Health

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.

Summary

Mr C was receiving his medication from a prison health centre nurse. The nurse considered that Mr C was concealing his medication. After consultation with a GP, Mr C's medication was removed. Mr C was given a review appointment with the GP and an alternative medication was prescribed.

Mr C complained that the medication was removed with immediate effect on an unproven allegation and that the alternative medication prescribed was inappropriate. We found that the medical staff had acted appropriately, did not have a requirement to prove an allegation before medication was removed, removed the medication appropriately and provided a reasonable alternative.

Summary

Mr C complained that an incorrect entry had been placed in his GP records which he had asked the practice to remove or mark 'to be disregarded'. He also complained that the board did not deal with his subsequent complaint in a timely manner.

Following investigation, we were of the view that the practice had taken reasonable action to try to establish the accuracy of the record which detailed a consultation alleged to have taken place between Mr C and a locum GP. As the locum no longer worked for the practice they were unable to speak to him. In order to establish if the record actually related to another patient the practice conducted a search of their records, including patients seen just before and after Mr C on the date in question. They also reviewed the records of patients with similar names and/or dates of birth. We considered that the practice had taken reasonable action to establish whether or not the record was inaccurate, but had been unable to do so. We did not uphold this complaint.

On the matter of Mr C's complaint to the board, we found that there had been delays in dealing with Mr C's complaint. However, Mr C had been kept informed during the process. Although we upheld this complaint, we did not make any recommendations on this matter.

Summary

Mr C attended his medical practice with a recurrence of back pain and sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) and it was agreed he would be referred to neurosurgery. Mr C complained about a subsequent delay in the referral being sent and about the practice's response to his complaint to them.

We took independent advice from a GP, who confirmed that routine referrals should normally be sent within one week. Mr C's referral was not sent for almost six weeks. We were critical of the practice for not having clearly explained the reason for the delay to Mr C. In their response to Mr C they had blamed general delays across the NHS system and had not accepted any specific fault on their part. However, the practice told us that the delay was caused by a delay in dictating and typing the referral letter. They informed us of the process they have in place to avoid a similar future occurrence.

The adviser also noted that Mr C attended the practice on a further three occasions in the interim period. They considered that his reported symptoms should have prompted the upgrading of the referral to urgent. They noted that urgent referrals should be sent within 24 hours. The adviser saw no evidence of Mr C having been asked questions to rule out further warning signs that may have necessitated an emergency hospital admission. We therefore found that there was an unreasonable delay in sending the routine referral and an unreasonable failure to upgrade this to urgent. We upheld this aspect of Mr C's complaint.

With regard to the practice's handling of Mr C's complaint, we noted in particular that Mr C did not receive a response to his initial complaint letter and that he was not referred to the SPSO at the end of the process. We were also critical of the practice for including details of Mr C's medical history in their correspondence to us that was not relevant to his complaint. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the practice:

• confirm that the management of back pain, and red flag signs, will be included as a learning need in the annual performance appraisals of the doctors in the practice;
• apologise to Mr C for the failures identified in the handling of his referral to neurosurgery;
• review their complaints handling procedure to ensure that both staff and patient guidance are consistent with each other and with NHS 'Can I help you?' guidance. In particular, they should ensure that complaints are appropriately acknowledged, timescales for response are clearly communicated to complainants, complaints are responded to in full, with any learning points clearly identified, and complainants are appropriately signposted to the SPSO;
• advise complaint handling staff to ensure that they refrain from including confidential patient information in complaint correspondence, where it is not relevant to the complaint issues that have been raised; and
• apologise to Mr C for the failures identified in their handling of his complaint.

Summary

Mr C complained that he was being required to work in the prison work-sheds despite it being a source of anxiety for him and causing him to suffer panic attacks. He considered that the prison health centre should have supported him in being excused from work on health grounds. He noted that a mental health nurse had briefly declared him unfit for work but that this decision was reversed following a multi-disciplinary review of his case.

The board told us that the decision to declare Mr C unfit for work had been reversed on the basis that it was considered his anxieties were being managed appropriately. They noted that a care plan had been devised to reflect this.

