Health

Summary

C complained about the care and treatment their grandparent (A) received when they were admitted to hospital. A was acutely unwell with a poor prognosis and was treated in the COVID-19 ward for a number of days. A's condition improved and they were discharged home. C complained that A did not have capacity to consent to treatment and that treatment to address A's confusion made their symptoms worse. C believed that clinicians failed to clearly communicate the treatment plan for A, that it was unreasonable for clinicians to focus on end of life treatment and that staff failed to meet A's basic needs.

In response to the complaint, the board explained that A was admitted with possible aspiration pneumonia and COVID-19. They said A was treated for COVID-19 and with antibiotics and that the care and treatment in this regard together with the assessment of A's capacity, was appropriate. Nursing staff gave A regular oral hygiene, but due to high flow oxygen therapy this was difficult. Appropriate assessment and treatment was undertaken with respect to A's skin.

We took independent advice from a consultant geriatrician (specialist in care and treatment of the elderly) and a nurse. We found that whilst many aspects of A's care were reasonable and of a standard expected, there was a significant failure with respect to the assessment of A's delirium. We also found that there were significant failures with respect to the level of personal care provided to A. Therefore, we upheld C's complaints relating to medical and nursing care and treatment.

In relation to communication with C and their family, we found that the records documented an appropriate level of communication with respect to decisions made about A's care. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to handle their complaint reasonably. We found that there was discrepancies and apparent inaccurate information contained in the board's response. Therefore it was reasonable to conclude that the board failed to carry out a reasonable investigation and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failure to handle and respond to the complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and A for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Staff to be compliant with HIS (2020) Prevention and Management Standards. All staff assessing pressure ulcer risk fully understand the risks and are able to put in place measures and equipment to minimise risk. Staff completing care rounding able to identify that patients at risk of pressure damage must have their position changed and not nursed in the same position for 24 hours.
• Relevant staff are familiar with the adult with incapacity process and the importance of delirium screening tools with patients where delirium is observed and evident.
• Staff responsible for undertaking oral care are trained and competent in assessing oral hygiene requirements, carrying out oral hygiene and accurately documenting this in the records.
• To ensure a person centred approach to assessment of continence and appropriate prescribing of continence management products.

In relation to complaints handling, we recommended:

• Complaints handling staff to be familiar with the complaints handling procedure. Clinical staff to be aware of the significance and importance of a thorough consideration of clinical records and reflecting on these in an open and transparent manner when offering responses to specific aspects of complaint.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late partner (A) who was admitted to hospital with hallucinations and delirium. C complained that hospital staff labelled A an alcoholic and that this negatively impacted the treatment that they received. A was treated for a suspected urinary tract infection (UTI) but died in hospital. C was critical of several aspects of the treatment A received, including concerns about their nutritional intake, the medication they were given and the staff's response to the rapid deterioration of A's condition.

In their response, the board apologised that C had been given the impression that staff felt the only cause of A's delirium was alcohol excess. The board explained A's clinical presentation and the reasoning for treating them for suspected UTI and alcohol withdrawal. The board explained A's condition rapidly deteriorated in hospital and resulted in a cardiac arrest. The board's position was that the care provided was reasonable.

We took independent advice from a consultant in respiratory and general medicine. We found that a reasonable working diagnosis of a possible infection was determined and the treatment plan was appropriate. We considered that the care and treatment provided was reasonable. Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the board's out of hours (OOH) service. A was experiencing worsening symptoms of disorientation, fatigue and abdominal pain. C telephoned NHS 24 and received a call back from an OOH GP who arranged for an ambulance to attend A's home. Paramedics examined A and called the OOH service who agreed that an OOH GP would carry out a home visit to A. Paramedics left the house and the OOH GP attended shortly afterwards. Upon examination, A was found to have a mild fever and fast heart rate, with all other observations recorded as normal. The OOH GP prescribed antibiotics. A died a few days later.

