Health

Summary

Mr A was referred to hospital by an out-of-hours GP after feeling increasingly unwell. On admission to Vale of Leven Hospital, Mr A was diagnosed as suffering from sepsis (a blood infection) and received treatment for this. Mr A's condition deteriorated over the following days and he was transferred to Royal Alexandra Hospital. Mr A's wife (Mrs C) complained that staff at Vale of Leven Hospital did not identify sepsis quickly enough and that Mr A was not transferred to Royal Alexandra Hospital soon enough.

We took independent advice from a consultant in respiratory medicine. The adviser confirmed that sepsis was identified immediately and noted that Mr A was treated appropriately, in line with the board's sepsis protocol. While the adviser noted that medical records should have shown greater detail about plans to transfer Mr A, they were satisfied that there was no inappropriate delay in transferring him. However, the adviser noted that the board should consider introducing a more robust set of criteria for the transfer of seriously ill patients.

After Mr A was transferred to Royal Alexandra Hospital, he was treated in the high dependency unit, where he died. Mrs C expressed concern that her husband did not receive treatment in the intensive therapy unit (ITU) and was not referred for dialysis. The adviser considered that Mr A received appropriate treatment and noted that the medical staff involved in Mr A's care decided that he was not suitable for escalation to ITU or referral for dialysis because of his multiple health conditions and deteriorating health.

While we did not uphold Mrs C's complaints, we made a recommendation to take into account the adviser's comments about the transfer between hospitals. We also noted that the board had acknowledged communication failings and had advised Mrs C that a new standard process template would be introduced for staff to record communication with families of patients. We accordingly made a further recommendation to confirm that this learning had been implemented.

Recommendations

We recommended that the board:

• feed back to relevant staff the adviser's comments regarding record-keeping and introducing more robust criteria for transferring seriously ill patients; and
• provide us with a copy of the new process template.

Summary

Mr C complained about the interactions with him by a therapist at the board. However, we were unable to investigate these because the information about those interactions was contained in the medical records of the patient, who was Mr C's son. The age of Mr C's son meant that he (his son) needed to give us consent to obtain his medical records; however, we were unable to obtain his son's consent. That meant we had no prospect of establishing the facts about Mr C's complaint or reaching a conclusion on it, and in the circumstances we had to close the complaint without investigation.

Summary

Following eye surgery, Mrs A was referred to an optometry practice by her consultant ophthalmologist to be fitted with a corneoscleral lens (a large diameter rigid contact lens) on her right eye to assist with eye moisture retention. Mrs A attended an appointment to be provided with instruction on the use and care of the lens which involved the use of a lens cleaning and disinfecting solution. At the end of the consultation Mrs A purchased the solution from the practice's reception.

Mrs A later used the solution, which is peroxide based, in its unneutralised state and suffered pain, inflammation and damage to the eye and the surrounding skin. Mr C complained on behalf of Mrs A (his wife) that the optometry practice had failed to ensure Mrs A was provided with an appropriate lens care regime and instructions on how to use the lens safely.

We obtained independent advice from an optometrist. The adviser said that what had happened in Mrs A's case been brought about by her misunderstanding of the correct contact lens cleaning regime which had led to her erroneously applying the solution to the lens in the pre-neutralised state just prior to insertion into the eye. The adviser found no evidence that what occurred had been due to failings in the advice and treatment Mrs A received from the optometry practice. The adviser said the advice and treatment they provided had been appropriate. We accepted this advice and did not uphold the complaint.

Summary

Ms C brought this complaint to us on behalf of her late grandfather (Mr A) in relation to the care and treatment he received from the board during investigations into urology symptoms, and subsequently, during an admission to the Jubilee Hospital.

Mr A was referred to urology in 2013 with symptoms indicating potential prostate cancer though treatment was not considered necessary. He was admitted to hospital following the identification of suspected metastatic cancer and a fall at home. He was cared for in a GP-led ward and received palliative treatment for his cancer symptoms. During his time in hospital he missed a consultant appointment because he was not informed of it. While the urology consultant was in contact with the GPs involved in Mr A's care, Mr A did not see a consultant after his diagnosis with metastatic disease until his death around four months later.

