Health

Summary

Mr C, who works for an advice agency, complained on behalf of Mr A who was concerned about the care and treatment given to his late wife (Mrs A). In particular, he was concerned that there was an avoidable delay by staff at Forth Valley Royal Hospital in establishing that Mrs A was suffering from breast cancer. While the board accepted that there had been a delay and apologised, they said that Mrs A had suffered from a rare form of cancer which had been difficult to diagnose.

We took independent advice from a consultant breast surgeon. We found that while Mrs A's form of cancer was a very rare variant, opportunities had been missed to diagnose her sooner. There had also been an initial delay in Mrs A being seen and her cytology (examination of tissue samples under a microscope) results had been incorrectly reported. We therefore upheld the complaint and made recommendations.

Recommendations

We recommended that the board:

• make a formal apology recognising the shortcomings we identified; and
• check that the changes they outlined to Mr A are now in place and that all excision biopsies, as well as cytology aspirates and needle biopsies, are formally discussed at multi-disciplinary team meetings.

Summary

Mr C complained that a district nurse had wrongly carried out a procedure to reinsert a catheter at home. The district nurse failed to reinsert the catheter three times and he had to be taken to hospital for the catheter to be reinserted. At hospital it was established that a false passage had been created during the attempts at catheterisation. The hospital successfully reinserted the catheter. Mr C felt that the district nurse had not followed protocols when attempting to reinsert the catheter.

We obtained independent advice on the case from a nurse adviser. She said that there were problems when the district nurse tried unsuccessfully to reinsert the catheter and that contact was made with Mr C's GP for advice. It was decided to arrange a non emergency ambulance to take Mr C to hospital for the catheter to be reinserted. The adviser said that Mr C had suffered a relatively rare but recognised complication of catheterisation and that this did not necessarily mean that there had been a failure in carrying out the procedure. It was also noted that attempts at catheterisation were made in the hospital, and therefore we could not be certain exactly when the problem arose. We did not uphold the complaint.

Summary

Ms C complained on behalf of her mother (Mrs A) who had been a patient in Victoria Hospital. Ms C felt that her mother should not have been asked if she agreed to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) being put on her notes, as her mother was in a state of delirium. Ms C said that she, as next of kin, should make the decision, not hospital staff.

We looked at Mrs A's medical records and we took independent advice from an consultant geriatrician. We found that hospital staff had documented their consideration of Mrs A's situation and their actions to a reasonable standard, and they had acted in accordance with the relevant guidance on resuscitation and DNACPR. The guidance is clear that a patient with capacity can consent to or refuse CPR, and if they lack capacity the decision rests not with the next of kin, but with a legally appointed proxy or with the lead clinician. In general terms, overall responsibility for making a decision about CPR rests with the lead clinician. In the circumstances, we did not uphold Ms C's complaint.

Summary

Mrs C's mother (Mrs A) was admitted to the Medical Assessment Unit (MAU) at Dumfries and Galloway Royal Infirmary via A&E after showing signs of a stroke. Whilst in hospital, Mrs A suffered a major stroke. Mrs C raised a number of complaints about the board, including that they unreasonably failed to give Mrs A a clot buster rtPA (an injection to break down blood clots) and that nursing staff failed to monitor Mrs A appropriately.

We obtained independent medical advice from a consultant physician and a nurse. The medical adviser said that the board unreasonably failed to give Mrs A a clot buster rtPA, although they said that the decision would have been a difficult one and would have had to have been made by a specialist.

In addition, the medical adviser said that when Mrs A was in A&E, the board should have carried out a specific risk categorisation using the ABCD2 score (a risk assessment tool designed to improve the prediction of short-term stroke risk after a 'mini stroke'). Had they done so, this would have shown that Mrs A was at very high risk of progression to acute stroke. The medical adviser also said that Mrs A should have been admitted to an acute stroke unit and given a carotid Doppler (a scan to detect a narrowed artery in the neck, which may cause a stroke). She should also have been monitored continuously by experienced staff, rather than being admitted to the MAU. The medical adviser also said that a plan should have been made for Mrs A's care in the event of a deterioration, which should also have been explicit about what to do if new stroke deficits were detected.

Both advisers said the nursing staff did not monitor Mrs A appropriately or observe her every two hours, as required. The medical adviser said that the scoring system used by staff to monitor Mrs A (the Glasgow Coma Scale or GCS) was not entirely suitable. The nursing adviser said that not taking Mrs A's vital signs for a period of over five hours was a serious failing. We upheld Mrs C's complaints and made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• feed back the failings identified regarding the clot buster rtPA, the ABCD2 score, carotid Doppler and admission to an acute stroke unit to the staff involved;
• identify and address training needs for staff in A&E and the MAU on guideline 108 of the Scottish Intercollegiate Guidelines Network;
• provide Mrs C and her family with a written apology for the failings identified in the first recommendation;
• feed back the failings identified in Mrs A's nursing care to the staff involved;
• complete their review of the use of the GCS score, taking into consideration the medical adviser's views, and provide us with evidence of the outcome of the review; and
• provide Mrs C and her family with a written apology for the failings identified.