We took independent advice from a GP. We found that it was an appropriate course of action to request a paramedic assessment upon receiving C's initial call to the OOH service. We also found that given the observations of the paramedics and the OOH GP, it was appropriate to treat and manage A at home and to take into consideration that A's own GP practice would be open some four hours later. Therefore, we did not uphold C's complaint but did provide feedback to the board in relation to the GP's record-keeping.

Summary

C's late parent (A) was referred by their GP to the board's ear, nose and throat (ENT) department on urgent suspicion of cancer. A's referral was originally vetted and agreed as urgent. In response to the COVID-19 pandemic, significant operational changes were made by the board resulting in A's referral being re-vetted and downgraded to routine the following month. Due to worsening of their symptoms, A contacted the board and it was agreed that A required further investigation by barium swallow (a test to look at the outline of any part of the digestive system). However, as an aerosol generating procedure, these procedures had been suspended by the board and A did not undergo the test until six month's after their initial GP referral. Following the barium swallow and further investigations, A was diagnosed with oesophageal cancer.

C complained that the care and treatment provided by the board to A had been unreasonable, noting the delays in investigating A's primary symptom of dysphagia (interference with the swallowing mechanism). C also considered A's age had negatively impacted the decision-making in respect of the investigations and treatment options they were offered, and they advised that A had not known until a month after their barium swallow that cancer had even been considered as the likely cause of their symptoms.

We took independent advice from a consultant ENT surgeon. We found that the referral to ENT should not have been downgraded to routine when it was re-vetted given A's symptom of dysphagia. On being seen at the ENT clinic, it was reasonable to refer A for a barium swallow at this stage but only if it had been done urgently. In A's case, the time between the request being made and their appointment was four months, which we considered was unreasonable in light of oesophageal cancer being recorded as a possible differential diagnosis on the referral form. We did not find that A's age had negatively affected the treatment options available to them. On the matter of when A became aware of their diagnosis or knowing that they were being investigated for cancer, we could not find any evidence to reasonably determine what was known or understood by A about the cause of their symptoms at the time. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in investigating and treating A's symptoms. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Evidence that the findings of this investigation have been fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding vetting processes.
• Patients referred with urgent suspicion of cancer symptoms should be appropriately assessed, taking into account relevant guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to adequately investigate and/or treat their late spouse (A)'s condition by failing to follow up their appointment at a gynaecological clinic.

A experienced abdominal pain and heavy menstrual bleeding. A's GP referred them to a gynaecology clinic. A attended the clinic and was referred for a scan. A was then discharged back into the care of their GP. A year later, A's GP referred them to gynaecology under a suspicion of cancer. A was subsequently diagnosed with endometrial cancer (a type of cancer that begins in the uterus). A was given various cancer treatments but later died.

C complained to the board about A's care and treatment. The board acknowledged that A's care was not to the standard it should have been. They accepted that the gynaecology clinic had failed to follow local treatment guidance in A's case. They apologised for this. C remained unhappy and asked us to investigate. C was concerned that the board had failed to adequately explain events.

We took independent advice from a gynaecologist. We found that the board had failed to follow their local clinical guidance in A's case. We welcomed the board's acknowledgement of this failing and their apology. However, given the significance of the failings identified we made additional recommendations for action by the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow the relevant clinical guidelines in A's case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Where local guidance varies from national guidance there should be appropriate review to ensure the variation has been adequately documented and controlled and diagnostic criteria and terminology is clear and appropriate. In undertaking the review we would encourage the board to consider our comments on the simplification of the local guidance and structure of its flowchart.
• Patients with heavy menstrual bleeding should receive appropriate care and treatment in line with the relevant clinical guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, an advocacy worker, submitted a complaint on behalf of their client (A). A received treatment from the board for muscular dystrophy (a group of inherited genetic conditions that gradually cause muscles to weaken) over a period of four years. While visiting abroad, A received an alternative diagnosis of polymyositis (a group of rare diseases that involve chronic muscle inflammation and weakness, and in some cases, pain). A complained that their condition was not appropriately investigated or diagnosed, leading to a delay in receiving appropriate care.

