Health

Summary

Mrs C complained that her mother (Mrs A) was left sitting in a chair for nine hours without access to a bed, whilst waiting to be moved to a new ward. Mrs C said that Mrs A had asked to go to bed during this time. The board told us that Mrs A had chosen to sit in her chair and was offered access to a bed in a side room if she wanted to lie down. We found that nursing records had not been kept on the day in question and we upheld the complaint because there was a lack of evidence of proper nursing care on the day in question.

Recommendations

We recommended that the board:

• offer an apology to Mrs A which recognises that she has a different account of what happened to that of the staff nurse, and which acknowledges the failure to keep reliable nursing records, and outline the steps taken to address the issues with ward staff.

Summary

Ms C's late mother (Mrs A) had a history of bladder cancer and following surgery, self-catheterised through a stoma (a surgically-made opening from the inside of an organ to the outside) in her stomach. She was admitted to Monklands Hospital in February 2014 complaining of severe abdominal pain and a number of tests were carried out. Mrs A was discharged and continued to see hospital specialists as an out-patient but was readmitted several months later for an operation to remove her right kidney. When the operation was carried out, recurrent bladder cancer was found. Ms C said that following this operation Mrs A's dementia worsensed. After several weeks, Mrs A was discharged again. She was readmitted the following month when she continued to deteriorate and she died several weeks later. Ms C raised concerns about the standard of medical care and treatment during Mrs A's three admissions to hospital and, in particular, said that the decision to carry out the operation was not reasonable and that medical staff failed to manage her pain and dementia in a reasonable way. Ms C also said that nursing staff failed to properly care for Mrs A's catheter and ensure that she had sufficient food and fluids and that the family had to provide personal care. Finally, Ms C raised concerns about the standard of communication.

We took independent advice from an urology adviser and a nursing adviser. We found that the medical care and treatment was reasonable including the decision to operate (although there was a record-keeping shortcoming). However, we also found that there were failings in relation to the standard of nursing care and treatment provided and communication. The overall assessment and care concerning Mrs A's dementia was below a reasonable standard and nursing staff failed to assess her capacity during two of her admissions to hospital. There were further shortcomings in relation to monitoring and recording fluid and nutritional intake. However, we were satisfied that clinicians did assist with Mrs A's catheter. In relation to communication, there was evidence that communication was challenging at times and no evidence that the family was as involved as they should have been in the wider care planning process.

Recommendations

We recommended that the board:

• ensure patients' capacity to consent to treatment on the ward is assessed and recorded in line with relevant guidelines and legislation and provide evidence of this;
• bring the nursing adviser's comments about shortcomings in communication to the attention of relevant staff and carry out audits to ensure compliance;
• bring the nursing adviser's comments about shortcomings in implementing the relevant standards in relation to dementia and nutrition, and the related record-keeping failings, to the attention of relevant staff and carry out audits to ensure compliance;
• apologise for the failings we identified; and
• ensure that sedation and/or analgesia prescribed in the ward before being taken for procedures out with the ward is fully and properly recorded in the medical records.

Summary

Mrs C was referred for a colonoscopy for bowel cancer screening and was asked to contact the hospital to book this in. Mrs C contacted the board to raise concerns that there were no arrangements for her to see a consultant beforehand. She was also concerned to discover the procedure was booked with a nurse rather than a consultant. After further correspondence, the board arranged an appointment for Mrs C with a consultant to discuss the procedure. While Mrs C was dissatisfied that this delayed the procedure for three weeks, she attended the appointment and chose to go ahead with the procedure with the consultant. After the procedure Mrs C complained to the board about the attitude of the male nurse who prepared her for the procedure, the procedure itself, and the board's communication about this.

The board issued two written responses to Mrs C's complaint and met with her and her MSP to discuss the outstanding issues. The board apologised for some aspects of the procedure, including that the male nurse had touched Mrs C when demonstrating the procedure and that another member of staff had entered the room during the procedure to access a storeroom.

After taking independent medical and nursing advice we did not uphold Mrs C's complaints. The advice we received was that the board's care, treatment and communication were reasonable and they had apologised where appropriate. We were concerned that the steps taken by the board may not be sufficient to address the privacy issues raised and we made a further recommendation about this. While we considered some aspects of the board's complaints handling could have been improved, we found their response was reasonable and in line with Scottish Government guidance.

Recommendations

We recommended that the board:

• consider whether there is a recurring problem with staff entering the endoscopy suite to access the storeroom during procedures and take steps to address this.

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.