We took independent advice from a senior mental health nurse. They noted that the clinical reasoning behind the initial decision to declare Mr C unfit for work, and the content and conclusions reached at the subsequent meeting, were not documented. They were critical of this and the lack of evidence of a comprehensive and structured assessment of Mr C's mental health needs having been carried out. They did not, therefore, consider that Mr C's mental health and fitness to work were adequately assessed prior to the meeting and on this basis we upheld Mr C's complaint.

However, the adviser noted that the care plan that was subsequently put in place took a reasonable approach in seeking to support Mr C's continued attendance at work.

Recommendations

We recommended that the board:

• provide evidence of the steps taken to ensure that, where appropriate, structured mental health assessments are carried out by prison healthcare staff;
• provide evidence of the steps taken to ensure that nurse record-keeping within the prison health centre complies with the Nursing and Midwifery Council standards; and
• apologise to Mr C for the failings this investigation has identified.

Summary

Mr C complained about the care and treatment received by his late brother (Mr A) in relation to Mr A's lung cancer and his admission to Forth Valley Royal Hospital following a cardiac arrest.

During our investigation we took independent advice from two advisers, a consultant in respiratory medicine and a consultant in anaesthesia and critical care medicine.

The board accepted that there had been unnecessary delays in Mr A's cancer care pathway, for which they apologised and outlined the action taken. The consultant in respiratory medicine said that while some delays had been unavoidable, others were unexplained and unreasonable, in particular the delays relating to the referral from primary care to secondary care. They also noted poor communication. We therefore upheld this aspect of Mr C's complaint. However, the advice we received from the consultant in anaesthesia and critical care medicine was that the decisions taken following Mr A's admittance to the hospital and the care and treatment he received were reasonable.

Recommendations

We recommended that the board:

• consider the adviser's comments in relation to the delays experienced by Mr C's brother, in particular the referral from primary care to secondary care and poor communication, to see what further lessons can be learned.

Summary

After a recurrence of cancer, it was agreed that Mr C's bladder and prostate would be removed. He had a pre-operative session about a stoma (a surgically made pouch outside the body) and his surgery was carried out a few days later. Mr C appeared to be recovering well, but he then began to suffer problems with his stoma leaking. He complained that this was as a consequence of the board not providing him with reasonable care or aftercare in relation to the stoma. It was the board's view that they had provided appropriate care to Mr C.

We took independent advice from a specialist pelvic cancer surgeon and we found that all of Mr C's care and treatment had been in accordance with relevant guidance. He had had significant problems after his operation but the board had taken all reasonable and appropriate efforts to resolve these. While it was very regrettable that Mr C had to endure difficulties which affected the quality of his life, there was no evidence of poor care. We did not uphold Mr C's complaint.

Summary

Mrs C complained that the board failed to provide appropriate nursing care to her husband (Mr A).

Mr A suffered from ischaemia (inadequate blood supply), which had previously resulted in the amputation of his right leg below the knee. He was admitted to hospital with ischaemia of his left foot and an ulcer. There was no surgical option available to address this issue and the plan was to delay amputation as long as possible. Mr A was being seen twice a week by district nurses following discharge from hospital.

Some months after discharge, a nurse identified deterioration in Mr A's foot and contacted Mr A's GP practice. The GP prescribed antibiotics; however, the district nurses did not schedule a further visit at that time. A nursing visit did not take place until six days later. The nurse who attended discovered a maggot infestation in Mr A's wound. Mr A was subsequently taken to hospital and received an above-knee amputation of his left leg.

Mrs C complained about the missed visit. She also complained about the board's communication. The board acknowledged failings had occurred and apologised to Mrs C.

After receiving independent advice from a nurse, we upheld Mrs C's complaint. We found that the board had failed to ensure twice weekly visits as required under Mr A's care plan. We also found the board's communication was below a reasonable standard. In addition, we found that while the board generally complied with wound management guidance, formal wound assessments were not conducted regularly. We made a number of recommendations to address these issues.

Recommendations

We recommended that the board:

• confirm they will audit district nursing formal wound assessment charts to ensure that they meet local and national guidelines and provide evidence of this;
• remind staff of the importance of ensuring requested visits are followed up and documented within patients' records;
• provide evidence that there are improved systems in place for communicating a patient's plan of care between team members and other healthcare providers;
• consider a scheme of each patient having a named nurse to contact if they have concerns outwith their scheduled visits;
• consider a scheme for planned visits to be on set days of the week; and
• apologise for the failings identified in this investigation.