Health

Summary

Mr C complained that a prison health centre nurse refused to give him a replacement asthma inhaler because he could not return the empty inhaler. Mr C said he was not told of this policy, and he complained about the board's handling of his complaint.

We could not determine whether the nurse's actions at the time were reasonable, as, other than the two differing accounts of what happened, there was no evidence to prove what actually happened. We also found that the board's handling of Mr C's complaint was adequate. We did not uphold either aspect of Mr C's complaint. However, we were concerned about the nurse's written record of the incident, and we made a recommendation to address this point.

There was no evidence that the board had informed Mr C of the inhaler exchange policy or protocol, and the board were unable to provide us with a copy of the protocol, as it was no longer available because the staff who had developed it had left the board. We upheld this aspect of Mr C's complaint, and we made recommendations to address the board's failings.

Recommendations

We recommended that the board:

• ensure that the nurse involved is reminded of the importance of complying with Section 10 of the Nursing and Midwifery Council code in relation to record-keeping;
• ensure that if prisoners are to continue returning empty inhalers, a replacement protocol is written without delay and is stored so it can be accessed and will not be lost due to staff changes; and
• ensure that prisoners are made aware of the replacement protocol, and provide us with evidence of this.

Summary

Ms C attended Glasgow Royal Infirmary with a swollen right leg and foot for investigation of a possible blood clot. Whilst at the hospital, staff took several blood samples from Ms C. Ms C complained that the laboratory at the hospital unreasonably lost one of her blood samples. She said her complaint was not about the length of time she waited for the results, but the fact that the blood sample went missing and that she was told by staff at the hospital that this was a regular occurrence.

We obtained independent medical advice from a nursing adviser. The evidence showed that on the day in question, the board's electronic healthcare information system was not operating properly and staff had to resort to manual recording of blood sample requests. Ms C's blood sample was taken at 14:00 and was received by the laboratory at 17:50. The accounts of staff involved indicated that there was some confusion over the method of transportation which was used to deliver the sample to the laboratory. Staff initially believed that the sample had been delivered by the pneumatic tube system (a network of tubes using compressed air to transport the samples to the laboratory). They then discovered that the sample was on a table in the A&E department waiting to be collected by a porter, and there had been a collection problem. The adviser said that the board's investigation and records indicated that the sample was lost, albeit temporarily, and then found by a member of staff and sent to the laboratory. We were critical of the board in this regard and we upheld Ms C's complaint.

On the matter of Ms C's concern that staff told her that blood samples being lost was a daily occurrence, the board indicated that there had been no previous complaints and their external accreditation review found that the laboratory met the quality standards. The adviser said that the board's response was reasonable.

Recommendations

We recommended that the board:

• review their written procedures for transporting samples to the laboratory to minimise the risk of this situation recurring; and
• provide Ms C with a written apology for the failings identified.

Summary

Miss C complained to us about the nursing care provided to her mother (Ms A) at Stobhill Hospital. Ms A had been transferred to a rehabilitation unit in the hospital after suffering a stroke. Her condition deteriorated and Ms A died.

Miss C complained in particular that her mother was not monitored properly, that her pain was not controlled appropriately, that staff had failed to prevent falls, that staff failed to maintain Ms A's dignity and that Ms A was unreasonably moved into a side room. Miss C also complained that Ms A's belongings were not dealt with appropriately.

We took independent advice from a nursing adviser. We found that Ms A's pain had been reasonably managed, that it was reasonable to put Ms A in a side room and that a care plan in relation to falls prevention was in place. However, we found failings in the nursing care provided to Ms A in relation to maintaining Ms A's dignity and the treatment of her belongings, therefore we upheld Miss C's complaint in view of these specific failings. We did not make recommendations, however, as we were satisfied that the board had apologised for the failings and had taken reasonable action to try to prevent similar problems occurring in the future.

Summary

Mrs C complained on behalf of her husband (Mr A) that the audiology department at the Victoria Hospital had unreasonably cancelled an appointment. Mrs C was also concerned that her husband did not have an appropriate hearing aid for his needs.

We took independent advice from a consultant clinical scientist in audiology. Regarding Mrs C's first complaint, the adviser was not critical of the board's cancellation of the appointment and noted that another, longer appointment had been arranged in its place. While we did not uphold Mrs C's complaint, we found evidence that Mr A and Mrs C had not been advised of the cancellation and so they had expected to attend two appointments. The adviser considered that the failure to advise them of the cancellation was not reasonable and therefore we made a recommendation.

Regarding Mrs C's second complaint, the adviser confirmed that Mr C had been given the appropriate hearing aid for his needs.

Recommendations

We recommended that the board:

• feed back the findings of this investigation to the staff in the audiology department; and
• apologise to Mr A for not informing him at the appropriate time that his appointment had been cancelled.

Summary

Mr C attended A&E at Glasgow Royal Infirmary following a sports injury. On discharge he was advised to take painkillers and use an ice pack. Mr C was later referred back to the hospital as he was continuing to suffer pain. Mr C complained to the board about his treatment but the board said that the examination, diagnosis and management plan he received at the time of his injury were appropriate.

Mr C complained to us that his condition had not been reasonably assessed by the hospital. We took independent advice from an emergency nurse practitioner. They found that although Mr C had been examined, there were shortcomings. Mr C's medical records did not properly record 'when, how, where, what and why', including the time of the injury and the advice given to Mr C about what to do should his pain continue. Had this advice been given, Mr C may have returned to hospital sooner and been given an earlier diagnosis. We upheld the complaint.

