Health

Summary

C complained about the maternity care they received from the board when they gave birth to their twins. C was suspected to have COVID-19 and this was confirmed the day after delivery.

C complained that they were placed in a room that wasn’t equipped for labour and that they were pushed towards a vaginal delivery, rather than a planned caesarean section. The board explained that the labour room was set up with equipment stored outside the room for infection control purposes. C also complained that they weren’t provided with appropriate postnatal care.

We took independent advice from a midwife. We found that the records supported reasonable decision making surrounding the delivery method and that appropriate discussions had taken place with C in this regard. We also considered that the records evidenced a reasonable standard of postnatal care and that the decision to store equipment outside the room was reasonable. Therefore, we did not uphold this part of C's complaint.

C was unable to see their babies in the neonatal intensive care unit (NICU) until after their COVID-19 isolation period ended. C complained that it wasn’t explained to them why they weren’t allowed skin to skin contact before the babies were taken away to the NICU. C also complained that there was no clear process in place for them to see their babies and that staff were initially unable to tell them when this would happen. The board acknowledged that C did not receive an explanation as to why skin to skin contact was not allowed. We noted that the board had asked staff to reflect on C’s negative experience of communication and we were satisfied they had demonstrated learning from this.

We found that the restrictions in place for visiting the NICU were reasonable, that there were clear processes and guidelines in place to support this, and that the records showed this was appropriately communicated to C. Therefore, we did not uphold this part of C's complaint. We provided complaint handling feedback to the board as we noted some inaccuracies in their responses to C.

Summary

C, a support and advocacy worker, complained on behalf of their client (A) that the board failed to ensure clinicians provided a surgical assessment and procedure to A within a reasonable time frame. A had been referred to the board’s neurosurgical department (specialists in surgery on the nervous system, especially the brain and spinal cord) following an injury to their back but decided to undergo a surgical procedure privately following delays from the board. A continued to experience pain and felt that the board's delay had led to an adverse outcome from the surgery.

We took independent advice from a consultant neurosurgeon. We found that the board unreasonably delayed the clinical assessment and treatment of A. We also found that there was an unreasonable delay to A being given a clinic appointment and that communication around the treatment time guarantee process could have been better. However, we could not say with any certainty that the delay led directly to an adverse outcome for A. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to progress their treatment within a reasonable timescale. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Consideration as to how to better manage patients’ expectations in terms of their treatment time guarantee calculation and how the treatment booking process works.
• Make improvements to the clinic booking process to ensure patients are seen within national waiting time targets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Please note the events this complaint refers to may have occurred some time ago due to a delay in publication. We publish our findings to share learning and inform improvement.

Summary

C complained on behalf of their partner (A). A had a telephone consultation with the practice and reported haemoptysis (coughing up blood) and a fever. A also reported that they had taken a lateral flow test for COVID-19 which was negative. A did not take a PCR test for COVID-19 prior to contacting the practice. The practice considered it was likely that A had COVID-19 and advised that they self-isolate for ten days after symptoms started. A's condition deteriorated and several weeks later they were admitted to hospital and diagnosed with bacterial pneumonia.

C complained that the practice did not offer A a face to face appointment and subsequently failed to correctly diagnose their condition of bacterial pneumonia, instead focussing on COVID-19 as being the cause of A's illness.

The practice considered that they had been following the guidelines in place at the time and had correctly signposted A to the COVID-19 Hub for further assessment. We took independent advice from a GP. We found that there was no evidence in the clinical record that A had been signposted to the COVID-19 Hub and that haemoptysis was never listed as one of the common symptoms of COVID-19 infection. We found there was a failure to offer A a face to face appointment, particularly given they had reported haemoptysis.

We welcomed that during our investigation the practice reflected further and accepted that A's complaint of haemoptysis merited further clinical consideration and assessment. Given that the practice have taken appropriate and sufficient action to learn and improve from this complaint, we did not recommended that they take any further action. However, we recommended that they apologise to C and A for not offering A a face to face appointment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for not offering a face to face appointment which may have led to bacterial pneumonia being considered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, an advocacy worker, complained on behalf of their client (A) about the care and treatment provided by the board during a four day admission to hospital. A, a type 1 diabetic (a condition where blood glucose levels are too high because the body cannot make the hormone insulin), was admitted for lower abdominal pain. A received an ultrasound scan on the following day which proved inconclusive. The next day A received a CT scan which showed free fluid, in keeping with a burst ovarian cyst. A was discharged the following day.

