Health

Summary

C complained that the board did not repeat a test for Helicobacter pylori (H. Pylori, bacteria usually found in the stomach) given their symptoms, abnormalities in their blood tests and low ferritin (a blood protein containing iron) levels. C was of the view that had their symptoms been properly investigated, they would have been found to have H. pylori and would have been treated earlier.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that C did not have Helicobacter associated symptoms which would have triggered re-testing (such as indigestion symptoms). As there was no clinical indication to repeat a test for H. pylori, we did not uphold C’s complaint.

Summary

C complained about various aspects of the treatment provided by the board to their late parent (A) who was initially admitted to Glasgow Royal Infirmary with a fractured hip following a fall. A was subsequently discharged after surgery and received care at home from district nurses. However, A developed an infection at the site of their surgical wound and was readmitted to hospital, where they underwent several further surgeries to control the infection. A went on to develop further infections and subsequently died.

C complained that there had been a delay in carrying out surgical repair of the hip, that A had been discharged without appropriate physiotherapy follow-up, that an out-of-hours GP had failed to readmit A to hospital sooner and that nursing staff were unaware of a surgical procedure A had undergone. C also complained that there had been a delay in referring A to psychiatry, that A developed further infections, that A’s skin had not been correctly looked after, that there had been poor communication about the decision to withdraw care and that there had been errors on A’s death certificate.

We took independent advice from specialists in orthopaedic surgery, general practice community nursing and hospital nursing. We found that reasonable care had been given in relation to the choice of surgical procedures A underwent. We also found that reasonable care had been given to the management of A's infections whilst in hospital, the level of community nursing care, the management of A’s skin, PICC line (a thin flexible tube inserted through a vein to give medicine directly into the bloodstream), referral to psychiatry and end of life care. However, we found that there had been unreasonable care provided in relation to a delay in carrying out A’s initial surgery. We also found failures by an out-of-hours GP to record sufficient detail about A’s condition and ensure A was provided with prompt antibiotic treatment, requiring A to complete two consent forms for the same surgical procedure. We further found that there was a failure to discuss with A’s family a decision taken by clinicians not to perform cardio-pulmonary resuscitation (where the heart and/or breathing is re-started if it stops) of A were it to be required. We also found instances of poor record-keeping by nursing staff and errors contained within A’s death certificate. As such, 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:

• Do not attempt cardiopulmonary resuscitation (DNACPR) decisions should be discussed with the patient or their power of attorney/next of kin and the DNACPR form should be completed appropriately.
• Patients' death certification should be completed accurately.
• Patients' nursing care should be clearly and accurately recorded. Entries should be legible, signed and dated and the use of abbreviations should be minimised.
• Patients should be given appropriately and timely treatment by out-of-hours GPs, which is clearly recorded.
• Patients should be given clear information during the surgical consent process to ensure that they are fully informed.
• Patients with a suspected hip fracture should be appropriately investigated within a reasonable timeframe.
• The nursing staff caring for a patient should have appropriate knowledge of their medical history including their care and 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.

Summary

C complained regarding the treatment that they had received from the board in relation to a pharyngeal pouch (a pocket in the lining of the pipe that carries food from the mouth to the stomach). They complained about issues regarding the surgery they had in relation to this and about the information they were given.

We took independent advice from an ear, nose and throat (ENT) surgeon. We found that C was given reasonable information in advance of their surgery and that it was reasonable to examine a pharyngeal pouch through surgery. It was appropriate that C's pharyngeal pouch was emptied of partially digested food as otherwise it would not have been possible to examine it. It was also reasonable that C was offered a cricopharyngeal myotomy (where a surgical cut is made in the muscle that allows swallowing to weaken it) to treat their pharyngeal pouch, as it is one of the treatment options set out in the relevant clinical guidance. Although an external myotomy was recommended, C was given the option to explore alternative approaches, but the clinicians felt the pouch was too small for stapling. In addition, it was reasonable that C's outpatient appointment with the ENT surgeon was cancelled, given they were unhappy to proceed with the proposed treatment option.

Therefore, we did not uphold the complaint.

