Health

Summary

C engaged with the board’s mental health services and believed that they had received a diagnosis of Borderline Personality Disorder (BPD, a mental disorder characterised by the instability in mood, behaviour, and functioning). They complained to the board that they had been prematurely discharged from mental health services. They also complained about delays, confusion affecting appointments, as well as a failure from the board to reasonably assess their condition.

The board’s position was that C had been discharged originally due to a lack of response to correspondence. When C was thereafter seen by mental health services they acknowledged some confusion with respect to the arrangement for an appointment. With respect to the subsequent appointments C attended, the board explained that there was evidence of possible BPD, but that a diagnosis had not been confirmed. A further appointment was arranged but C did not manage to keep the appointment. The board considered that the psychiatric consultations, over the telephone, were appropriate and did not uphold C’s complaints.

We took independent advice from a specialist in community psychiatry. We found that it was reasonable to discharge C given the evidence available and that they had received no response to their attempts to contact them. Given attempts were made to contact C, we did not uphold the complaint that C was unreasonably discharged.

With respect to the psychiatric assessment and diagnosis of BPD, we found that the assessments carried out were careful and competent, the diagnostic statement was reasonable and that there was no firm diagnosis made, with reasonable advice and plan for follow up. Whilst it was concerning that C had formed the view that the diagnosis was definite, and it was acknowledged that assessments via Teams were preferred over telephone (as occurred in this case), we found that the assessment of C was reasonable. We did not uphold the complaint.

Summary

C complained on behalf of their parent (A) who was in hospital when they passed away. C complained about the hospitals communication with A and their family during their hospital admission.

We took independent advice from a nursing adviser. We found that there was evidence of a good standard of communication in the medical notes.

Summary

C presented to the medical practice with nausea and weight loss. Following blood tests, a significant drop in haemoglobin levels was noted and anaemia (deficiency of healthy red blood cells in blood) was diagnosed. C complained that they were not referred on to secondary care for admission or investigation at this point. A few days later, C collapsed and suffered internal bleeding as a result of a large gastric ulcer (a perforation or hole in the lining of the small intestine, lower oesophagus or stomach).

The practice advised that C was a new patient to the practice and had recently been in hospital with acute kidney injury. On first presentation they had a urine infection, which was treated with antibiotics. Following the blood test results, examinations were carried out to check for internal bleeding. No signs of bleeding had been found but C had a bladder full of urine and their catheter was bypassing. The doctor referred to district nursing for a catheter change and a repeat blood test. This was to check whether C was experiencing further kidney injury. There were no obvious signs of dyspepsia (a condition where digestion is impaired) as no heart burn was recorded.

We took independent medical advice from a GP adviser. We found that it would have been appropriate to make an urgent cancer referral based on the symptoms, but that it was reasonable not to have suspected a gastric ulcer. We also found that there was no record that the causes of the anaemia had been fully explored or that a treatment plan and safety netting advice had been considered or communicated.

We upheld the complaint as we considered that although many of the actions had been reasonable, it did not appear that a cancer referral, a treatment plan or safety netting had been properly considered, recorded or communicated. We did not consider that this had changed C’s outcome and acknowledged that the practice had taken steps to learn from the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not fully exploring C’s symptom history and medication, for not communicating a treatment plan and for not providing worsening advice in case of deterioration. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.

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

• The practice should consider scheduling regular peer reviews to ensure that consultations are fully recorded including treatment plan and safety netting advice. Staff should be aware of NICE Guidelines and Scottish Referral Pathways for suspected cancer.

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 late parent (A) who passed away from cancer. C complained that the practice had unreasonably failed to diagnose A’s cancer. A was suspected of having a chest infection and was given multiple courses of antibiotics. A also had a number of blood tests which C said that A was not always sure what the blood tests were for, nor were they told the results.

We took independent advice from a GP adviser. We found that the blood tests which were carried out were done so for clinical reasons and that there was no error in the taking or analysing of the blood test results. Some of the blood tests were requested by hospital departments. The practice explained that they would not normally contact a patient if the test results were normal. A CT scan carried out by the hospital did not show any malignancy and this would have been reassuring for the GP’s treating A. We did not uphold this complaint.

Summary

C complained on behalf of their late parent (A) that the board unreasonably failed to diagnose A’s cancer, from which they later died.

We took independent advice from a respiratory consultant adviser. We found that clinical management from the respiratory team carried out appropriate investigations.

We found that there was a failure in communication of the CT results to A and their family and that there was also a delay in intervention following the abnormal CT report, that a biopsy could have been carried out earlier, and that there was no need to await review at an MDT.

On balance, we found that there was no evidence of an unreasonable delay in diagnosing cancer, therefore we did not uphold this complaint.

Summary

C complained that the board failed to provide reasonable care and treatment to their late parent (A), who died following an admission to hospital. This included issues relating to A contracting COVID-19, that the board unreasonably failed to carry out an SAER/independent review, and that the board failed to reasonably respond to the complaint.

We took independent advice from a specialist in geriatrics (medical care for the elderly). We found that the board had carried out a review of A’s care and had accepted some failings, including that there had been an unnecessary transfer and a delay in cleaning. They apologised for this and had taken improvement action and organised training, which we welcomed and considered were appropriate.

