Health

Summary

Ms C, who works for a voluntary agency, complained on behalf of Mr A that the care and treatment he received was inadequate and that his subsequent complaint had been poorly handled. Mr A had suffered repeated problems with dental bridgework failing. Ms C said he had been seen by a number of different dentists, causing problems with continuity of care. Mr A also believed that a tooth had been prepared for a crown inappropriately and that he had had an unnecessary extraction, and that he had unreasonably been refused bridgework treatment.

We took independent dental advice, which stated that Mr A had received a comprehensive examination. It was not practical to fit a bridge because of decay in the teeth it would have to be attached to. It would also not have been appropriate to attempt any other restorative work until Mr A's gum disease issues were dealt with. The advice noted that Mr A had been insistent that a bridge be fitted, but the dentist had correctly refused on the basis that this would be inappropriate and would worsen the condition of his teeth.

We found that Mr A's care and treatment was reasonable in the circumstances. His complaint had been thoroughly investigated and a response provided within a reasonable timescale.

Summary

Mr C complained about the mental health care and treatment of his late wife (Mrs C) in the weeks prior to her suicide. Mrs C had a history of mental illness, and was referred urgently to psychiatry by her GP due to returning symptoms. Mrs C was assessed and a plan was made to treat her at home with support from the Intensive Home Treatment Team (IHTT). After four weeks, the IHTT referred Mrs C to her local team (Rehabilitation and Enablement Services Mental Health Team (RES MHT)) for further care. However, due to problems with the referral process there was a delay in transferring care and a ten day gap between appointments. Mrs C completed suicide the day after her first RES MHT appointment.

The board conducted a Significant Clinical Incident investigation into Mrs C's death. While the review team concluded the care was appropriate, they identified problems with the transfer process, and a lack of documentation about the role Mrs C's family had in her care planning. In response to Mr C's complaint, the board acknowledged failings in involving Mrs C's family in her care planning and in the referral process. The board apologised to Mr C and provided information on a number of actions underway to improve the RES MHT service.

After taking independent mental health and psychiatry advice, we upheld Mr C's complaint. We agreed with the board's findings that there was a lack of involvement of Mrs C's family in her care planning, and failings in the referral process. We also found that, while a comprehensive risk assessment was carried out, the management plan did not include a summary formulation of risk (as required by the local policy). While we considered the board had already taken appropriate action to address the issues found in relation to the RES MHT, we asked that they provide details of action taken in relation to the IHTT.

Recommendations

We recommended that the board:

• remind staff of the requirement to implement a summary formulation of risk (as well as a risk management plan) under the Clinical Risk Screening and Management Policy; and
• demonstrate that action has been taken to improve documentation of carer involvement (and patient consent to this) by IHTT staff in care planning and risk management.

Summary

Mrs C complained to us that her daughter (Miss A) had been detained unreasonably under an emergency detention certificate (a 72-hour emergency section) after displaying symptoms of a mental disorder. We are normally unable to consider complaints about detention under the Mental Health Act, as there is a right of appeal to a mental health tribunal. However, there is no right of appeal against an emergency detention certificate and we were able to consider this aspect of Mrs C's complaint. We took independent advice on Mrs C's complaint from a psychiatric adviser. We found that Miss A had met the criteria for detention and it was reasonable that she was detained under an emergency detention certificate. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that nursing staff at Parkhead Hospital had restrained Miss A unreasonably around the time she was detained. We found that the restraint used by staff had been reasonable and was consistent with normal practice at that time.

Miss A had been discharged and the emergency detention certificate had been revoked when she saw a consultant on the day after she had been detained. Mrs C complained that appropriate medical staff were unavailable until the day after Miss A was detained. She said that if an appropriate doctor had been available at the time Miss A was admitted, she would not have had to be detained in hospital overnight. We found that is that it is common, accepted practice that there was no consultant on the ward when Miss A had been admitted to hospital out-of-hours. We also found that it was reasonable that Miss A's detention was reviewed and revoked within 24 hours. We did not uphold this aspect of Mrs C's complaint. That said, we found that the board had failed to issue an adequate response to Miss A's complaint to them and we made a recommendation in relation to this.