Summary

Following a short psychiatric hospital admission, C presented unwell on several occasions over the course of the next month. C complained that they weren’t sectioned under the Mental Health Act and given appropriate treatment. C’s behaviours at that time had prompted police involvement and the outcome of clinical assessments concluded that these behaviours were not driven by a mental health problem. C disagreed with this and was very distressed to subsequently be subject to a short imprisonment, before a judge ordered that they be admitted to a psychiatric unit.

We took independent advice from a consultant psychiatrist. We found that based on the information available at the time, reasonable conclusions were reached by the clinical team regarding the nature of C’s condition and the cause of their behaviours. We found that the action taken was in line with accepted practice in the circumstances. The clinicians all reached a consistent view as to the nature of C’s presenting condition and none were able to identify an underlying psychotic issue. We considered that C’s condition at that time was significantly different to when they were subsequently admitted to hospital, at which time a psychotic cause had become apparent. We did not uphold this complaint.

Summary

C’s adult child (A) had spent time in hospital due to abdominal pain, following which complaints had been raised and promises made that action would be taken to prevent any recurrence. A few years later, A spent time in hospital again as a result of abdominal pain and swelling, bruising to the legs and breathing issues. During the admission, A required cardiopulmonary resuscitation (where the heart and/or breathing is re-started if it stops) and died in hospital. A post-mortem examination established that A had rheumatoid arthritis-related constrictive pericarditis (a condition that causes the flexible sac that surrounds the heart to become stiff, preventing the heart from functioning properly).

C raised a number of concerns regarding the clinical investigations carried out into A’s symptoms, the time taken to reach a diagnosis and the quality of clinical nursing care provided. C complained about the standard of communication from the board’s staff and expressed their concern that the improvements that had been promised previously had not been implemented by the board.

We took advice from an independent nursing adviser. We found that multiple, relevant, investigations were carried out to establish the cause of A’s symptoms, appropriate specialist advice was sought, a reasonable treatment plan was followed and that the true nature of A’s heart condition was not detectable, despite the appropriate investigations having been carried out. Given this, we found that the medical care and treatment provided to A had been of a reasonable standard. We did not uphold this aspect of the complaint.

We found that the board’s monitoring and management of A’s fluid balance and wound care was not of a reasonable standard, and that there were apparent issues in terms of the nursing staff’s engagement with A and their family. We found that the board had failed to provide A with a reasonable standard of nursing care. We upheld this aspect of the complaint.

While we found the board’s communication with C following A’s death was generally reasonable, we found that the board unreasonably failed to apologise to C for not contacting them when A became unresponsive. Given this, and that there were communication failings that the board had accepted, we found that the board had failed to communicate with A’s family appropriately during their admission and following their death. We upheld this aspect of the complaint.

We did not find any evidence that the actions and service improvements promised following C’s earlier complaint were implemented by the board. We also found that if actions were taken, they were not effective, as the board accepted that similar issues had recurred. We found that the evidence the board provided regarding actions taken as a result of their later commitments were from too small a sample of patients and taken over too short a period to adequately demonstrate that issues identified had been addressed. Given this, we found that the board had failed to implement the actions and service improvements promised following C’s earlier complaint. We upheld this aspect of the complaint.

We found that C’s complaint was taken seriously and investigated thoroughly. However, there were delays to starting an investigation into the most recent issues raised by C and to arranging a meeting regarding these. We also found that the board’s communication with regard to the Chief Executive’s attendance at any meeting and how the most recent issues would be taken forward were poor. Given all of the above we found the board failed to handle C’s complaint reasonably. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for failing to contact them when A became unresponsive. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for failing to effectively implement the actions and service improvements promised following C’s original 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 conduct an audit of the relevant ward's current compliance with their obligations to monitor fluid balance and wound condition to ensure that the improvements that have reportedly been made since C’s complaint are reflected in the nursing care currently provided on the ward.
• The board should conduct two audits of the general quality of nursing care in the relevant ward to demonstrate an improvement in standards over the next six months.
• The board should effectively implement the actions and service improvements promised following C’s original complaint and take action to effectively address issues regarding nursing care, communication, attitude and behaviour.