Whilst there were a number of aspects of care provided to A which were appropriate and reasonable, given the unnecessary transfer, the apparent delay in cleaning, and failings with regard to communication, on balance, we upheld this aspect of the complaint.

We also identified complaint handling failings. Whist the complaint response was detailed and lengthy, and attempted to address all of C’s concerns, we upheld this aspect of the complaint, given the lack of detail in the complaint response regarding learning and improvement actions.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in communication, and the lack of information in the 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 are implementing an electronic handover which will reduce the risk of human error and highlight any issues timeously.
• Patients who have disabilities such as hearing impairments which may result in them and their families requiring additional support should have their communication needs fully supported and met.
• The board held Deaf Awareness sessions.

In relation to complaints handling, we recommended:

• Complaint responses should contain full information to explain decisions and should include information about learning and improvement actions.

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 parent (A) that the board did not provide a reasonable standard of nursing care. A was admitted to hospital with COVID-19 and had to be nursed in isolation due to their COVID-19 positive status.

We took independent advice from a nursing adviser. We found that the majority of the events described by C and A would not necessarily be documented. That in itself was not evidence of a failing, merely that events documented in the notes would be largely clinical in nature rather than communication. Due to the time that had passed since the events complained about, staff did not recall the specific period of care. We found that there was no evidence of unreasonable nursing care or treatment in the medical notes. As such, we did not uphold the complaint.

Summary

C spent time in hospital for their mental health. C complained about how the board had managed their prescriptions and about the lack of treatment for their physical symptoms of migraines and hand/arm injuries.

We took independent advice from a consultant psychiatrist adviser. We found that C’s perspective was recorded in contemporaneous notes, that they had requested a change of medication and that their doctor agreed to the trial of an alternative. C’s consent was regularly sought and this was good practice. The evidence suggested that C’s reports of physical symptoms were also properly investigated and that C was offered appropriate pain relief for their migraines. As such, we did not uphold the complaints.

Summary

C complained about the care and treatment provided to their late parent (A). A underwent surgery to treat hypertension (high blood pressure). A few days later, A’s condition deteriorated with the cause thought to be sepsis (a life-threatening reaction to an infection). A’s condition worsened further and they were transferred to the High Dependency Unit (HDU). A died later that day.

C complained that there had been a failure to administer antibiotics that A had required and that there had been unreasonable delays in transferring A to the HDU, which resulted in A being left in a state of distress. C also complained about the conclusions that the board had reached about A’s care following a Significant Clinical Investigation (SCI).

The board stated that A had been monitored every 30 minutes and that there had been no delay in providing antibiotics to A. The board accepted that there had been a failure in communication between nursing and porter staff which had led to a delay in A being transferred to HDU. However, the board considered that this would not have resulted in a different outcome although it was acknowledged that this would have reduced A’s family’s distress.

We took independent clinical advice from an acute medicine and nursing adviser. We found that there were a number of failings in the care provided to A following the initial deterioration in their condition. This included failure to initiate tests to identify sepsis, failure to commence intravenous fluids (medical technique that administers fluids, medications and nutrients directly into a person's vein) and failure to perform necessary blood tests, as had been outlined by A’s consultant. There was also no evidence that A had received antibiotics nor had been monitored with the frequency stated by the board. We also found that nursing staff failed to escalate a further deterioration in A’s deterioration and that there had been an unreasonable delay of around two hours in transferring A to HDU. In addition, we found that several aspects of the nursing records fell below the professional standards required by the Nursing and Midwifery Council and that the board’s SCI had failed to identify areas of learning arising from this case. For these reasons, we upheld this complaint.

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:

• Significant Clinical Incident reports should:
• (i) be reflective and learning processes that consider events against relevant standards and guidelines,
• (ii) ensure failings are identified and any appropriate learning and practice improvements are made and,
• (iii) be in line with Learning from adverse events through reporting and review - A national framework for Scotland: December 2019 (healthcareimprovementscotland.org)
• Treatment plans should be comprehensive and document the working diagnosis. Patients should receive the treatment plan recorded in the medical records following consultant review unless there is a change of plan. If this happens this should be clearly recorded.
• Where the cause of a patient’s deterioration is suspected to be due to sepsis, the sepsis bundle should be initiated.
• Patients should be assessed, in accordance with the NEWS guidance relative to the patient's NEWS score. Where there is deviation from this, this should be recorded. In addition, patients who are assessed to have a NEWS score of five or greater should be escalated urgently for further assessment in line with NEWS guidance. NEWS scoring documentation should be fully completed and recorded.
• For patients where there is the presence of red flags indicating an ECG, this should be acted on without delay.
• Where blood tests are requested in order to investigate a deterioration in patient's condition they should be processed and reviewed as soon as possible. Patients should receive the appropriate blood tests to adequately assess the cause of deterioration and any tests that have been specifically requested by clinicians.
• Where a deteriorating patient requires to be transferred from the ward for more intensive treatment, the transfer should take place as soon as possible and without undue delay. A record should also be made showing which member of staff has requested the transfer, the time at which the transfer was requested and to whom the request was made.
• Nursing records should be documented in real time, as far as it is reasonably practicable to do so. They should also include a clear timeline of events, the actions taken by nursing staff (including in what order) and details of all communication with relatives and other healthcare professionals.

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.