Health

Summary

C complained to us about the medical and nursing care their late parent (A) received. A attended hospital for a bronchoscopy (a procedure to look directly at the airways in the lungs using a thin, lighted tube) and a biopsy (a medical test to determine the presence or extent of disease). A became unwell and was admitted. The biopsy result confirmed that A had cancer. It was considered A was not fit for treatment and a palliative approach to care was recommended. A’s condition worsened and they died in hospital.

C complained about aspects of A’s care and treatment. C also complained about the communication from medical staff. The board did not uphold C’s complaint but apologised because they felt that communication had been poor. C remained unhappy and escalated the complaint to us.

We took independent advice from a specialist in general medicine and in acute nursing. We found that A’s care and treatment was reasonable. We also found that the communication with C and A was reasonable. Therefore, we did not uphold C’s complaints. However, we did provide the board with feedback on telephone updates to patient’s families.

Summary

C complained about the care and treatment their spouse (A) received over a number of years by the board.

C submitted a complaint to the board expressing A’s concern that they did not take reasonable care when carrying out two surgeries. C and A were dissatisfied with the board’s investigation and response to their complaint.

A underwent surgery in their abdomen in an attempt to resolve recurring infections and said they suffered significant pain afterwards. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We were satisfied that this surgery did not cause the pain that A had linked to the procedure. However, we were critical of the board for failing to recognise that scans taken prior to the surgery had shown evidence of staples in A’s abdomen from previous surgeries. We found that the staples were a likely source of A’s infections and that this should have been identified prior to the surgery taking place. Had it been identified, A’s management plan may have been different. Therefore, we upheld this aspect of C’s complaint.

A also underwent a procedure on their reproductive organs. C complained that the procedure that was carried out, as described in the record of the operation, was not the one to which A had consented. We found that it had not been possible to complete the planned procedure due to an issue in the affected area, which had not been apparent until the procedure began. Whilst we were critical of the way that the procedure was described in the records, we found that the procedure itself was reasonable and appropriate in the circumstances. Therefore, we did not uphold this aspect of C’s complaint.

C and A complained that despite the board’s complaints procedure stating that complaints could be submitted in writing, in person, or over the telephone, the board insisted that A’s complaint was submitted in writing. A explained that they found it difficult to put their complaint in writing and had specifically requested a meeting with the board to discuss their concerns. This request was denied. We found that although there were reasonable reasons for asking A to submit the complaint in writing, these were not explained clearly by the board, and A was given no explanation as to why their request for a meeting was refused. We were critical of the board’s communication with C and A regarding the complaint, and of delays in the early stages of the board’s investigation. Therefore, we upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. 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 board should share this decision with the clinical staff involved in A’s treatment with a view to identifying ways of avoiding similar issues in the future.

In relation to complaints handling, we recommended:

• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when they make a 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 that the board provided their late parent (A) with inadequate care and treatment when they were an in-patient in hospital.

C complained to the board that they had failed to provide A with adequate personal care, nutrition and hydration. C also complained that the board had failed to accommodate A’s disabilities. The board identified failures in A’s care and apologised for these. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that more consideration should have been given to A’s minimal fluid intake, and the impact of this in terms of delirium and escalation to medical staff. In addition, we found that it appeared that more could have been done to support A in relation to their toilet needs.

Therefore, we upheld the complaint.

Additionally, we found that the board did not provide C with sufficient explanations related to the learning and improvement taken from A’s experience. We also found that the board had delayed in providing C with copies of minutes from a meeting and that no appropriate apology had been made for this. We made recommendations in light of these failings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings 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:

• Where a meeting with a complainant is held to discuss their concerns, the meeting should try to ensure that full explanations of what occurred and of any learning and improvement action being taken as a result are provided to the complainant at the time. Following up on a meeting with a copy of the minutes of that meeting and the board’s final response letter should be issued to the complainant as soon as possible thereafter.

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 Scottish Ambulance Service (SAS) on behalf of A for whom they hold welfare Power of Attorney. A waited for an ambulance for nearly 21 hours. A has multiple sclerosis (a disease that affects central nervous system), lives in a care home and usually has a catheter (a thin tube used to drain and collect urine from the bladder). The catheter was not working and there was concern that A had an infection.

C was unhappy with the delay as A had a known history of sepsis (blood infection) as a result of urinary infections. C also said that A’s case had been incorrectly prioritised, that they had received only two calls from SAS during the wait, and that the overall time waiting for the ambulance had been unreasonable.

We found that A’s case had been correctly triaged and prioritised by SAS clinical support desk paramedics, however, we noted that SAS did not meet their own standards for the frequency of welfare calls but recognised that the service was under extreme pressure at the time. We upheld the complaint that the ambulance response time was unreasonable as it had taken nearly 21 hours to attend the patient, which significantly breached the 60-minute target for cases like A’s.

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 on behalf of their client (B) about the care and treatment provided to B’s late sibling (A). A had attended the A&E in mental distress, had attended their GP the same day, and had a hospital appointment with the crisis team a few days later. At this appointment it was considered that hospital admission was not required. A completed suicide a short time later. B felt that the board had failed to provide reasonable care and treatment to A.