Recommendations

We recommended that the board:

• make a formal apology; and
• ensure that our findings are made available to the member of staff concerned and that they review the Nursing and Midwifery Council code in relation to record-keeping.

Summary

Mr C complained that a hospital unreasonably delayed communicating an abnormal microbiology report to the relevant consultant.

We were satisfied that Mr C had a more appropriate remedy for his complaint and we considered that it would be reasonable for Mr C to use this remedy rather than SPSO. We decided to discontinue our investigation into Mr C's complaint.

Summary

Mr C complained about a change that prison healthcare staff made to his medication dosage. He also complained that he had not been included in the investigation into his complaint.

We took independent advice from a medical adviser. Their view, which we accepted, was that Mr C's medication had been appropriately prescribed and so we did not uphold this complaint.

We also found that Mr C had been consulted during the investigation, and so we did not uphold this complaint either.

Summary

Mrs C raised concerns about the care and treatment she received at Aberdeen Royal Infirmary. She complained that she was provided with inappropriate gynaecological treatment for her reported symptoms, that her operation was cancelled on the day of the proposed surgery, and that she was discharged despite having received pre-medication. She complained that there was poor communication about her medication and about the rescheduled operation. She also complained that the length of time she would have to wait for the rescheduled operation was unreasonable.

We took independent advice from a consultant gynaecologist and a consultant physician. We were advised that both the treatment suggested and the management of Mrs C's medication were reasonable. We were also advised that the date given for the rescheduled operation meant that the board had failed to meet the target guarantee time in line with The Patient Rights (Scotland) Act 2011 and that, as such, the delay was unreasonable. However, the medical records demonstrated that alternative options had been discussed with Mrs C's GP. We were advised that Mrs C's operation would not be classed as medically urgent.

We were concerned that the board was unable to provide copies of Mrs C's medical records from her admission to Aberdeen Royal Infirmary and that therefore the adviser was unable to comment on the care and treatment provided after Mrs C was admitted to hospital, including her discharge and the level of communication.

While the medical records demonstrated there was some communication with Mrs C and her GP following the cancellation of the operation, we were not satisfied that this was adequate.

Recommendations

We recommended that the board:

• provide a plan detailing the changes which have been made to prevent a recurrence in relation to the failure to store medical records securely;
• apologise to Mrs C for the failings identified in this investigation; and
• remind relevant staff involved in this case of the importance of maintaining comprehensive records in line with General Medical Council guidance.

Summary

Mr C complained to us about the care and treatment he had received from the maxillofacial (the speciality concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) unit at Aberdeen Royal Infirmary. Mr C had been referred to the unit because of a lesion (an area of abnormal tissue) on his palate.

A biopsy (tissue sample) was taken out but two weeks later he suffered a bleed from the site of the biopsy and had to re-attend the hospital. The following morning, Mr C experienced another bleed and was again advised to attend the hospital. After experiencing a further bleed on the next day, he contacted the hospital and was given the option of readmission for the bleeding to be monitored. Mr C refused this as he was due to go into a private hospital the next day for prostate surgery.

Mr C was admitted to the private hospital for the prostate surgery. However, he suffered a serious bleed from the site of the biopsy and it was decided the surgery could not go ahead. Instead a maxillofacial consultant was called and they took action to stop the bleeding from Mr C's palate, in theatre under general anaesthetic. Mr C had to pay for this procedure. He subsequently complained about the care and treatment he had received from the board's maxillofacial unit.

We took independent advice on Mrs C's complaint from a specialist in oral and maxillofacial surgery. We found that the biopsy had been carried out in a reasonable manner. We also found that the treatment provided by the maxillofacial unit in response to Mr C's bleeding had been reasonable and appropriate. We did not uphold the complaint.

Summary

Mr C complained about his treatment at Victoria Hospital. Mr C had injured his shoulder and felt the care and treatment provided by A&E was not reasonable. Mr C said his examination had been inadequate and inappropriately carried out and that he had been referred first for physiotherapy, rather than orthopaedic examination.

Mr C's physiotherapist diagnosed a serious injury and Mr C was referred to an orthopaedic specialist. He underwent a scan and was told he was not suitable for surgery as he was too old and the joint had suffered too much wear and tear. Mr C received a further examination as part of a second opinion offered by the board. This examination found Mr C to be a suitable candidate for surgery and he underwent a successful operation.

Mr C complained that the delay in diagnosing his shoulder injury had affected his treatment and chances of making a full recovery. We took independent advice from a consultant in emergency medicine and from a consultant orthopaedic surgeon. We were advised that Mr C had been treated appropriately in A&E and that it was normal practice to refer patients for physiotherapy in such cases. However, we were advised that Mr C's orthopaedic treatment had fallen below a reasonable standard as Mr C was within an appropriate age range for treatment. We therefore found that Mr C's orthopaedic treatment had been unreasonable.

Mr C also complained that the board had not responded reasonably to his complaints. Although the board's responses had on occasion been delayed, we found that their responses to Mr C's complaints were reasonable and so we did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• provide evidence that the orthopaedic specialist has reflected on the case and in particular the assessment of the adviser on Mr C's suitability for surgery; and
• apologise to Mr C for the failings identified in this report.