C complained that A was discharged, having received no treatment, in pain, and without follow-up referrals. C complained that as a type 1 diabetic, A’s diabetes and food intake had not been correctly managed. The board said that treatment, discharge, and diabetes management were appropriate. The board apologised for not offering meals after breakfast on the day of discharge.

We took independent advice from a gastrointestinal and general surgeon (specialist in the digestive system). We found that A’s nutritional intake had been appropriately restricted due to investigations which were necessary to rule out surgery. A's diabetes had been appropriately managed via an insulin infusion called a sliding scale. We found that no treatment or follow-up care would be indicated for a burst ovarian cyst as this would usually resolve itself. We found that prior to discharge, A’s pain had reduced such that they were able to manage it with paracetamol alone and that discharge was therefore appropriate. Therefore, we did not uphold this part of C's complaint.

C also complained about the quality of complaints handling. We found that although there was a delay in providing a complaint response, this was because a meeting was being organised and that C was appropriately informed of the delays. Post decision correspondence was also delayed. However, this did not breach the Model Complaints Handling Procedure, which does not specify timescales for post decision correspondence. As the board had already increased administrative staff, improved procedures and apologised, we did not uphold this part of C's complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the practice in the months prior to A’s death in hospital. C complained that the practice failed to look at A’s leg and foot pain and that A was only prescribed water tablets. C also said that no home visits were arranged for A, that they were informed that A had a hiatus hernia (when part of the stomach moves up into your chest), and that A’s family did not receive a telephone call back when promised.

We took independent advice from a GP. We found that there was no failure on the part of the practice to look at A’s leg and foot pain or that A was prescribed water tablets. We also considered that there was no need for home visits in the time specified and that A had been diagnosed with a hiatus hernia in hospital. Finally, we considered that the practice had provided a reasonable explanation in relation to not phoning the family back given that A’s family had called an ambulance for A by the time in question, so a telephone consultation was no longer required. Therefore, we did not uphold C's complaint. We did provide feedback to the practice that they may wish to remind staff of the importance of keeping clear documentation for every home visit.

Summary

C had a history of multiple facial trauma and had undergone various procedures over the last decade in relation to their nose and face. C then received further injury which caused damage to their nose.

C complained that the board refused to perform any further investigations or the reconstructive surgery they considered was required. This was despite numerous GP referrals to the ear, nose and throat (ENT) department. C stated that they continued to suffer ongoing pain and symptoms associated with their facial injuries. C complained that the board were acting on the basis of a psychological assessment from a number of years ago, which suggested investigation and treatment could be damaging to C. C strongly objected to the content of this assessment.

We took independent advice from an ENT surgeon. We found that it was reasonable for the board to take into consideration the psychiatric assessment that warned against unnecessary investigations and treatment unless indicated on objective grounds. However, we considered that given the passage of time since that document was produced, and because C had recently been assaulted potentially causing new injury, it was reasonable for C to be reassessed. Therefore, we upheld C's complaint.

We also noted failings in relation to complaint handling and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Where a significant period of time has elapsed since a patient was clinically assessed and there is evidence that the patient’s clinical situation has changed, the patient should be offered a clinical reassessment.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement. The board should comply with their complaint handling guidance when investigating and responding to complaints.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

When it was originally published on 22 March 2023, this case referred to a Medical Practice in the Ayrshire and Arran NHS Board area. This was incorrect, and should have read a Medical Practice in the Fife NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

C complained about the end of life care their late spouse (A) had received from the practice. A had Lewy body dementia (a progressive dementia that results from protein deposits in nerve cells of the brain which affects movement, thinking skills, mood, memory, and behaviour) and was cared for at home by C. When A’s condition deteriorated, C complained that the GP had not visited them at home to assess their decline. C also complained that there had been a delay in initiating their end of life care plan allowing access to appropriate pain relieving medication and to the community palliative care team for support.

In response, the practice said that although a GP had not visited A at home in their final weeks, a number of GPs had been in constant liaison with the district nursing team about their care and prescribing appropriate medications. They noted that their duty doctor had not been aware of, or could refer into, the palliative care team but following liaison with the district nursing team, this was progressed and A had received assistance thereafter.

