Health

  • Case ref:
    201406424
  • Date:
    May 2016
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

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.
  • Case ref:
    201406354
  • Date:
    May 2016
  • Body:
    A Medical Practice in the Greater Glasgow and Clyde NHS Board area
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

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.
  • Case ref:
    201405868
  • Date:
    May 2016
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

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.
  • Case ref:
    201405055
  • Date:
    May 2016
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

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.

  • Case ref:
    201405031
  • Date:
    May 2016
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

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.
  • Case ref:
    201404954
  • Date:
    May 2016
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

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.
  • Case ref:
    201504192
  • Date:
    May 2016
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    communication / staff attitude / dignity / confidentiality

Summary

Mr C complained about the board after they shared a letter containing sensitive information about him with his school. He said that he had made it very clear that he was not comfortable with information being shared in this way and felt that his confidentiality had been breached.

Mr C then wrote to his doctor, outlining his concerns and explaining that these circumstances had caused him a great deal of distress and anxiety. His doctor responded, apologising if she had misunderstood but had thought that consent had been given by him for this to happen. Mr C remained dissatisfied with this response, as he did not feel that his complaint had been taken seriously.

We found that Mr C's complaint had not been formally investigated through the board's complaints procedure. His doctor had also noted in her records that she intended to seek consent from Mr C at their next appointment. However, the notes for the appointment in question did not contain clarification on whether or not consent had been asked for or given. We took independent advice from an adviser, who stated that they did not consider it to be reasonable to share sensitive information without consent being clearly given and recorded. We accepted this advice and, as such, upheld the complaint.

Recommendations

We recommended that the board:

  • apologise to Mr C both for breaching his confidentiality and for the on-going distress and anxiety that this breach has caused him; and
  • apologise to Mr C for not properly escalating his concerns and investigating them through their complaints procedure.
  • Case ref:
    201504055
  • Date:
    May 2016
  • Body:
    A Medical Practice in the Grampian NHS Board area
  • Sector:
    Health
  • Outcome:
    Not upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the care and treatment provided by the practice. Mr C had attended the practice over the course of approximately three months with symptoms including weight loss, diarrhoea and vomiting. He was ultimately diagnosed at A&E with an intussusception of his small bowel (a condition in which a part of the intestine folds into another section of the intestine). Mr C raised concerns about the time taken to diagnose his condition, including whether appropriate investigations (including a CT scan, which uses x-rays and a computer to create detailed images of the inside of the body) were arranged. He also raised concerns that a GP had identified he had signs of an intussusception but did not appropriately treat this as an emergency.

The practice said Mr C's symptoms were fully and appropriately investigated. They observed that Mr C was referred for specialist investigation at an early stage which provided an alternative explanation for his symptoms. They also said intussusception is a very rare condition in adults. The practice said the medical records did not indicate the GP had diagnosed an intussusception.

After receiving independent advice from a GP, we did not uphold Mr C's complaint. The adviser agreed that there were complicating factors in the diagnosis. The adviser considered that the investigations arranged were appropriate in the circumstances, and found no evidence that a GP had diagnosed an intussusception prior to Mr C's admission to A&E. While we found Mr C's care and treatment was reasonable in the circumstances, we recommended that the practice use this case to consider and share any learning on the presentation and causes of intussusception in adults.

Recommendations

We recommended that the practice:

  • use this case to consider and share any learning on the presentation and causes of intussusception in adults.
  • Case ref:
    201502853
  • Date:
    May 2016
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained on behalf of her son (Mr A) about the severe toe pain he suffered since undergoing a total nail avulsion (complete removal of the toenail) in 2013. Mr A had been seen by podiatry staff on a number of occasions following the surgery. As a result of the severe pain, Mrs C said that Mr A had lost his confidence and been unable to undertake his usual activities. Mrs C was concerned that a number of investigations, tests and referrals appeared to be undertaken only when she complained to the board two years after the initial surgery.

We took independent advice from a medical adviser. They said that the treatment decisions were reasonable in light of the main post-operative complications associated with a nail avulsion. However, while the initial referrals, tests and investigations appeared to be carried out within a reasonable time, repeating the surgical and other investigations when previous investigations had not provided a diagnosis to the problem delayed referral onto a specialist pain team. We found this to be unreasonable, so we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

  • review their processes to ensure referrals to specialised pain teams are made within a reasonable time;
  • bring our decision including the adviser's comments to the attention of relevant staff; and
  • apologise for the failures our investigation identified.
  • Case ref:
    201500611
  • Date:
    May 2016
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    nurses / nursing care

Summary

Ms C and her cousin (Mr A), complained about the care and treatment Mr A's late mother (Mrs A) received at Kincardine Community Hospital. Mrs A had dementia and had been admitted to Kincardine Community Hospital from Aberdeen Royal Infirmary for a period of rehabilitation following a fall at home. Ms C and Mr A also complained about the board's handling of their complaint.

Mr A said that he raised concerns with nursing staff about his mother's care while she was a patient in Kincardine Community Hospital, in particular, in relation to her developing pressure ulcers. Staff at the hospital and Mr A were also not told for several weeks that Mrs A had been diagnosed with a pelvic fracture while she was in Aberdeen Royal Infirmary. When Mrs A was discharged to a nursing home she was found to have a pressure ulcer on her sacral area (at the base of the spine) but Mr A had not been informed about this.

We took independent advice from a nursing adviser who said there were serious failings in record-keeping and in compliance with guidance and best practice on the prevention and management of pressure ulcers. As a result, Mrs A's care was random and left to chance. Furthermore, although Mrs A was at high risk of developing pressure ulcers, there was a delay in managing her as high risk. We also found that the pelvic fracture incident had not been recorded as it should have been and there were failures in communicating with Mr A concerning aspects of Mrs A's care. Overall, the advice we received was that the standard of nursing care provided to Mrs A was very poor and we were critical of those failings.

In relation to the board's handling of Ms C and Mr A's complaint, although the board had apologised to them and had carried out a significant event analysis (SEA) we found that the board had not identified and acknowledged serious failings with Mrs A's nursing care and that, overall, the board's complaints handling was poor.

Recommendations

We recommended that the board:

  • feed back the findings of the investigation to relevant staff, for reflection and learning;
  • provide us with an action plan to address the failings identified in relation to record-keeping; skin and tissue viability care (to include a review of the education and training of nursing staff in skin and tissue viability care); and communication;
  • apologise to Mr A and Ms C for the failure to provide reasonable care to Mrs A;
  • feed back the findings of this investigation to the relevant staff who were involved in the SEA and complaints handling and reflect again on Mrs A's complaint by reviewing what went wrong with her care;
  • consider a review of their SEA process and the training of staff who carry out such reviews, and give consideration to whether there should be an external independent review of how this is undertaken;
  • provide evidence that the pelvic fracture incident has been reported and the date when it was recorded on the system;
  • provide evidence of the review process concerning discharge documentation; and
  • apologise to Mr A and Ms C for the failings to respond reasonably to their complaints.