Recommendations

We recommended that the board:

• issue a written apology to Miss A for the failure to respond to the matters raised in her complaint.

Summary

Ms C, an advice agency worker, complained on behalf of the family of Mrs A. Two GPs at the practice had visited Mrs A's home on request and diagnosed that she had a urinary tract infection, for which they prescribed medication. After the GPs left, the family tried to move Mrs A upstairs to her bedroom, but in the process she suffered a leg injury. An ambulance was called and she was admitted to hospital for that injury.

The family complained that Mrs A was not very mobile and that the GPs should have admitted her to hospital, rather than simply leave them on their own to manage an elderly, immobile patient in a home with steep stairs.

We took independent advice on this case from a GP. Our investigation established that the GPs had acted in line with guidance on hospitalisation in the SIGN guideline, 'The Management of Urinary Tract Infection in Adults'. (SIGN is the Scottish Intercollegiate Guidelines Network, which is an organisation that develops clinical guidelines for the NHS in Scotland.) In other words, they had appropriately identified that, in her case, Mrs A should be treated at home but that hospitalisation might become appropriate. The GPs had also appropriately arranged urgent referral to a multi-disciplinary team, who would be able to help Mrs A with self-care and mobilisation.

The GPs considered that they had advised the family that Mrs A might need to remain downstairs initially. In the absence of independent evidence, the facts around this could not be established either way. The lead GP felt on reflection that he could have checked more whether the family had understood his advice and information, and said he would check this more in future cases.

Summary

Mr C was referred to Glasgow Dental Hospital by his dentist in January 2015. He attended the appointment in March but told the hospital he did not wish to see the same clinician again. Mr C also requested a second opinion following the outcome of this appointment. Mr C's case was passed to hospital management for a new appointment to be made.

In the meantime, Mr C changed dental practitioner. In July 2015, he was referred back to Glasgow Dental Hospital by his new dentist. However, the hospital replied to say they were unable to offer Mr C an appointment because of a previous history of aggressive behaviour and non-attendance. They suggested that future treatment be carried out by Mr C's dental practice.

In December 2015, Mr C complained to the board about not being provided with a second opinion after his March appointment. The board apologised for not carrying out a second opinion, but maintained that they were unable to offer an appointment. Mr C then complained to us.

We took independent advice from a dentist. They said it appeared that a second opinion had not been offered as a result of administrative oversight. They said that this was unacceptable, but noted that the board had acknowledged this and looked into their procedures to prevent such a situation recurring. We asked the board to advise us of the action they have taken.

The adviser also said that the board were entitled to discharge Mr C back to the care of his dentist because of the non-specialist nature of Mr C's treatment, episodes of aggressive behaviour towards clinical staff and multiple non-attendance at appointments. We accepted this advice, although on balance we upheld the complaint because a fuller explanation should have been provided and because of the failure to organise a second opinion.

Recommendations

We recommended that the board:

• advise us of the action taken to prevent a situation occurring whereby a request for a second opinion is not actioned.

Summary

Ms C complained that she had been referred to the Glasgow Dental Hospital for treatment for gum disease. Ms C had concerns about her treatment and, in particular, the failure to treat properly an abscess (a painful swelling caused by a build-up of puss) in her mouth. Ms C visited both the hospital and the board's out-of-hours service, but the problem was not properly diagnosed over several visits.

We took independent dental advice on Ms C's complaint. The adviser said that Ms C was treated correctly for the problem which had led to her referral to the hospital. However, the advice we received was that Ms C should have been x-rayed on her first attendance with an abscess. The failure to do this had prevented her abscess being properly diagnosed or treated. The adviser noted this was contrary to General Dental Council (GDC) guidance.

We therefore found that whilst Ms C's treatment plan was reasonable for her original dental problem, it was unreasonable for the board not to have followed the appropriate diagnostic guidance when she developed an abscess, so we upheld her complaint.

Recommendations

We recommended that the board:

• review its procedures to ensure that patients presenting with abscesses or associated swelling receive x-rays in line with GDC guidance; and
• apologise for the failures identified in this case.