Summary

Mr C complained about the board following the death of his partner (Mrs A). Mrs A had attended A&E at Galloway Community Hospital with abdominal pain. She was recorded to have a high temperature and fast heart rate. The doctor who examined Mrs A diagnosed her as having a urine infection, and he discharged her with antibiotics. The next day, Mrs A was accompanying a friend to a hospital in another board area when she collapsed. She developed signs of sepsis (blood poisoning), originating in the gall bladder, and despite resuscitation and intensive care, she passed away.

In their response to Mr C's complaint, the board accepted that the early signs of sepsis had been missed at Mrs A's initial attendance at A&E and apologised for this. However, Mr C brought his complaint to us as he wanted further assurances that appropriate steps had been taken to avoid similar mistakes in the future.

We took independent advice from a medical adviser, who considered Mrs A's initial diagnosis when she attended A&E to be unreasonable based on her symptoms at the time. We also found Mrs A's elevated heart rate and temperature to be of sufficient concern that further investigation should have been warranted and admission to hospital considered. As such, we upheld the complaint.

In response to our enquiries, the board provided extensive details of procedural changes and training that had taken place in Galloway Community Hospital to aid in the diagnosis and treatment of sepsis, so we did not consider that any recommendations of this kind were necessary. We did, however, make a recommendation regarding the doctor who assessed Mrs A, and we asked the board to apologise to Mr C.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified; and
• confirm that the doctor who assessed Mrs A has discussed the treatment they provided to Mrs A at their annual appraisal.

Summary

Mr C complained about the care and treatment of his late mother (Mrs A) at Borders General Hospital. He raised concerns that staff unreasonably put in place a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order without discussing this with him, despite him holding welfare power of attorney. We took independent advice from a consultant physician. They found no evidence of the decision having been discussed initially with Mr C. We were critical of the board for failing to properly involve Mr C in discussions and we upheld this part of the complaint.

Mr C also complained about the actions of staff in relation to his mother's feeding. In particular, he questioned the process surrounding the insertion of a PEG (percutaneous endoscopic gastronomy) feeding tube. The advice we received indicated that Mrs A's nutritional intake was appropriately monitored throughout her stay. We were satisfied that Mr C was appropriately consulted and involved in decisions in this regard, including the decision to insert a PEG tube. We did not uphold this part of Mr C's complaint. In addition, Mr C complained about the general nursing care provided to his mother. We took independent advice from a senior nurse who reviewed the records and advised that the overall nursing care provided to Mrs A was of a good standard. We did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained about the adequacy of the board's response to his complaint. We found their response generally to have been of a reasonable standard. However, in addressing Mr C's concerns surrounding the DNACPR decision, they provided some information that was not supported by the medical records. Furthermore, while the board acknowledged and apologised for a failure to prescribe some of Mrs A's usual medication, they did not identify a subsequent gap in the prescribing chart. We upheld this aspect of Mr C's complaint. We made some recommendations in relation to both the complaints handling and prescribing failures identified.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to properly involve him in discussions about Mrs A's DNACPR status;
• remind their medical staff of the importance of involving patients and their carers in discussions about end of life care and of documenting such discussions;
• review their process for checking and prescribing relevant medication following admission and inform us of the steps they have taken to avoid a repeat of the failings this investigation has highlighted;
• apologise to Mr C for the inadequate response to his complaint; and
• remind complaints handling staff of the importance of investigating and responding to complaints comprehensively and accurately, ensuring that the information provided is supported by available evidence and that any discrepancies are reflected in their correspondence with complainants.

Summary

Mrs C suffers from fibromyalgia (a long term condition that causes pain all over the body). Over the course of several years, she received a number of treatments including acupuncture and attended the pain management clinic at Crosshouse Hospital. Unfortunately, none of the treatments resulted in good control of Mrs C's pain and, in early 2014, a decision was made to discontinue her acupuncture course and to discharge her. It was suggested that she attend a pain management programme but Mrs C disagreed and complained to the board.

We took independent advice from a consultant in anaesthesia and pain specialist and we found that Mrs C had received all the standard pain management approaches for fibromyalgia but that her treatment had not been successful. We learned that this was not uncommon. Mrs C had also had a second opinion but it was agreed that there was little that could be done for her that would likely make a significant lasting difference and that it would be futile to continue.

While it was evident that Mrs C suffers considerable pain and it was hugely disappointing that medication or other intervention would not help her, there was no evidence to suggest that this was the consequence of any action or inaction on the part of the board. For this reason, we did not uphold the complaint.

Summary

Mr C contacted NHS24 to tell them that he had taken an overdose of paracetamol. He was advised to go to the local A&E department as soon as possible for blood tests and treatment. He agreed to do so. He called back some time later advising that he no longer intended to go to A&E. As a result, NHS24 asked a doctor from the board's GP out-of-hours service to call him. The doctor called and discussed the potential impact of the overdose and highlighted how important it was to attend A&E but Mr C still refused to attend. Following the call, the doctor discussed Mr C's call with the specialist mental health team and they suggested that the doctor call for an ambulance to attend Mr C's home.

