Health

Summary

Miss C's mother (Mrs A) was admitted to hospital at Mearnskirk House, following her discharge from the Prince and Princess of Wales Hospice where she received five weeks' care with advanced cancer. Miss C's sister (Mrs D) took their mother home from the hospital and Mrs A was officially discharged from the hospital into Mrs D's care three days later, following a meeting earlier that day at the hospital with medical staff and the family to discuss Mrs A's care.

Miss C complained about the board's decision to discharge her mother from the hospital and the way this decision was made. She listed a number of concerns, including that her mother was discharged without any input from her GP, with no care package in place and with no referral to a district or palliative care team.

We obtained independent medical advice on Miss C's complaint from a consultant physician in elderly care medicine. The adviser said this was an unusual case in that Mrs A had been taken home by Mrs D for a week's trial prior to her formal discharge. The board did not have time to plan Mrs A's discharge in the normal way. Mrs A and Mrs D were adamant that Mrs A should go home and the adviser said it would, therefore, be difficult to be critical of the board if their normal discharge procedure was not followed when they were trying to accommodate Mrs A and Mrs D's wishes. Therefore, we did not conclude that the board unreasonably discharged Mrs A from the hospital.

Summary

Mr C, who works for an advice agency, raised a complaint on behalf of his client (Ms B) about the care her mother (Mrs A) received while in Glasgow Royal Infirmary. In particular, Ms B was concerned that staff failed to take account of her advice about her mother's early onset of Parkinson's Disease and that they failed to deal appropriately with Mrs A's mobility issues and the risk of falling while in the hospital. She also complained that the communication between the hospital staff about Mrs A's care was inadequate and that the board's complaint response was inadequate.

During our investigation, we took independent advice from a mental health adviser and a nursing adviser. We were satisfied that Mrs A's risk of falling was reasonably assessed on admission and there were regular and focussed assessments of mobility with involvement from medical, nursing and physiotherapy staff. We also found that the nursing assessments, charts and notes were of a good standard and that Mrs A's medical records were clear about her level of mobility and the assistance required. However, we were concerned that, while the advice we received from the mental health adviser was that Mrs A may have been able to comprehend and recall instructions and that prior to a fall in the hospital she had been assessed as safe and independent with a walking frame, Mrs A's abbreviated mental test score was ineffectively recorded in the medical records. We found that there was a failure to re-assess Mrs A's cognitive state and keep this under review while in the hospital.

We were also concerned that, while the board apologised for the delay in replying to Ms B's complaint, there was a failure to provide updates or provide an explanation for the delay.

Recommendations

We recommended that the board:

• ensure that where a patient presents with confusion and memory impairment, their cognitive state is assessed on arrival to the ward and kept under review;
• ensure that cognitive testing results are effectively recorded in the medical records; and
• remind staff of the importance of adhering to the NHS Scotland complaints procedure.

Summary

Mrs C, who works for a voluntary agency, complained about the care and treatment that her client (Mrs A) had received during admissions to the Southern General Hospital, the Victoria Infirmary and the New Victoria Infirmary. Mrs A was initially admitted after a fall where she broke her arm and leg. Whilst Mrs A was in hospital, she suffered a series of falls, some of which resulted in further injury.

After taking independent advice from a nursing adviser, we did not uphold Mrs C's complaint that a fall Mrs A had while using the toilet at the Southern General Hospital was caused by unreasonable circumstances. The advice we received was that it was appropriate for Mrs A to have been allowed privacy to use the facilities after being assisted there by nursing staff. Although we did not uphold this aspect of the complaint, we did make a recommendation about this.

We also took independent advice from a consultant physician and geriatrician who considered whether it was reasonable that staff at the New Victoria Infirmary had not identified a hip fracture following a fall there. We did not uphold this complaint as the advice we received was that there was no indication that, following the fall, Mrs A had sustained a fracture. The adviser also said that an appropriate medical assessment had taken place. We also did not uphold Mrs C's complaint that Mrs A had to wait too long for surgery following admission to the Victoria Infirmary. We found that surgery had taken place within the recognised standard of 48 hours.

We did, however, uphold a complaint about Mrs A's premature discharge from the New Victoria Infirmary. We found that records, including National Early Warning Scores (NEWS), were unavailable and it was not clear whether there had been a failure to complete these or if they had been lost. These records, had they been available, would have enabled the adviser to confirm whether the decision to discharge was reasonable.

We also found that nursing staff caring for Mrs A should have requested a medical review before she was discharged due to her recent falls history and the level of pain she was experiencing.

Recommendations

We recommended that the board:

• ensure that the relevant staff are made aware of the nursing adviser's comments on toilet supervision requirements and facilities checks;
• issue an apology for the failing to request a medical review prior to discharge;
• make the relevant staff aware of the nursing adviser's comments on requesting a medical review; and
• take steps to ensure NEWS scores are appropriately taken and recorded on the ward and that medical records are appropriately stored.