We took independent advice from a GP. We found that the practice had not provided a reasonable standard of end of life care to A. We considered they should have carried out an earlier assessment of A’s palliative and end of life needs to inform better care planning, that there was an unreasonable delay in providing A with appropriate pain relieving medication, and noted that staff lacked awareness of the community palliative care team and the referral process. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of end of life care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients experiencing a reported deterioration in their condition should be appropriately assessed in accordance with relevant national guidelines.
• Patients receiving end of life care should have their response to pain relieving medication appropriately assessed and any required changes promptly administered.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted and discharged from hospital on two separate occasions. A died shortly after their third admission to hospital.

We took independent advice from a consultant in geriatric medicine and general medicine (a specialist in care of the elderly).

We found that while some aspects of A’s care were reasonable, particularly in relation to cardiac (heart) care, given the complexity and combination of A’s conditions, age and frailty, A should not have been discharged the day after their first admission. A should have remained in hospital given that a deterioration in their condition was very likely to occur, and as they also required further detailed assessment of their mobility. It was determined that A’s combination of problems would have required inpatient care even for a previously healthy patient and the acute exacerbation of A’s conditions would have been profound and life threatening.

We also found that there was a lack of detailed assessment of A’s mobility difficulties prior to being discharged. We found that the board failed to take account of the evidence in A’s records that they had struggled with their mobility and had needed supervision and support. We noted that an assessment of A’s mobility had been part of the medical plan at the time of their first admission. Given the severity of A’s illness, age, and the difficulty with walking, there should have been a specific and detailed assessment of A’s mobility prior to their discharge. We also found that the board failed to provide a full response to C’s complaint.

Taking account of the evidence and the advice we received, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in discharging A from the hospital the day after their admission, for failing to carry out a full and detailed assessment of A’s mobility prior to their discharge and for the failure to provide C with a full and informed response in relation to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• In similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and in line with recognised guidelines.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and accurate.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide reasonable care and dental treatment to them over a period of several months. During clinical examinations, C raised concerns about experiencing pain from a particular tooth.

We took independent advice from a dentist. We found that while treatment provided by the dental practice was, in general, reasonable, there were some missed opportunities to further investigate the condition of the tooth in question. Further investigations would have been appropriate to help determine whether the tooth was the actual cause of the pain. We found that further information obtained at subsequent appointments would have helped confirm that C’s pain was the result of a localised infection. The board accepted that in retrospect, the pain was due to the tooth that was ultimately extracted. Given the missed opportunities to further investigate the condition of the tooth in question, develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the missed opportunities to further investigate the condition of the tooth in question, for the failure to develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Dentists should act in line with the Scottish Dental Clinical Effectiveness Programme's Management of Acute Dental Problems.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the practice failed to refer them for an x-ray following a fall, which contributed to a delay in diagnosing fractured vertebrae.

C attended A&E following their injury and then attended the practice a few days later (first consultation). C then had a GP telephone appointment the next day due to ongoing pain (second consultation), and subsequently attended the practice again in person some weeks later (third consultation). C complained that their symptoms were not fully investigated and an obvious bend in their neck was overlooked.

We took independent medical advice from a GP. We found that the practice’s actions at the first and second consultations were reasonable in relying on the outcome of the recent A&E assessment, and that an onward referral for x-ray imaging was not indicated at that point. We found, however, that C’s ongoing pain should have been considered persistent by the time of the third consultation, and that their spinal tenderness should have been regarded as significant. We found that these symptoms should have been regarded as ‘red flag’ symptoms (possibly indicative of a more serious pathology), and should have triggered onward referral for imaging assessment.

Instead, C was referred for physiotherapy following the third consultation. C subsequently contacted the practice on a fourth occasion to request that this referral be expedited. A GP received this message and concluded that C did not meet the criteria for an urgent referral. The GP did so without taking a history and/or examining C. We found that it was unreasonable to make this decision without evidence. If an examination had been arranged following this fourth contact by C, it may have given rise to an x-ray referral.

We concluded that the practice unreasonably missed opportunities to refer C for an x-ray at the third consultation, as well as at the time of C’s subsequent contact regarding the physiotherapy referral. On balance, we upheld this complaint. We noted the practice had already reflected extensively on their management of C and identified things they would do differently in future.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to refer them for further investigation following the third consultation, and for concluding that they did not meet urgent referral criteria without taking a history or examining C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients should be referred on for appropriate investigation when they present with red flag symptoms. The practice should ensure that they follow relevant guidelines and that they are aware of and alert to red flag symptoms.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.