Summary

Ms C complained to us about the care and treatment she was given when she went into the Princess Royal Maternity Unit to give birth to her daughter. When her labour was slow to progress and other alternatives were unsuccessful, her baby was delivered by caesarean section (an operation to deliver a baby which involves cutting the front of the abdomen and womb). However, doctors noted that she was not recovering from surgery as expected. She was taken back into surgery when she collapsed, two hours and twenty minutes after her caesarean section, and was found to have had a major internal bleed. Ms C raised concerns that her caesarean section was not carried out appropriately, and that doctors did not notice her deterioration quickly enough. She said that this resulted in a prolonged recovery time for her, and difficulties relating to her time with her new-born baby.

We sought independent advice from an obstetric adviser. They reviewed Ms C's medical notes in detail and did not raise any concerns about the way Ms C's caesarean section had been carried out. However, they did raise concerns about how medical staff responded to her deteriorating condition in the two hours after her caesarean section. They noted that a blood test had been taken but not followed up. They noted that medical staff did not maintain appropriate records of their decisions and plans. They also considered that Ms C's deterioration was not appropriately escalated to both anaesthetic and obstetric teams. They said that, if all this had been done, it was likely that Ms C's second operation could have been undertaken 45 minutes earlier, before her condition had become so critical.

We noted the obstetric advice on Ms C's care and treatment and upheld her complaint. We made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• review the post-operative escalation policy, to ensure concerns are escalated to both obstetrics and anaesthetics when post-operative concerns persist;
• share these findings with the staff involved, and remind them of the need to record their findings, working diagnoses, plans and timescales for review;
• review mechanisms for receiving blood test results to ensure that results are identified and acted on promptly;
• review staff competencies and potential training needs on the early diagnosis of occult/internal haemorrhage and on scanning an acute surgical abdomen; and
• apologise to Ms C for the failures we identified, and for the distress caused to her and her family.

Summary

Mrs C complained about the standard of medical and nursing care and treatment her late mother (Mrs A) received as an in-patient at New Victoria Hospital in October and November 2014. Following a hip operation, Mrs A was transferred from another hospital to a rehabilitation ward at the New Victoria Hospital. She had underlying health conditions (including hospital acquired pneumonia, lung disease and heart disease) and contracted clostridium difficile (a common bacteria that infects the colon). Whilst in hospital, her condition deteriorated and she died less than a fortnight after being transferred to the New Victoria Hospital.

We took independent advice from a medical adviser and a nursing adviser. Turning first to medical issues, we found that while appropriate investigations were carried out within a reasonable time and treatment decisions were reasonable, there were shortcomings. These included that senior clinicians should have been more involved in Mrs A's care and medical staff had failed to implement the relevant do not attempt cardiopulmonary resuscitation (DNACPR) policy. We also found that there was a failure to discuss the possibility of Mrs A's death with her family within a reasonable time. Also, the day before Mrs A's death, medical staff should have discussed her condition with an intensive care unit doctor sooner and it would have been reasonable for medical staff to have had a discussion with them the day before. Related to this, it was not clear whether the on-call doctor had followed up contact from a member of nursing staff about Mrs A's condition or whether they had been informed of her condition following the change of oxygen supply.

Turning now to nursing issues, we found that there were shortcomings in relation to infection control and nutrition which the board had addressed. However, we also found shortcomings around the implementation of an early warning system guidance (the National Early Warning Score - NEWS) and that nursing staff failed to monitor and assess Mrs A on the day before her death in line with this guidance. We also found failings in record-keeping.

Recommendations

We recommended that the board:

• consider the issues around end of life care including communication and take steps to ensure no recurrence;
• bring the medical adviser's comments in relation to record-keeping, implementing the DNACPR policy and escalating difficult significant clinical decisions to relevant staff, and take steps to ensure no recurrence;
• bring the nursing adviser's comments about shortcomings in implementing NEWS policy to relevant staff; and
• apologise for the failures this investigation identified.