Summary

Mr C saw a dentist at the practice. Arrangements were made for future treatment and Mr C attended a further appointment a few weeks later. In the interim, ownership of the practice had changed and Mr C was seen by a new dentist. He complained that the practice had not advised him of this change. The practice responded to Mr C's complaint and explained that they had been assured by the previous owner that all patients would be advised of the changes prior to the transfer. They also advised that no other patients had reported problems with this and that they were reassured that it had been an isolated incident.

After investigating Mr C's complaint, we accepted his position that he was not made aware of the upcoming changes at the practice. However, as the practice expected all patients to have been informed of this by the previous owner, we considered it was reasonable that they did not take steps to separately advise Mr C of the changes. Consequently, we did not uphold this complaint. We made a recommendation to the practice that they review their complaints handling procedure as, during our investigation, it was noted that some parts were not in line with Scottish Government guidance on NHS complaints.

Recommendations

We recommended that the practice:

• review their complaints procedure to ensure that it reflects the requirements of the Scottish Government's 'Can I help you?' guidance.

Summary

Ms C complained to us about the medical and nursing care her mother (Mrs A) received at the Royal Alexandra Hospital before her death from heart failure. We took independent advice on Ms C's complaints from a nursing adviser and from a medical adviser who is a consultant physician and geriatrician. We found that the medical and nursing care provided to Mrs A had been reasonable and appropriate. It had been reasonable to catheterise Mrs A, as medication that she had been receiving for her heart failure made her pass urine continuously to try to reduce her excess fluid. It was also important to measure her urine output accurately during this treatment. We also found that the nursing care she received for pain and hydration was reasonable, as was the decision to give her oral and not intravenous antibiotics. In addition, the end of life care provided was consistent both with usual clinical practice and with the relevant guidance. We did not uphold these complaints.

Ms C also complained that staff in the hospital had not discussed a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form with her, before this was put in place for Mrs A. The records said that this had been discussed with Mrs A's daughter. Although it was not clear whether this was Ms C or her sister, we were satisfied that the board had acted in line with the relevant procedure on this. We did not uphold this complaint either.

Finally, Ms C complained that the board had not communicated with her properly. We found that the communication with Ms C at this distressing time for her, just before her mother's death, had not met her needs. We upheld this aspect of Ms C's complaint, although we were satisfied that the board had apologised to her for this and had shared their findings with relevant staff.

Recommendations

We recommended that the board:

• provide us with a copy of their action plan to address the failings they had identified.

Summary

Mr C was suffering from hoarseness and was referred to hospital by the medical practice for an out-patient appointment at the ear, nose and throat (ENT) department. He was seen by a consultant who identified no suspicious findings and he was discharged back into the care of the practice. Mr C continued to have the same symptoms and was re-referred some time later. He was later seen by a speech and language therapist who identified possible malignancy in the voice box and thereafter, Mr C was diagnosed with cancer. Mr C complained that there had been unreasonable delays in referring him for a further ENT appointment and that the practice's communication with the hospital had not been adequate.

After taking independent advice on this case from an adviser, who is a general practitioner, we did not uphold Mr C's complaint about delay in referral. We found no evidence that there had been unreasonable delay in making referrals and the adviser explained that it was reasonable for doctors at the practice to have been reassured when the initial ENT consultation revealed no sinister findings. Although the adviser considered the majority of the practice's communication with the hospital to have been reasonable, we upheld Mr C's complaint about communication as we found that the initial referral to ENT was categorised as routine, rather than urgent in line with the relevant guidance. The advice we received, however, was that this had no impact on Mr C as the subsequent ENT consultation had not identified any sinister findings. We made a recommendation to the practice to ensure they are aware of the issue.

Recommendations

We recommended that the practice:

• review both the Scottish Intercollegiate Guidelines Network (SIGN) and Greater Glasgow and Clyde guidance to ensure staff are familiar with the referral criteria and confirm to us that the review has taken place.

Summary

Mrs C raised a number of issues about the care and treatment her late mother (Mrs A) received during a number of admissions to Glasgow Royal Infirmary during 2013 and 2014.

During our investigation, we took independent advice from a nursing adviser and a physician and orthogeriatrician (who specialises in the care of elderly patients with conditions involving the musculoskeletal system) who has experience in the assessment and management of a range of medical problems. While some aspects of the care and treatment Mrs A received during the various admissions was reasonable, we identified a number of concerns. In particular, in relation to her first admission to the hospital, the physician and orthogeriatrician adviser found no evidence that an appropriate multi-disciplinary assessment had been carried out to ensure a safe discharge home. The physician and orthogeriatrician adviser and the nursing adviser also had concerns about the adequacy of record-keeping by both medical and nursing staff in relation to a number of the admissions. In relation to Mrs A's second admission, we noted that the board accepted there had been a delay in diagnosing a fracture to Mrs A's wrist. We were critical of this delay.

