the criteria now in place for medical referrals to the critical care unit in a written policy; and
• issue a written apology to Mr C for the delay in transferring Mrs A to the critical care unit.

Summary

Mr C, who works for an advice and support agency, complained on behalf Mrs A. Mrs A's husband (Mr A) was suffering from neck pain and had also experienced some episodes of blood in his urine. He attended at the A&E department of Inverclyde Royal Hospital and was also attending the urology out-patient clinic following a referral from his GP. Mr A was diagnosed with a muscular neck condition at two emergency department attendances. The blood in his urine was considered to be connected to a medicine he was taking to help prevent blood clots. Mr A was later admitted to the hospital via the A&E department and was subsequently diagnosed with lung cancer which had spread to the vertebrae in his neck.

Mr C complained about the care and treatment that Mr A had received as Mrs A felt that his condition could have been diagnosed earlier if appropriate tests had taken place.

After taking independent advice from a consultant in A&E care, a respiratory consultant and a urology consultant, we upheld this complaint. Whilst no failings were identified in relation to the urology investigations or the care that Mr A received following his admission and diagnosis with lung cancer, we found that there had been issues in the two attendances at the A&E department. The advice we received was that the diagnosis that Mr A had received was not reasonable and that other issues had not been appropriately considered. The A&E adviser highlighted that after Mr A's second attendance, it would have been reasonable to discuss his case with more senior doctors.

Recommendations

We recommended that the board:

• apologise for the failings in care provided by the A&E department during Mr A's two attendances;
• ensure that the findings of this investigation are discussed at the next appraisals of the relevant clinicians; and
• review the procedure for escalation to senior staff for patients presenting at emergency departments with progressive symptoms or signs.

Summary

Ms C, who works for an advice and support agency, complained on behalf of her client (Ms B) who had concerns about the care and treatment received by her mother (Mrs A) at Gartnavel General Hospital. Mrs A was admitted to the hospital for rehabilitation and post-operation recovery following surgery to remove a tumour from her lung. Mrs A acquired a chest infection during her admission and suffered from vomiting and diarrhoea. Mrs A died while in the hospital.

Mrs A had been unable to swallow following surgery. Ms C said that Ms B had concerns about the way staff administered nutrition to Mrs A via a percutaneous endoscopic gastrostomy (PEG) tube (a tube that enters the stomach through a small incision in the abdomen). Ms C also expressed concern that staff had failed to update Ms B and communicate with her appropriately during Mrs A's admission. Ms C noted that Ms B considered that the board had not followed the DNACPR (do not attempt cardiopulmonary resuscitation) policy in relation to Mrs A. Ms C also said that Ms B was concerned that staff had failed to manage the risk of diarrhoea and vomiting on the ward.

We took independent nursing advice. The adviser found no evidence in the medical records that staff had failed to provide Mrs A with appropriate PEG tube care and treatment. They also considered that the records showed that staff had communicated reasonably with Ms B. The adviser also found that staff had followed DNACPR policy appropriately and noted evidence of a discussion with Mrs A and completion of a DNACPR form. Regarding the management of diarrhoea and vomiting, the adviser was satisfied that the board had appropriate procedures in place and that nursing staff had acted reasonably in accordance with these. We therefore did not uphold Ms C's complaints.