During our investigation of this complaint, we obtained independent advice from a urology adviser and a GP adviser. The urology adviser did not raise any concerns about the care and treatment Mr A received in relation to his prostate cancer. They noted that the timescales for Mr A's clinical review were not appropriate but that these timescales were overtaken by events. The adviser noted that the urology consultant had written to the GP on several occasions setting out his opinion of Mr A's condition and treatment decisions, though it was not recorded as to whether this had been explained to Mr A. Once he was in hospital, Mr A's care and treatment had been discussed at case conferences which included family members. When Mr A was first admitted to hospital, doctors completed a form to instruct that he should not be resuscitated in the event of a heart attack (a DNACPR form). This form was subsequently overturned following discussions with Mr A's family. This was noted on his medical records. Though Ms C said she saw Mr A's name on a list on the ward, there was no evidence of inaccurate records held by the board.

When Mr A was discharged to a nursing home, the family thought he was going to have rehabilitation so he could return home. Records passed between the board and the nursing home indicated he was being transferred for management of cancer symptoms. The GP adviser explained that Mr A was receiving palliative care, and it was possible that if his condition had stabilised he would have been able to return home. His condition deteriorated more rapidly than had been expected, and this could not have been foreseen. We accepted the advice provided by the advisers in relation to Mr A's care and treatment.

Ms C also raised concerns about the way her complaint was handled. She said that her grandmother (Mrs A) was contacted directly to gain consent, and that this was not appropriate. She also raised concerns that the board used the wrong name for Mrs A and that they did not provide a response within the appropriate timescales. We noted these issues and considered that the board failed to follow their complaints handling procedure.

Recommendations

We recommended that the board:

• feed back findings to the staff involved for reflection and learning;
• apologise to the family for the failings identified in our investigation;
• review their processes to ensure that complainants are contacted when consent is needed from a patient or next of kin; and
• review their processes to ensure that, where an investigation cannot be completed within 20 days, they contact the complainant to explain this.

Summary

Mrs C complained about the care and treatment provided to her late grandson (Mr A) during an admission to Royal Cornhill Hospital. Mr A had a history of mild learning disability, drug and alcohol misuse and self-harm. He had a previous admission a couple of months earlier following attempted hanging and also attempted to hang himself while an in-patient when his discharge was planned. Mr A was discharged with support in the community but was readmitted following a further attempted hanging several weeks later. Mr A remained on the ward for two weeks and was then discharged again. Mr A completed suicide by hanging that evening. Mrs C complained that staff had not adequately assessed Mr A and that the discharge decision was unreasonable.

Following Mr A's death the board conducted an adverse event review. The board did not consider Mr A suffered from a major mental illness and although he was at risk of harming himself, staff did not consider an ongoing hospital admission would be in his best interests.

After taking independent psychiatric advice, we did not uphold Mrs C's complaints. We found that staff had appropriately assessed Mr A and reasonably concluded he did not have a major mental illness and would not benefit from ongoing hospitalisation. The adviser also explained that hospitalisation does not necessarily prevent attempts to self-harm (and noted that one of Mr A's previous attempts at suicide occurred in the in-patient setting). In view of Mr A's participation in the discharge planning and his previous pattern of behaviour, the adviser considered there was no indication that Mr A planned to harm himself that evening and it was reasonable for staff to predict that, although Mr A may attempt self-harm in future, he would likely warn someone before doing so. Overall, we considered that Mr A's suicide was an event that could not have been predicted by staff at the time of discharge.

Summary

Ms C complained about the communication between her grandfather (Mr A), who had prostate cancer, and the medical practice. Mr A was cared for by the practice at home, on a GP-led ward and while he was in a nursing home. Mr A died ten days after his admission to the nursing home. Ms C complained that the practice had failed to communicate appropriately with Mr A in relation to his cancer diagnosis and treatment options, despite the practice having access to this information.

We took independent advice from a GP adviser. They noted that Mr A was being seen by a consultant urologist (a clinician who treats disorders of the urinary tract) and that it was the urologist's responsibility to discuss Mr A's cancer diagnosis and treatment options with him, not the GP's. We therefore did not uphold Ms C's complaint.

The adviser noted that there was a delay in referring Mr A for an ultrasound scan and that the national referral guidelines for suspected cancer had not been followed. We therefore made a recommendation in relation to this.

Recommendations

We recommended that the practice:

• ensure the relevant GP familiarises themselves with the national guidelines for cancer referral and considers identifying this as a learning point for their annual appraisal.

