Health

Summary

Miss C's mother (Mrs A) was admitted to Glasgow Royal Infirmary with an exacerbation of her chronic obstructive pulmonary disease (COPD – a disease of the lungs in which the airways become narrowed). Miss C complained about the care and treatment her mother received from the board whilst in hospital and the arrangements for her subsequent transport home. She was concerned that her mother was weaned off oxygen too early. She was also concerned that the board should not have considered her mother for a normal flight home when she had been admitted to hospital with a severe COPD attack and chest infection. Miss C said that her mother should have been transported home by air ambulance.

We obtained independent advice on the case from a consultant respiratory and general physician. The adviser said there was no evidence to suggest that Mrs A was weaned off oxygen too early. They explained that Mrs A needed oxygen from day one to day five of her admission but that from day six to day eight her oxygen levels were stable and at a satisfactory level and no additional oxygen was required.

In terms of Mrs A's discharge and transport home, the adviser said that as Mrs A had been assessed appropriately by the board, her condition was deemed to be stable and she had recovered from her recent COPD exacerbation. We found that, on balance, it was reasonable for her to have been discharged and flown home on a short, low altitude, commercial flight without provision of additional oxygen.

Although we concluded that Mrs A received reasonable medical care during her in-patient stay and that her discharge arrangements were appropriate, we were concerned about the standard of the handwriting in Mrs A's medical records, the standard of the photocopy supplied to this office, the board's handling of Miss C's complaint and the board's late submission of their comments on this case to our office. We therefore made some recommendations to address these issues.

Recommendations

We recommended that the board:

• feed back the failings identified in our decision on Miss C's complaint to the staff involved;
• ensure that in future readings are clearly recorded in patient records; and
• provide Miss C with a written apology for the failings identified.

Summary

Ms C said that a nurse injured her child's arm while removing a plaster cast. She complained to the board who made their own investigations but concluded that the cast had been removed in an appropriate way, and that neither the nurse or the doctor concerned had noted any injury.

We took independent nursing advice and we found that the records did not show any evidence of the child being distressed or injured. There was no evidence to show that the plaster cast had been removed in an inappropriate way. The complaint was not upheld.

Summary

Ms C, an advice worker, complained to the board about immunisations given to the child of her client (Ms A) by the community nursing team. The child had been given additional vaccinations on two occasions and the staff had failed to keep accurate records. Although the board upheld the complaints, Ms A felt they had not taken her concerns seriously.

We took independent nursing advice. The adviser found that vaccination errors had occurred but that the board had carried out a detailed investigation into the causes and that appropriate action had been taken to prevent a repeat occurrence. We upheld Ms C's complaints but made no additional recommendations.

Summary

Mrs C complained to us that the board had failed to provide reasonable care and treatment to her son (Mr A) when he attended the Royal Alexandra Hospital after taking an overdose of prescribed medication. Mr A was discharged from the hospital later the same day. Mr A had continuing symptoms of nausea and was given medication to prevent nausea and vomiting. He died two days later. This is thought to have been due to the effects of the overdose he took before attending hospital.

We took independent advice from a consultant in emergency medicine. They found that the level of medication taken by Mr A fell into the range that could cause death and required careful medical assessment and close observation. They noted that staff in the hospital ought to have contacted the National Poisons Information Service to discuss the matter, particularly as Mr A had taken a multi-drug overdose. We considered that the information service would have advised that Mr A should not be discharged until he was free of symptoms, as death can occur up to 54 hours after ingestion of the prescribed medication. Mr A was not free of symptoms as he required medication to control his vomiting.

Although we could not say whether Mr A would have survived had appropriate action had been taken, his symptoms could have been managed better had he remained in hospital. We therefore upheld Mrs C's complaint. However, we were satisfied that the board had learned lessons from the failures in Mr A's care and that the action they had taken in response to these failings was reasonable.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings in her son's care.

Summary

Miss C's mother (Mrs A) had cancer and was receiving care at home. During an admission to Glasgow Royal Infirmary for a review of her care, Mrs A suffered a fall. After her fall, Mrs A underwent a scan and was discharged two days later.

The scan report was issued six days after the scan took place and showed a fracture to Mrs A's L1 vertebra (a bone in the base of her spine). Miss C said that on Mrs A's discharge from hospital, Mrs A's family had been told that the scan was clear.

Mrs A's family continued to care for her at home but were concerned about her continuing back pain. They asked her GP to check the results of the scan with the hospital. Miss C said that the family was told that Mrs A had suffered a fracture to her L3 vertebra (a different bone in the base of the spine). Mrs A died the next day. Miss C was concerned that Mrs A had been cared for without her family being aware of her fracture.

Miss C complained to us that the family had not been reasonably informed about the results of the scan. We took independent advice from a consultant in general medicine and a radiologist. They noted that the fracture was clearly visible on the scan, but although the hospital's computerised audit trail showed staff had reviewed the scan, this was not documented in the medical records and there was no evidence that the results had been communicated to Mrs A or her family. While we did not find evidence that staff had given incorrect information to Mrs A or her GP, we were critical that staff did not identify the fracture and share this information. We therefore upheld this complaint.

Miss C also complained about the provision of Mrs A's pain relief during her admission. The advisers noted that staff had assessed and monitored Mrs A's pain appropriately and provided pain relief when required. We therefore did not uphold this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• apologise to Miss C's family for the failings found during our investigation;
• feed back our findings about the lack of documentation and communication of the scan results to the medical staff involved; and
• review and address any training needs for the staff involved, in relation to interpreting scans of this kind.

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.