We took independent clinical advice from a consultant neurologist (specialist in diagnosis and treatment of disorders of the nervous system). We found that the investigations carried out by the board were reasonable and on receiving further information from an overseas clinician, the board took reasonable steps to consider this information.

We considered that the board reasonably investigated A's symptoms. Therefore, we did not uphold C's complaint.

Summary

C asked a doctor at the practice to complete a DVLA medical examination. The doctor advised C that they did not have capacity to assist C and directed them to a private firm who could help.

C made a complaint to the practice about the decision and availability of doctors at the practice. In their response, the practice asked C to apologise for insulting staff or they would be removed from the practice. C was subsequently removed from the practice list. C made a further complaint to the practice regarding the decision to remove them from the practice list. The practice responded to the complaint, explaining the rationale for removing C. C was dissatisfied with the responses provided by the practice to their complaints.

We found that, whilst C's complaint was likely to have been difficult for staff to learn about, the practice's response was poor. Demanding C apologise was not an appropriate manner in which to try and establish an understanding or re-build trust between a complainant and members of staff. Therefore, we upheld this part of C's complaint.

We also found that it was not reasonable for the practice to have treated C's complaint as having caused an irretrievable breakdown of the relationship between C and the practice. The practice did not follow the appropriate process should they have wished to warn C about the appropriateness of the complaint. Therefore, we found it was unreasonable for the practice to remove C from the practice list and upheld this part of C's complaint.

The practice apologised to C.  While we acknowledge that an apology was given, that apology did not, in our view, meet the SPSO guidelines on apology, as was required by our recommendation.  In this respect it only partially met the recommendation.

Our office tried to engage constructively with the practice over a considerable period of time about giving a further apology, recognising that the original circumstances giving rise to the complaint, were rooted in an already difficult relationship with the C. The practice did not issue any further apology to C. The Ombudsman considered the extent to which it would be in C’s and in the public’s interest to escalate the matter and apply her statutory powers as set out in our Support and Intervention Policy. Having had regard to the length of time which had passed, the fact there had been partial compliance, and changes there had been at the practice in the meantime, the Ombudsman determined that a further apology, even were it to be issued by the practice, would no longer be meaningful, so would not be in either the C’s, or the public’s, interests to pursue.

The Ombudsman has communicated with the practice to communicate her disappointment about the practice’s failure to engage meaningfully with her office and their poor attitude, and to confirm additional steps her office will take when considering complaints received about the practice in the future

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to focus their response on the issue of C's complaint and in responding in an inappropriate manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failures identified and the decision to remove them from the practice list. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Complaint responses focus on issues of complaint raised by complainants. Staff should be familiar with the practice's complaints handling procedure and reflect on appropriate approaches to communicating with service users, highlighting communication it deems to be offensive or inappropriate and how to resolve complaints in an effective manner.
• Staff should be familiar with the practice's complaints handling procedure and reflect on appropriate approaches to communicating with service users and how to resolve complaints.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

This decision was originally published on 16 August 2023. On the 24 July 2024, we added the following information: 

"The practice apologised to C.  While we acknowledge that an apology was given, that apology did not, in our view, meet the SPSO guidelines on apology, as was required by our recommendation.  In this respect it only partially met the recommendation.

Our office tried to engage constructively with the practice over a considerable period of time about giving a further apology, recognising that the original circumstances giving rise to the complaint, were rooted in an already difficult relationship with the C. The practice did not issue any further apology to C. The Ombudsman considered the extent to which it would be in C’s and in the public’s interest to escalate the matter and apply her statutory powers as set out in our Support and Intervention Policy. Having had regard to the length of time which had passed, the fact there had been partial compliance, and changes there had been at the practice in the meantime, the Ombudsman determined that a further apology, even were it to be issued by the practice, would no longer be meaningful, so would not be in either the C’s, or the public’s, interests to pursue.