Summary

Mrs C complained about a decision taken by the board to cancel her heart surgery and the lack of communication to her about this decision. She was also concerned that her complaint had not been dealt with appropriately because members of the complaints team had been involved with the decision to cancel her surgery.

We took independent advice from a consultant cardiologist. We found that there were appropriate reasons for the surgery to have been postponed until an independent review was sought to endorse Mrs C's management plan.

However, we found the communication in relation to the postponement of the surgery to be unreasonable. The board apologised to Mrs C that she was not informed beforehand that a further clinical meeting would be held. We also considered that the board should have sought Mrs C's input in relation to the independent review and informed her that there was a possibility it would delay her surgery.

We did not find that there had been a conflict of interest in the complaints staff handling of Mrs C's complaint about the cancellation of her surgery. The decision to cancel the surgery was taken by relevant clinical staff involved in her care. We therefore concluded that her complaint was investigated appropriately.

Recommendations

We recommended that the board:

• draw our findings abut the failure to adequately communicate the decision to postpone the surgery to the attention of the multi-disciplinary team involved in Mrs C's care; and
• apologise for failing to seek Mrs C's input in relation to the decision to obtain an independent review.

Summary

Mrs C complained that her husband (Mr C) did not receive a reasonable standard of care from the practice. Mr C suffered from a number of health conditions, including asthma, and passed away from sudden cardiac arrest whilst he was a patient at the practice. Mrs C felt that the practice did not investigate Mr C's condition urgently enough, and said that there had been a sequence of failed attempts to diagnose and treat Mr C.

We took independent advice from a GP adviser. The adviser noted that the practice had investigated Mr C's condition within a reasonable timeframe and with the appropriate level of urgency. The adviser said that appropriate investigative tests had been arranged and concluded that the care Mr C received was reasonable. We accepted the adviser's comments and we did not uphold Mrs C's complaint.

Summary

Mr C, who works for an advice and support agency, complained about the care and treatment of his clients' late daughter (Miss A). Miss A attended the practice on a number of occasions from May 2014 with symptoms including a persistent cough, sore joints, fatigue and weight loss. A number of possible diagnoses were considered and investigated but Miss A's symptoms persisted. In October 2014 following an out-of-hours attendance, Miss A was admitted to hospital and diagnosed with endocarditis (a rare and potentially fatal infection of the inner lining of the heart). Miss A passed away in hospital a few weeks later. Her parents raised concern that a window of opportunity had been missed to diagnose Miss A. They felt that there was a delay in the practice arranging appropriate investigations and referrals.

The practice met with Miss A's parents and carried out a significant event analysis. The practice considered the care provided was reasonable, although they identified some learning points for improvement including improving continuity of care and having a lower threshold for investigatory blood tests in young people with persistent symptoms.

After taking independent medical advice we did not uphold Mr C's complaint. We found the practice had arranged appropriate investigations in view of Miss A's symptoms, including seeking advice from Miss A's former specialist to check for any connection between her symptoms and another ongoing condition and making referrals to hospital specialists. The adviser explained that Miss A's symptoms varied over this time and appeared more in keeping with a respiratory problem (which the GPs appropriately investigated). The adviser considered symptoms indicating a possible problem with the heart were first documented at the out-of-hours admission in October 2014, so it was not a failing that the practice did not investigate this possibility earlier.

Summary

Mr C complained about the way in which his pain relief medication was handled by the prison health centre and that the doctor refused to see him in private.

Mr C had been prescribed pain relief for pain in his leg. This was later stopped and an alternative medication prescribed. However, due to concerns that Mr C was failing to take the medication in the way it was prescribed, this medication was also stopped and further alternatives, including anti-depressants, were suggested.

We took independent advice from a GP adviser. We found that, when reviewing Mr C's medication, the health centre had acted in line with Scottish national guidelines on the management of chronic pain and on prescribing. We considered the health centre's actions to be reasonable given the assessments carried out for Mr C.

The board told us that there were no records of Mr C asking to see health centre staff in private. We considered that in a secure environment, it would not be unreasonable for Mr C to be accompanied at health centre appointments. We saw evidence of only one occasion on which Mr C had been accompanied and that this was reasonable. We therefore did not uphold Mr C's complaints.