We took independent advice from a mental health nursing adviser. We found that the board had carried out a detailed review of A’s care and had taken some action which was reasonable. However, we found that the risk assessment carried out by the board when A presented at A&E lacked transparency and rigour. The assessment carried out a few days later provided more detail, however, it lacked a structured risk assessment and the clinical reasoning behind not offering any ongoing planned follow-up and the weighing of current and historical risk indicators against protective factors was not fully transparent. The record keeping of the risk management decisions was also not sufficient to show the way in which risks factors and protective factors were balanced. We also found that it was unreasonable that the board’s administrative systems resulted in an erroneous early diagnosis of borderline personality disorder being recorded. We found that the Adverse Event Review process did not appear to attempt to establish why things occurred as they did, rather than simply establishing what occurred. Therefore, we upheld the complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for failing to provide reasonable care and treatment to A. 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:

• Processes for risk assessments should ensure that information is gathered from all professional and non-professional sources, and that decision-making is a transparent, structured process based upon best possible evidence.
• The AER process should explore the influence of factors such as systems and processes, supervision, team-working, management decision-making, patient factors, resources, training, and policies / protocols in order to establish why things occurred as they did.

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 that their grandparent (A) received at the Royal Infirmary Edinburgh (RIE). A was admitted to the RIE following a fall. Following a period of recovery, A was discharged to their home. A was subsequently readmitted to the RIE a short time later and died in hospital following this second admission.

C complained to the board about aspects of A’s care during their first admission to RIE, including the board’s management of A’s nutrition and hydration, the physiotherapy A received, and the planning for A’s discharge, but the board did not identify any failings.

We took independent advice from a geriatrician adviser. We found that the management of A’s nutrition and hydration, the provision of physiotherapy to A, and the planning for A’s discharge was reasonable. We did not uphold C’s complaints.

Summary

C attended the A&E department at the Royal Infirmary of Edinburgh having suffered a fall and was diagnosed with muscular pain. They re-attended four months later, when a diagnosis of fractured vertebrae was made. C complained to the board that there were failures to fully investigate their symptoms and arrange appropriate x-ray imaging at the initial attendance.

When responding to the complaint, the board had initially concluded that a ‘red-flag’ symptom had been missed which should have prompted imaging. They upheld C’s complaint, apologised and outlined the steps that they would take to learn from this. They subsequently reviewed their position with neurosurgery colleagues and decided that C had been managed appropriately.

We took advice independent advice from an emergency medicine consultant. We found that C was appropriately assessed and did not meet the criteria in the relevant guidelines for their injury to have been considered high-risk and requiring imaging. We did not uphold the complaint. We found that we weren’t critical of the board for reviewing and revising their decision. However, we were critical that they had not communicated this to C and shared recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform them that they had changed their position, as outlined in their final complaint response. 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 board should follow-up on the findings of complaint investigations and ensure that any identified learning actions are taken forward. If the board decide against taking promised actions, and particularly if this is as a result of a change / retraction.

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 on behalf of their partner (A) about the care and treatment provided by the board when A had hip replacement surgery. Specifically, C complained about the management of A’s pain in the post-operative period. The board acknowledged the discomfort experienced by A, but when it became apparent that surgeons could not manage A’s pain effectively, the Pain Management Team was involved. The board considered the care delivered following surgery, and in reducing medication after discharge, was reasonable.

We took independent advice from an anaesthetics and pain management adviser. We found that whilst pain management in the post-operative period is challenging, the board’s management of A’s pain was reasonable following surgery. We did not uphold this aspect of the complaint.

Additionally, we found that, with respect to reducing A’s medication, the advice provided by the board to A following discharge was appropriate. On this basis, we did not uphold this aspect of the complaint.

Summary

C complained about the care and treatment provided to their sibling (A) by the practice. A had previously been diagnosed with breast cancer a number of years ago. A became ill and attended the practice on several occasions over the year. The GP considered A had gastroenteritis (inflammation of the stomach and intestines). A’s symptoms persisted and A was referred to hospital for a colonoscopy (examination of the bowel with a camera on a flexible tube). The request was rejected. A presented at the practice with the same symptoms on two further occasions and the practice made an urgent ‘suspicion of cancer’ referral to the health board. A scan showed a tumour attached to A’s right kidney. A died some months later.

C complained that despite A’s multiple attendances at the practice and concerns that the cancer had returned, the practice failed to reasonably respond to A’s worsening condition and delayed or failed in carrying out appropriate investigations and associated tasks.

We took independent advice from a GP adviser. We found that initially there was no unreasonable delay in the practice recognising the seriousness of A’s symptoms and that the appropriate referrals for a colonoscopy and ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) were made. We also noted that it would not have been appropriate for the practice to have undertaken a CEA blood test (carcinoembryonic antigen test, a blood test used to help diagnose and manage certain types of cancers) and that the actions of administrative staff in filing away test results was appropriate and in line with established good practice.

However, we found that there was a failure to include clinically important information in referrals and in consultation documentation, and that there was a delay in sending A’s suspicion of cancer letter. We also found that the practice should have considered undertaking some additional blood tests when it was clear A was deteriorating, or documented the awareness of any blood tests undertaken by the hospital during this period. Therefore, on balance, we upheld the 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 available at www.spso.org.uk/information-leaflets.

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

• Appropriate and timely blood tests should be considered when it is clear a patient is deteriorating in cases similar to A’s or awareness of any blood tests undertaken e.g. by hospital documented.
• Notes of consultations should include appropriate detail including a description of the length and progression of symptoms along with any potentially relevant past history.
• Referral letters should include a clear history, examination and relevant background information.

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 was referred by their local health board ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) department to the general hospital for specialist eye surgery. C underwent a vitrectomy procedure (the surgical operation of removing the vitreous humour from the eyeball) which they felt was not managed appropriately as their retina was still detached following the procedure and they had to undergo further surgery from an independent health provider. The board felt that they had provided an appropriate standard of care and treatment to C.

We took independent clinical advice from an ophthalmology adviser. We found that there were no concerns about the standard of treatment which was provided to C. C had suffered a serious eye injury and although the retina was not fully reattached during surgery, this was a recognised complication of the surgery, and that further surgery would be required at some point. We did not uphold the complaint.