Health

Summary

C complained about the care and treatment provided by the board to their parent (A), who was admitted to hospital with a suspected liver problem. Ascites (a build-up of fluid in the abdomen) was diagnosed and paracentesis (a drain of the fluid) was performed, during which it was noted that A had accidentally bumped the drain. The following day A reported being in pain and, after a CT scan, it was determined that A was suffering from an un-operable arterial bleed. Shortly thereafter A died.

C complained that A’s consent was not properly obtained, that staff had failed to carry out the drain procedures reasonably, that A’s pain was not managed appropriately, that a CT scan was delayed, that communication from the board had been poor and inconsistent and that the level of review undertaken after the incident was not sufficient.

We took advice from an independent medical adviser in gastroenterology (medicine of the digestive system and its disorders). We found that the timescale for the CT scan was reasonable, that pain medication was appropriate, that the case had ultimately been appropriately reviewed and that the drain procedure appeared to have been carried out by appropriately trained staff under adequate supervision.

However, we found a number of failings. Firstly, the board had obtained verbal consent but failed to adequately record this. Secondly, the board’s complaints response had unreasonably focused on A having bumped the drain as being the cause of the arterial bleed. This was something that could not have been known with any certainty. Additionally, this explanation was not consistent with the post-mortem examination and internal case review, both of which found that the more likely cause of the bleed was as a recognised complication of the drain insertion. Therefore, we upheld these aspects of the 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:

• Patients and their families should be given clear, consistent and accurate information about the patient's care and treatment, including any complications. Complaint responses should be accurate, and evidence based.
• In future, the board will get formal written consent from patients for this type of procedure. They will also prepare a consent booklet, which will be reviewed by their gastro clinical governance group and their clinical guidelines group.

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 orthodontic care (dentistry dealing with the prevention and correction of irregular teeth) provided to their child (A), particularly that A's treatment had been unreasonably discontinued. The dental practice's decision to discontinue was based on a failure to comply with the requirements of the orthodontic treatment. C complained that the orthodontist had not raised any significant concerns previously, and that there had been a lengthy period without review due to Covid-19 restrictions.

We took independent clinical advice from an orthodontic adviser. We found that the records evidenced only intermittent or periodic poor oral hygiene, as opposed to the consistently poor oral hygiene noted by the orthodontist. We also found that there was evidence of valid clinical grounds to support the stoppage of A’s treatment. However, we also found that there were significant failings regarding the way the decision was communicated.

At the last appointment A attended, the records give the expectation that treatment was continuing. C tried to contact the orthodontic practice following this appointment to find out when the next review appointment would take place. When they did not receive a reply they submitted a complaint, the response to which communicated the decision to discontinue treatment. This was several months after A had last been seen. The orthodontist failed to clarify in the response why they had not replied to C’s communication after the last appointment, and it was not made clear specifically when it had been decided A’s treatment should be discontinued. We found that the orthodontist’s actions were not compliant with General Dental Council standards for communicating with patients. We found that the orthodontist’s decision to discontinue A’s treatment was unreasonable, particularly in relation to the way it was communicated. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A 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:

• Communication with patients and/or their guardians should be carried out and documented in line with the relevant standards (Standards for the Dental Team, GDC).
• The orthodontist needs to ensure that complaints are handled in line with the NHS Complaints Handling Policy. This requires a response to be issued within twenty working days of receipt of a complaint, addressing all the issues raised and showing that they have been fully and fairly investigated.

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 there was an avoidable delay by staff at a community hospital in referring them to the specialist clinic at the local general hospital when they suffered a detached retina. C attended four consultations at the community hospital before they were referred to the specialist clinic and they felt that the delay had had an adverse effect on their sight. The board maintained that appropriate treatment was provided.

We took independent advice from an ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) adviser. We found that the clinicians at the community hospital had taken advice from specialists at the general hospital and had monitored C’s condition by regular ultrasound scans. When C’s condition deteriorated and evidence of retinal detachment was found on a scan, C was referred to the specialist for continuing treatment. We therefore did not uphold the complaint.