Mr C complained to our office as he was unhappy that the doctor failed to take appropriate steps to ensure he was safe following the call.

We considered Mr C's concerns and reviewed the board's records. We also sought independent advice from an adviser who is a GP. Having done so, we were satisfied that the doctor did provide appropriate advice to Mr C and, by calling an ambulance, the doctor had taken appropriate steps to ensure his safety. As a result, we did not uphold the complaint.

Summary

Mr and Mrs C complained about the care and treatment provided to their daughter (Ms A) at Ayr Hospital. Ms A had a complex medical history and had required several operations over the course of her life.

Ms A suffered repeated urine infections and underwent an operation for this in the hospital. During the operation, Ms A breathed in fluid from her stomach. She was admitted into the intensive care unit (ICU) and placed on a ventilator. Ms A deteriorated over the weekend and did not recover, and she died shortly afterwards in the ICU.

Mr and Mrs C complained Ms A's care was inconsistent and that there was an inadequate level of medical staffing over the weekend. Mr and Mrs C said they had been given contradictory accounts of Ms A's condition and it had been a shock when they were informed treatment was to be withdrawn from her. They believed this should have been discussed with them and that the way the staff broke the news to them was inappropriate. They also complained that, after she died, Ms A was left connected to drips and monitors, which they felt was inappropriate.

The board met with Mr and Mrs C following their complaint. They did not discuss Ms A's care and treatment but they apologised if staff had increased the family's distress through their language or actions.

We took independent advice from a consultant in intensive care medicine and a senior nurse. The advice we received was that the care and treatment was reasonable. The medical records showed an appropriate level of medical review, along with the correct treatment for Ms A's condition. We found that communication with Mr and Mrs C was appropriate. It was, however, unreasonable for the family to have been left with Ms A after she died, without any attempts by staff to ascertain their wishes. We found this had added significantly to the family's distress. Although the care and treatment was reasonable, the board had accepted there were failings in communication with the family. We found they had apologised appropriately but that they needed to provide evidence of the actions taken to prevent a recurrence. We upheld this part of Mr and Mrs C's complaint and made recommendations to the board.

Recommendations

We recommended that the board:

• provide evidence that the actions identified in Mr and Mrs C's meeting with the board (following their complaint) have been carried out; and
• remind nursing staff of the importance of establishing family members' wishes should a patient die whilst in the ICU.

Summary

Mr C complained about his wife (Mrs A)'s neurological consultation which they both attended, the correspondence following this consultation, and the way the board handled his complaints. Mr C said that the way the consultation at Crosshouse Hospital had been conducted failed to meet Mrs A's specific needs and requirements arising from the fact that she was autistic and had dyslexia, Asperger's syndrome and anxiety. Mrs A was subsequently diagnosed with a disc protrusion (a common form of spinal disc deterioration that causes neck and back pain) by another consultant and Mr C said that the failure to meet Mrs A's needs meant that the first consultant missed the diagnosis.

We took independent advice from a medical adviser and an equalities adviser. We found that it was not reasonable to expect the first consultant to have diagnosed a disc protrusion and the findings from a later investigation were not evidence that the diagnostic process had been hindered. In relation to the equalities aspect of the complaint, however, it was not clear that the consultation booking process and the consultation procedure would meet the needs of people with disabilities generally. While we found that the consultant was aware Mrs A had specific needs and requirements and had made adjustments in line with their understanding of them, the current process (whereby information about the consultation was normally read by the consultant just before the patient was seen) did not enable the board to plan ahead and make reasonable adjustments once a patient's needs were known. It was also not clear if staff had received appropriate training about making reasonable adjustments. We therefore upheld the complaint in light of the evidence in relation to the equalities aspect of the consultation booking process and consultation procedure.

With regard to the other aspects of Mr C's complaint, we found that the subsequent correspondence about the consultation was reasonable and that the board handled Mr C's second complaint in a reasonable way. However, we were concerned about the way that the board had handled Mr C's first complaint in that there was an unreasonable delay and staff were not as proactive as they should have been in keeping Mr C informed about the delay and the reasons for it. Moreover, the complaint was only resolved when the board revisited it after their substantive response to the complaint and it was not clear why this did not happen when they first investigated it.

Recommendations

We recommended that the board:

• carry out an equality impact assessment on the board's consultation booking process and consultation procedure;
• confirm the provision of training and guidance to ensure that clinical and booking staff make reasonable adjustments for patients with additional needs for consultations or, if this has already been delivered, provide us with evidence of the training and guidance;
• bring our decision, including the equalities adviser's comments, to the attention of relevant staff;
• bring our findings about complaints handling to the attention of relevant staff; and
• apologise for the failures this investigation identified.