The Ombudsman has communicated with the practice to communicate her disappointment about the practice’s failure to engage meaningfully with her office and their poor attitude, and to confirm additional steps her office will take when considering complaints received about the practice in the future."

Summary

C complained about the care and treatment provided to their relative (A) by the practice.

A attended the practice frequently within a year and was later diagnosed with an aggressive form of cancer. A died shortly after. C believed that A's concerns were not properly taken into account when they attended the practice and that A should have been referred sooner for investigations. The practice provided a detailed reply to C, stating their view that A's concerns had been investigated appropriately, and that there had been no indication for a cancer referral.

We took independent advice from a GP. We found that there was no reason to suspect cancer as a possible cause of A's symptoms. However, as symptoms persisted, an urgent cancer referral should have been considered. We found that it was highly unlikely, given the aggressive nature of A's cancer, that the delay in A's diagnosis had any impact on the outcome of A's disease. Although A's initial treatment was reasonable, we found that there were failings in care in that the practice should have made an urgent referral for A sooner. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C, and A's immediate family, for the failure to make a referral for A in line with the Scottish Government guidelines. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The practice should be familiar with the Scottish Suspected Cancer Referral Guidelines and refer patients for specialist assessment in accordance with the guidelines.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late parent (A) by the board. A had dementia and was experiencing worsening delirium following a urinary tract infection. A was admitted to hospital by an out-of-hours doctor who visited A at home. C's sibling accompanied A in the ambulance but was told that they were unable to stay with A in hospital due to COVID-19 visiting restrictions. A was transferred to a side ward and later that evening, fell from the bed. A had a head laceration and complained of right hip pain. A head CT and hip x-ray were undertaken which confirmed a right hip fracture. A was transferred to an orthopaedic ward (specialists in the treatment of diseases and injuries of the musculoskeletal system) but it was decided A would not survive an operation due to the fall and hip fracture trauma. A died a few days later.

We took independent advice from a consultant geriatrician (a specialist in the care of older adults) and a senior nurse in falls prevention.

We found that a reasonable level of information from A's family was recorded and taken into account by medical staff, that the assessment of A's delirium was reasonable and that it is common practice for a doctor to try and speak directly with a patient with significant dementia or delirium to allow them to assess the individual's capacity. We also found that it was reasonable to transfer A to a side room, that the action taken by medical staff following the fall was reasonable, as was the communication with the family. Furthermore, that the pain relief was reasonable and was a priority of staff who saw A.

However, we found that there were a number of failings in the nursing care and treatment provided to A. We found that it was unreasonable that no family members were allowed to stay with A, that there was a lack of information documented in the nursing records and a lack of completed paperwork in relation to assessments that should have been carried out on A. Whilst nursing staff's immediate attendance and commencement of the post fall assessment and escalation tool was reasonable, we also found that there was a delay in contacting the family and failure to use a straight lift. Therefore, we upheld this part of C's complaint.

C also complained that the board failed to carry out a reasonable investigation into A's fall in hospital. We found that a serious adverse event review (SAER) should have been carried out instead of a local adverse event review (LAER). Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology.

What we said should change to put things right in future:

• Family members should be communicated with in a timely manner, particularly after a patient has fallen whilst in hospital, and the detail of conversations should be recorded. Relevant staff should be aware of the requirements for the assessment for potential fracture, safe manual handling for possible fracture including using flat lift equipment.
• Patients' nursing care should be clearly and accurately recorded including any conversations with family members. Entries should be legible, signed and dated.
• Adverse events should be reviewed and reported in line with relevant guidance and in a way that fully reflects the patient journey and outcome with appropriate regard to learning and improvement and communication with the family throughout the process.
• Assessments such as mobility; bedrail and TIME assessments should be completed appropriately and consistently and recorded in the nursing records.
• Relevant staff should be aware of changes to guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.