Summary

C complained to the board on behalf of their partner (A) about the length of time taken to arrange a lumbar puncture test (LP, a procedure used to collect a sample of fluid from the spine) following assessment by a neurologist (specialist of the nerves and the nervous system). C had regularly contacted the board requesting an update on C’s appointment and eventually decided to complain when they were told to ask A’s GP to re-refer them. On complaining, A received their LP appointment. The board advised that the delays had been caused by the Covid-19 pandemic and that A had now been appointed to see a neurology consultant.

We found that the board had separate processes in place for arranging LPs depending on whether a patient was seen by a locum consultant or a member of the board’s own staff. As A was seen by a locum consultant, they were required to be added to an anaesthetist’s (administer of drugs) list which ran every three-four months. Had they been seen by the board’s own staff, they would have arranged the LP test directly without the need to refer them to a separate list. In A’s case, the original anaesthetist’s list that they were appointed to was cancelled, as was the second due to the onset of the pandemic, which meant that A was required to wait 10 months for this test. We upheld this complaint.

C also complained that the board failed to provide pain relief to A while waiting for the LP test. While we considered C’s expectations to be reasonable in respect of the results of the LP test confirming A’s diagnosis and informing decisions about future care and treatment, including management of their pain, we considered that this aspect of their care to remain the responsibility of A’s GP at this time. As such, we did not uphold this part of C’s complaint.

Finally, we found that the board’s complaint handling was unreasonable, particularly in relation to the failure to act on the lack of equivalence in service provision despite this problem being known following the board’s own investigation of C’s complaint. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to arrange the LP test reasonably and for failing to reasonably respond to their 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:

• The board should implement a sustainable model for listing the patients of locum doctors to ensure that they timeously receive LP tests. This should include a contingency plan to prevent long delays for patients when lists are cancelled.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement. All staff dealing with complaints should be familiar with the Model Complaints Handling Procedure, understanding the importance of communication and the need to demonstrate thorough investigation and action taken on the points raised.

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 treatment provided to their late parent (A) from the board during a hospital admission. C complained that A had been discharged from hospital when it had been unsafe to do so, that staff had failed to insert an intravenous line so that A could receive fluids, that A had developed a pressure sore on their sacrum (a bone in the spine), and that insufficient investigations had been carried out to establish the cause of A’s refusal of treatment.

The board stated that A had received fluids intravenously on admission but that their cannula (a tube that can be inserted into the body) had become blocked. Further unsuccessful attempts were made to reinsert the cannula before A declined any more attempts to be made. A also had refused to accept oral treatment and did not wish to undergo investigations to establish cause of their illness, preferring instead to be discharged home. The board also stated that A had been non-compliant and had not wished to change position in bed resulting in the development of a pressure sore, for which arrangements were put in place with district nurses upon A’s discharge.

We took independent advice from a consultant geriatrician. We found that the investigations the board had carried out to establish the cause of A’s illness had been reasonable as had the overall treatment provided during A’s admission. We noted that the records showed A had declined several attempts to treat their symptoms and carry out further investigations and that there was no evidence in the available records to indicate that A had lacked capacity to make decisions about the medical treatment that they wished to receive. In relation to A’s discharge, the records also showed that the board had requested an assessment of A to be carried out by their Integrated Assessment Team but that this could not be completed due to A leaving the hospital. We found that management of A’s pressure sore had reasonable.

For these reasons, we did not uphold the complaint.

Summary

C complained about the care and treatment provided to their late parent (A) who had a number of medical conditions. During an admission to hospital, A’s condition deteriorated, and they died.

C complained that A’s deterioration was not appropriately managed and that they contracted Listeria Meningitis (a serious disease in which there is inflammation of the membranes of the brain and spinal cord, caused by bacterial infection) and Clostridium Difficile (C-Diff; infection of the large intestine triggered by long term use of antibiotics). C also complained that a medication to treat diarrhoea was inappropriately prescribed because A had a diagnosis of ulcerative colitis. C further complained that staff did not communicate with A’s family that they were suspected of having sepsis. C also raised concerns about the board’s handling of their complaint and the standard of record keeping which was referred to in their complaint response.

The board acknowledged that the medication to treat diarrhoea should not normally be prescribed in patients with ulcerative colitis and that there was no clear record of the discussions that were held with A’s family. The board confirmed that Public Health investigated the source of listeria meningitis and concluded it was not likely a hospital-based transmission.