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 they received from the board for their right sided hearing loss. They complained that they had been misdiagnosed and wrongly advised that a hearing aid would improve their situation, and that no surgery would help them. C later accepted a second opinion and was referred to a hospital outwith the board area where they received a different diagnosis and treatment (a bone anchored hearing aid) which they said improved their quality of life.

We took independent advice from an ear, nose and throat consultant. We found that C’s audiogram (hearing test results graph) had been unreasonably misinterpreted and C was misdiagnosed. We found that the treatment that was given (a standard hearing aid) was not suitable for C’s actual condition. We found that C should have been offered a Crosaid (a device worn behind the ear which routes sound from the affected ear to the unaffected ear), or the surgical option (a bone anchored hearing aid) which was eventually provided when C obtained a second opinion.

We also considered that C was not provided with reasonable advice regarding the use of a hearing aid, that there was a failure to take a careful history for C and pick up on the clues in the referral letter from C’s GP as to the nature of the onset of C’s hearing loss, and a failure to arrange appropriate investigations for C. We also found that there had been failures in the way in which the board had communicated with C about their hearing loss, and we were critical of the way the board investigated and responded to C’s complaint. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably advising them that they had otosclerosis (a disorder, sometimes hereditary, in which there is formation of new bone around the base of the bone of the middle ear, resulting in progressive hearing loss), when they had sensorineural hearing loss (resulting from damaged hair cells in the inner ear), failing to provide C with appropriate treatment for their hearing condition and failing to provide appropriate advice on the use of hearing aids. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informan-leaflets.

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

• For the board to appropriately interpret scan results, make appropriate diagnoses in cases such as this, take into account all relevant information, including patient history/GP referral information and test results, identify and arrange appropriate investigations and provide appropriate treatment and advice on the use of hearing aid devices.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring and governance system should ensure that concerns raised are appropriately investigated, failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement. There should be a review of complaints by senior staff during the board’s investigative process.

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 follow-up care provided to their late partner (A) who died around four months after suffering a heart attack. The board said that A was followed up by the cardiac rehabilitation service in line with established practice. We took independent advice from a consultant cardiologist (a specialist in diseases and abnormalities of the heart). We found that A's follow-up care was reasonable in the circumstances (of no face-to-face consultations due to the COVID-19 pandemic). We also found that it was reasonable for the board not to follow up on blood tests taken at A&E following A's attendance with chest pain. The board said that the test results showed no evidence of a new cardiac injury. We considered it reasonable to have excluded a new cardiac injury as the cause of A's chest pain, and we were not critical of the care provided. Therefore, we did not uphold these aspects of C's complaint.

C also complained about the conduct of a telephone consultation with a cardiac rehabilitation nurse. A called to report symptoms of breathlessness and C complained that the nurse diagnosed a chest infection and/or anxiety over the phone, and did not arrange for A to be seen. However, the nurse did not recall making such a diagnosis, and their recollection was that there was no apparent indication for A to be seen. We were unable to reconcile the differing recollections, and we considered that the actions of the nurse appear to have been consistent with reasonable practice. C was unhappy that the call was not documented. The board said that the call was not documented as A had been discharged from the cardiac nurse service, and in such circumstances patients are directed to their GP for any advice required. We noted that referral back to primary care for non-urgent symptoms is consistent with established good practice. We did not uphold this complaint.

Finally, C complained that A's post mortem described A as having severe heart disease, and they complained that they had been advised everything was fine following A's heart attack and stent insertion. We found that comparison between findings pre and post death, four months apart, is problematic and can be complicated by a number of factors. We noted that the disease seen at post mortem may not have been present four months earlier and we considered A's care was reasonable based on what was known at the time. We did not uphold this complaint.

Summary

C complained about the care and treatment that their late parent (A) received at University Hospital Monklands. A was admitted to hospital to have fluid drained from their abdomen but died in the hospital a few days later. C was concerned that the drain was left in too long and caused A to suffer a perforation of the bowel, and that medical staff delayed and/or failed to investigate whether A had suffered internal damage as a result.