We were also concerned that Mrs A experienced delays when she had to again attend the hospital. In addition, the advice we received and accepted from the physician and orthogeriatrician adviser was that an earlier ultrasound would have been more appropriate management, and the use of diuretics during Mrs A's fourth admission to the hospital would not generally be regarded as appropriate.

We upheld several aspects of the complaint and made a number of recommendations to address the failings.

Recommendations

We recommended that the board:

• apologise for the failings we identified;
• remind staff of the need to carry out an appropriate multi-disciplinary assessment to ensure safe discharge;
• consider the nursing adviser's comments about the standard of record-keeping and provide details as to how improvements to nursing documentation will be implemented;
• consider the suggestions made by the physician and orthogeriatrician adviser in relation to the need for attention to be given to the process of review of x-rays and report back to us on any further action taken;
• consider this case to see if any further lessons can be learned and report back to us on any action taken;
• take steps to ensure that medical staff are complying with Records Management: NHS Code of Practice (Scotland); and
• bring the physician and orthogeriatrician adviser's comments about the timing of ultrasounds and the use of diuretics to the attention of relevant staff and report back to us on any action taken.

Summary

Mr A had mental health problems. His mother (Mrs C) complained to us about the care and treatment Mr A received when he attended the Western Infirmary on three occasions after taking overdoses. We took independent advice from a medical adviser, who is a consultant in emergency medicine, and from a psychiatric adviser. We found that the medical care and treatment provided to Mr A when he attended the hospital, along with the care he had received there for his mental health problems, had been reasonable. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that staff in the hospital had not treated Mr A with respect and that a member of staff had shouted at him. The notes in the medical records about this specific incident were detailed. However, as always with written records, the exact content of the conversation was impossible to determine and there were differing views of the conversation. There was no clear and objective evidence that a member of staff had shouted at Mr A or that staff had failed to treat him with respect. In the absence of such evidence, we did not uphold this aspect of the complaint.

Finally, Mrs C complained that the follow-up arrangements each time Mr A was discharged from the hospital were unreasonable. We found that Mr A had been physically fit on each occasion that he was discharged, and that the discharge plans in relation to his psychiatric care were reasonable and appropriate. We did not uphold this aspect of Mrs C's complaint.

Summary

Mrs C, who is an MSP, complained on behalf of Mr A about the board's failure to offer him robotic surgery to treat his prostate cancer. Mr A considered that there were clear benefits in having robotic rather than open or keyhole surgery. He complained that the board had failed to explore the options available to him, including the option of pursuing robotic surgery privately, after he was diagnosed with prostate cancer.

We took independent advice on the complaint from a medical adviser, who is a consultant urological surgeon with experience in the management of prostate cancer. We found that Mr A had received appropriate counselling regarding the treatment options available from the board for his prostate cancer. However, although the board did not offer robotic surgery for prostate cancer at that time, we found that for completeness, the option of having robotic surgery privately should also have been mentioned to Mr A. There was no evidence that this had been mentioned to him and he said that he had only found out about it through his own research. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board had failed to offer Mr A robotic surgery and that they failed to refund the cost when he had the surgery privately abroad. We found that it was reasonable that the board did not offer robotic surgery to Mr A, as they had offered him alternative surgery. The board were investigating the feasibility of purchasing a robot system and there was no requirement to offer robotic surgery at that time. We also found that it had been reasonable for the board to decline funding the surgery elsewhere. We did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr A for the failure to mention the option of pursuing robot-assisted surgery privately, when advising him of his treatment options; and
• make the relevant staff aware of our decision on this matter.

Summary

Mrs C's late husband (Mr A) was admitted to Glasgow Royal Infirmary with numerous fractures following a fall. After eight days in hospital, his condition deteriorated and he died of a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Mrs C raised concerns about the orthopaedic, medical and nursing care and treatment provided saying that Mr A had not been given the best opportunity to survive given the failures in care.

We took independent advice from several medical advisers and a nursing adviser. We found that the treatment decisions to reduce the risk of pulmonary embolism were reasonable and that the risks of a pulmonary embolism could not be eliminated completely. Having said that, there was a missed opportunity for a more senior specialised medical review during this period as Mr A's National Early Warning Score (NEWS), a guide used to determine the degree of illness of a patient, was at a level that should have triggered an escalation of clinical care. We also found that there was poor record-keeping, and these failings resulted in unnecessary distress to Mrs C and her husband. In relation to nursing care, we also found record-keeping failings and a failure to alert medical staff of Mr A's deterioration during this period. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• ensure record-keeping by medical staff complies with relevant guidance;
• bring our findings to the attention of relevant medical staff;
• take steps to ensure healthcare professionals comply with the NEWS guidelines or clearly set out the rationale in patients' clinical records for non-compliance;
• ensure record-keeping by nursing staff complies with relevant guidance;
• bring our findings to the attention of relevant nursing staff; and
• apologise for the failings identified.