We took independent medical advice from a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). We found that A’s overall care and treatment was reasonable. A was appropriately treated with intravenous steroids and antibiotics and the decision to not provide surgical intervention was reasonable. It was noted that A was at high risk of developing C-Diff given that they had been prescribed a strong immune suppressant. With regards to the listeria meningitis breakout, we found that the board appropriately sought external review and specialist public health and microbiology advice. We also found that the standard of record keeping was reasonable. Therefore, we did not uphold these aspects of the complaint. However, we found that there was insufficient evidence of clear communication with A’s family about their condition and the fact that they had sepsis, and that the board failed to provide a full response to the complaints raised. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to communicate with A’s family that they were suspected of having sepsis and for failing to provide a full response to the complaints raised. 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 should understand the importance of, and ensure that they communicate clearly with patients and their families about their condition.

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 a delay in diagnosing their late partner's (A) oesophageal cancer. The board had already acknowledged that A’s cancer could have been diagnosed sooner and apologised for failing to fully investigate their symptoms. However, C did not consider that the board had provided a satisfactory explanation as to why A’s cancer was not diagnosed at an earlier stage.

We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that initial examinations had identified a lesion in A’s throat, but that this was not found on a subsequent examination (a microlaryngoscopy - an examination of the throat with magnification). The board, therefore, did not arrange any further ENT follow-up. We noted C’s history and presenting symptoms and considered that there were multiple red flags for cancer. We found that further radiological investigations should have been ordered and that it was unreasonable for investigations to have stopped at that point. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to conduct further investigations. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 their adult child's (A) treatment in the months prior to their death. A completed suicide soon after they had been assessed by nurses from the Crisis Assessment and Treatment Service (CATS) and Specialist Drug and Alcohol Service (SDAS). C complained that the risk to A’s life wasn’t properly assessed, and that the family weren’t appropriately involved. C also complained that board staff failed to take follow-up action when A had communicated suicidal thoughts in previous months, and that there was no follow-up plan in place following discharge from a hospital admission.

We took independent advice from a mental health nurse and a psychiatrist. We found that the assessment prior to A’s death did not explain how it was concluded that there was no immediate risk when A was exhibiting a number of risk factors. There was no evidence of these risk factors being effectively weighed against protective factors, and no evidence of hospital admission having been considered and ruled out. There was also no evidence of C and A's sibling (B) having been appropriately involved in the assessment. We found that the post-assessment care plan was not sufficiently robust, and that the notes were not clear as to the level of the family’s agreement with this. B contacted CATS out of hours service post-assessment to express concern about A and complained that no help was provided. We found that there was an unreasonable failure to arrange a follow-up telephone consultation.

With regards to a lack of follow-up further to A’s previous report of suicidal thoughts, the board said that they could find no record of this having been reported to them. We found that there was evidence in the GP record of the GP having contacted SDAS about this. We found that there was a failure to record or act upon this communication from the GP. It was noted that this may not have had a material impact on the eventual outcome, as A was later admitted for assessment and stabilisation, though, we found that there was an unreasonable delay in A receiving any follow-up following their discharge from this admission. The board had already acknowledged this and taken steps to address it.

C also complained about a reduction in dosage of A’s anti-psychotic medication during the aforementioned admission. We found that A was appropriately involved in this, but that there was no evidence of proactive involvement of family members in these discussions. We also found that there was a lack of clarity surrounding the prescribing of Pregabalin (an anticonvulsant and nerve-pain relief drug). The board had already undertaken to establish good practice guidelines to ensure medication safety in polypharmacy (the simultaneous use of multiple medicines by a patient). The board also acknowledged a number of issues relating to communication with the family and a failure to involve them in care planning. We found that there was an overall failure to involve family members as partners in the care process. We, therefore, upheld all aspects of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the identified shortcomings in the crisis assessment, and failures to involve and communicate with them regarding A’s care. 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:

• Approaches to risk assessment should be systematic and evidence-based, and clinical judgements effectively reasoned in clinical records.
• Families’ views should be respected and they should be involved as partners in the care process as far as confidentiality imperatives allow. Working with families should be central to recovery-focussed mental health care, and should be governed by agreed guidelines/standards for practice and regular monitoring.
• Risk management should explore all available options for keeping people safe within the context of placing the minimal necessary restrictions upon their freedoms. In the interests of transparency, clinical records should demonstrate the options considered for keeping people safe and why chosen courses of action were preferred over other available alternatives.
• There should be more robust approaches to risk assessment, record-keeping and family participation. Families' views should be respected, and they should be involved as partners in the care process as far as confidentiality imperatives allow.
• To be effective in preventing recurrences of serious incidents, investigations should be carried out with due thoroughness to get to the root causes underlying tragic events. SAER processes should be robust and allow critical information to be gathered from all stakeholders.
• Systems and processes for monitoring the effectiveness of record-keeping should be robust, and clinical record-keeping practice should form part of each practitioner's clinical supervision activity.