We took independent advice from a consultant hepatologist and gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found that without a post mortem it was impossible to determine the cause of the perforation. We also found that while A's drain had been left in longer than recommended, it was unlikely that the delayed length of time the drain was left in and the subsequent perforation were related, as A did not have any immediate complications nor signs of problems from the drain for a number of days before developing a bowel perforation.

We found that the clinical action taken by the team involved in A's care at this time was reasonable. Once there was a suspicion of a perforation occurring, a chest x-ray had been carried out and this had been good practice. The board acknowledged and identified lessons to be learned and we considered the board's actions to address what occurred were reasonable. However, we found that the delay in removing the drain was unreasonable and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in removing A's drain. 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:

• There should be good communication between the medical team (inserting the drain) and the nursing team with regards to the timing and the removal of a patient's drain.

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 and B complained about the board's handling of reports of alleged elder abuse in relation to a family member (A). They also complained that the board had failed to handle appropriately a referral made to the District Care Panel (DCP) for residential care for A, and had failed to give sufficient consideration to A's circumstances and that they were at risk of harm when rejecting the request. They also complained that following concerns for A's welfare, A had been removed from their place of residence, but the board had failed to properly assess A's care needs or to provide A with a reasonable level of support. In pursuing these matters, C and B said that the board's communication with them had fallen below a reasonable standard.

We took independent advice from a social worker. We found that although the Adult Support and Protection (ASP) investigation was procedurally sound, it had been lacking in quality. The board's analysis of A's circumstances and the Personal Outcome Plans were lacking, and were not persuasive in assessing a care need. As such, we found that the board had failed to safeguard A. We upheld this aspect of the complaint.

We also found that although the DCP handled A's referral for residential care appropriately, the information provided to the DCP was lacking in terms of the quality of the ASP investigation and the robustness of the case presented regarding A's situation. As such there was a failure by the board to prioritise securing urgent short-term accommodation that took account of A's circumstances. We upheld this aspect of the complaint.

We found that following A's removal from their place of residency, the board had followed up with A reasonably. We did not identify any further shortcomings in the board's assessments of A's care or living needs. We did not uphold this aspect of the complaint.

Finally, we found that the board had, at times, failed to respond to C and B's questions and requests for information regarding their concerns about A. We also found that there had been occasions where the board's correspondence with C and B had been unreasonably slow. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the poor handling of their correspondence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C, B and A for the issues 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 (i) share this decision notice with the staff involved in A's case with a view to reflecting on how the ASP investigation could have better identified the nature and extent of their situation and pushed for an outcome that would have better protected A; and (ii) use this case as a reflective exercise to consider the effect of undue pressure and trauma on decision-making in ASP cases.
• The board should review how they track and respond to general correspondence to ensure all points are responded to fully and within a reasonable timescale.

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 treatment that they and their child (A) received from the board. Over the course of nine months, C and A attended a number of appointments with the board's Child and Adolescent Mental Health Service (CAMHS) in respect of difficulties A was experiencing. C complained about the content and nature of these sessions. In their view, the board failed to progress a neurodevelopmental assessment of A within a reasonable timescale, which C considered was one of the key reasons for the referral. C also felt inappropriate assertions were made about them and their parenting skills. In C's view, they were unreasonably picked on during sessions with CAMHS. As a result of this, C's view is that CAMHS failed A and did not provide them with reasonable care and treatment.

C also complained about a child concern referral that was made by the CAMHS service. C considered this to be inappropriate and that it was done in response to them raising concerns about the actions of CAMHS.

We took independent advice from two advisers: a mental health nursing specialist and a clinical psychologist, both with a background in CAMHS. We found that the care and treatment provided by CAMHS was reasonable in the circumstances. Given the content of the referrals from A's GP and social worker, CAMHS embarked on an appropriate course of treatment and therapy. While we recognised that this did not result in a positive outcome for C or A, we did not consider the board's actions to be unreasonable. Therefore, we did not uphold C's complaints about the care and treatment provided by CAMHS.