Summary

Ms C was referred to the former Southern General Hospital in Glasgow by her GP for investigation of secondary infertility. A HyCoSy scan (a procedure to detect whether the fallopian tubes are damaged or blocked) and blood tests were arranged. The board took ten months to arrange the scan. Ms C said that because of the time it was taking to see a consultant gynaecologist to discuss the results of the scan and as the board could not provide her with a timescale of when she would get an appointment and as she was suffering severe abdominal pain, she arranged to be seen privately by a consultant gynaecologist abroad. The private consultant gynaecologist reviewed the results of her HyCoSy scan and carried out an ultrasound scan and, as a result, recommended a laparoscopy to confirm and, if necessary, treat endometriosis. A laparoscopy is surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin.

Ms C said that although she presented this information to the board's consultant gynaecologist, they refused to arrange a laparoscopy. Ms C said she paid for the laparoscopy procedure abroad. It confirmed a diagnosis of endometriosis and she had surgery to treat and cure her symptoms.

We took independent advice from a consultant gynaecologist. We found that there was an unacceptable delay in arranging Ms C's HyCoSy scan, the result of which was not normal and that a laparoscopy should have been arranged for Ms C by the board. Based on the clinical advice we received, we were satisfied that the board should have offered Ms C a laparoscopy to provide the definitive diagnosis. Therefore, we upheld Ms C's complaint.

We were also critical that the board were unable to locate and provide us with Ms C's complete clinical records and we made a recommendation to address this.

Recommendations

We recommended that the board:

• apologise to Ms C for the delay in arranging a HyCoSy scan, the failure to offer her a laparoscopy and for losing her medical records;
• refund to Ms C the invoiced cost of her ultrasound scan, laparoscopy and associated treatment arranged abroad;
• provide evidence that the delay in carrying out the HyCoSy scan has been addressed;
• feed back the comments of the adviser and the findings of this investigation to the consultant gynaecologist for reflection and learning, to include the importance of the management of medical records; and
• take steps to ensure that they are complying with 'Records Management: NHS Code of Practice (Scotland)'.

Summary

Mr C complained about the care and treatment received by his daughter (Miss A). Mr C raised concerns that there was not a reasonable care plan in place to address Miss A's borderline personality disorder (BPD) diagnosis and that the input she was receiving was not sufficient and was not in line with recognised guidance in this area. He also raised concerns that Miss A had been prescribed anti-psychotic medication despite this not being recommended for the treatment of BPD.

We took independent medical advice from two consultant psychiatrists. We were advised that there was a reasonable care plan in place for Miss A over the period in question. However, there was no evidence that this had been appropriately reviewed on a regular basis. It also noted that the care plan might have benefited from the inclusion of additional information. While a more structured approach to Miss A's care planning (known as the Care Programme Approach) might reasonably have been deemed unnecessary given her circumstances, we saw no evidence of this having been considered. We were advised it would have been good practice for this to have been considered and for any decision not to utilise this approach to have been documented. On balance, we upheld this aspect of the complaint.

With regards to the level of intensity of treatment provided to Miss A, we were advised that she had been considered for a range of additional therapies but deemed unsuitable at the time of each assessment. As such, the advisers considered that the current level of provision was appropriate to her circumstances. Mr C also complained that group treatment sessions had not been provided but we noted that Miss A had also been assessed, and deemed unsuitable, for therapies that could have been delivered as group sessions. We did not uphold these aspects of the complaint.

We were advised that it was common practice for anti-psychotic medication to be used to help alleviate some of the effects of BPD, despite there being very little evidence for such an approach. We concluded that this was reasonable in Miss A's circumstances and did not uphold this aspect of the complaint. However, we noted that the rationale for this should have been discussed with Miss A and that it would have been helpful for this to have been recorded in her care plan.

Recommendations

We recommended that the board:

• remind Community Mental Health Teams (CMHTs) to ensure that review dates are set and adhered to for care plans and that reviews should be clearly documented in the records;
• remind CMHTs to consider the use of the Care Programme Approach in complex cases and clearly document any decision not to utilise this approach; and
• ask CMHT staff to reflect on the advice we received and consider enhancing the level of detail included in future care plans.