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.

When this report was first published on 21 December 2022, it referred to A as the 'child' of C.  This was in reference to their familial relationship however the summary was amended to read 'adult child' on 22 December 2022 for clarification.  We apologise for any confusion caused.

Summary

C complained about the board's handling of their grandparent's (A) consent for a surgical procedure. A had vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain) and was resident in a care home. A had Adults With Incapacity (AWI) status and their child had Power of Attorney (PoA) for their welfare and financial needs. A was admitted to hospital due to abnormal liver function tests. It was subsequently decided that they should undergo an invasive procedure.

C complained to the board that A’s consultant obtained their consent for the invasive procedure without any contact being made with A’s next of kin or listed PoA. In response to C’s complaint, the board said that the relevant consultant considered that A had the capacity to make this decision. The board reiterated that the presence of a PoA does not mean that an individual is unable to make their own decisions. They said that it was the consultant's clinical professional opinion at that time that A had the capacity to consent to the invasive procedure as they were aware of being previously offered the procedure and said that they wanted something done.

We took independent advice from a mental health nurse adviser. We found that there was sufficient information available in the clinical records to highlight A’s potential capacity issues and it was unreasonable that this was not properly considered. We found that A’s consent for the procedure was not properly obtained. In light of this, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for not obtaining consent properly and deficiencies in the documentation surrounding the assessment of A's capacity, PoA arrangements and consent process. 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:

• That the board take steps to ensure full compliance with the requirement to assess and review patients’ capacity where necessary.
• That the board take steps to ensure that staff fully complete the MDT assessment documentation to ensure full information relating to capacity and welfare arrangements is recorded and available.

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 standard of medical treatment provided to their late spouse (A) by the board following diagnosis and treatment of upper tract urothelial cancer (a type of kidney cancer). A’s condition deteriorated and they died. C complained that clinicians failed to, amongst other things, communicate with them in a reasonable way about treatment options and take reasonable action in response to A’s clinical condition.

We took independent advice from a urology specialist (concerning the male and female urinary tract, and the male reproductive organs) and a renal specialist (concerning the kidneys). We found that A’s cancer had likely been more aggressive than originally suspected. However, given the information available at the time, the option of treatment offered to A had been a reasonable approach. We also found that the board had failed to adequately document that all treatment options had been discussed with A, and that a specialist renal cancer nurse should have been available to the family sooner. We found that had A’s treatment been carried out sooner (and in line with cancer waiting time standards), it may have improved their health outcomes. For these reasons, we upheld this aspect of C’s complaint.

C also complained that during a hospital admission the board had failed to reasonably manage the removal of A’s nephrostomy tube (a catheter inserted through the skin and into the kidney) causing them to suffer an arterial trauma (or bleed). We found that bleeding is a recognised complication of such a procedure and there was no evidence to indicate any failings in the removal of the tube. We did not uphold this aspect of C’s complaint.

C further complained that when A’s condition deteriorated following dialysis, unit staff advised the family to take A home, or to take them to the emergency department themselves. C also complained that there had been no end-of-life plan in place for A. We found that there was insufficient evidence to determine what advice had initially been offered to the family by unit staff. However, we found that the process around the decision-making to admit A for ward care had been appropriate, and although there had been no end-of-life plan in place, the ‘wait and see’ approach to treatment had been reasonable in this case. Therefore, on balance, we did not uphold this aspect of C’s 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:

• The board should ensure all discussions between patients and clinicians are clearly documented in line with required standards.
• The board should give consideration to the use of specialist renal cancer nurses in supporting patient diagnosis/patient management from an early stage.
• The board should review urgent suspicion of cancer referrals to address treatment waiting times, ensuring that there are appropriate mechanisms in place to monitor progress from diagnosis to definitive treatment.

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.