Health

Summary

C complained about the care and treatment provided by the board to their child (A) during a consultation with an orthoptist (specialist in the diagnosis and treatment of eye movement disorders) and optometrist (healthcare professional who provides primary vision care) in relation to the management of A’s strabismus (a squint) and wide-angled esotropia (inward turning of the eye). C made several complaints, including the board's failure to assess the size of the squint, failure to adequately dilate A’s irides using cycloplegic drops (drugs used to paralyse muscles in the eye), issuing a prescription for glasses based on an inaccurate refraction test result, displaying poor clinical knowledge about A’s condition and poor record-keeping. C also complained about how their complaint had been handled by the board, particularly in relation to a meeting that had taken place to discuss the complaint.

In response, the board stated that, while A’s refraction test indicated a greater amount of myopia (short-sightedness) than previous tests, differences could occur for a variety of reasons, such as the amount of dilation of the irides. In patients with dark irides, such as A, dilation could be difficult but this had been recognised by the clinicians and drops to dilate were appropriately re-instilled, with the prescription issued in accordance with the test results. The board accepted, however, that there had been communication issues between the orthoptist and optometrist but measures had been put in place to improve this. The board also agreed to amend A’s notes to reflect more accurately what had been discussed at the consultation and arrange a further review of A much sooner than had been agreed.

We took independent advice from a consultant in paediatric ophthalmology. We found that A’s refraction test results were inaccurate and should have caused the optometrist to question whether A’s irides had been adequately dilated rather than issuing an incorrect prescription. We also found that the records showed that the drops instilled by the clinicians had been administered at inappropriate intervals, which had likely resulted in A’s irides being inadequately dilated. We were critical of the board’s handling of the complaint, particularly in relation to the board taking advice from an optometrist who had insufficient clinical experience of the issues under consideration. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in 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:

• Where the outcome of a refraction test indicates that a significant increase to a prescription is required, clinicians should (i) question whether the patient’s irides have been sufficiently dilated, particularly in patients with darkly pigmented irides; and (ii) consider whether it is necessary to repeat the refraction at a follow-up appointment rather than proceed to issue the increased prescription.
• Where different types of eye drops require to be administered in order to achieve dilation of irides before carrying out a refraction test, clinicians should administer each set of drops at intervals of at least five minutes.

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 their pregnant partner (A) attended a local hospital as A was experiencing abdominal discomfort. A was examined and recommended to attend the main regional hospital, advising C to drive them there. The journey time was approximately 3 hours and on arrival A was examined and advised that labour may be starting. A was later told that labour was unlikely to be starting but remained in hospital overnight and discharged the following day.

The following week, A suffered vaginal leakage and attended the local hospital where they were examined by a clinician and advised that they suspected A’s waters had broken. A was advised to go to the main regional hospital and they were told that an ambulance was not needed. C therefore drove A to the main regional hospital.

An examination at the main regional hospital revealed that A’s waters had broken and in the early hours of the following day they went into labour. Later that afternoon clinicians gave A and C a number of options: continue with natural labour, attempt a process of augmentation (helping along a labour that's not progressing as it should), or an immediate caesarean delivery (an operation to deliver a baby that involves cutting the front of the abdomen and womb). A and C both agreed to a caesarean. The procedure was carried out and the baby (B) was delivered. However, clinicians had to resuscitate B.

A scan of B’s brain three days after birth revealed a likely injury which was later confirmed as periventricular leukomalacia (PVL, a softening of white brain tissue near the ventricles which often causes problems later with muscle control and thinking or learning problems). Following repeated scans over several weeks as the cysts continued to form, this was eventually categorised as grade three level of severity.

C raised concerns with the board regarding the care and treatment that A and B had received. C met various clinicians but remained dissatisfied. The board offered to have the events subjected to an external review but terms could not be agreed and the review was not carried out.

We took independent advice from a neonatal consultant. We found that, during both admissions, the board failed to provide reasonable care to A and their unborn child and that the board failed to fulfil their obligations under duty of candour. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to provide optimal care, for failing to carry out adequate assessment, for failing to complete suitable documentation and for failing to make safe transport arrangements. 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 and A for failing to provide reasonable care by omitting to timeously administer prophylactic antibiotics to A on arrival at the regional hospital and apologise for the board failing to fulfil their duty of candour obligations when the antibiotic incident was identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should offer C a final opportunity to address their outstanding questions in relation to the care of A and B in a format agreeable to both parties.

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

• Establish record keeping systems that prompt midwives to detail a full assessment and ensure there is cross checking with the consultant unit at the regional hospital.
• Establish a protocol for managing premature rupture of membranes in remote locations and commence treatment where appropriate, prior to transfer.
• Establish standard documentation and standard operating procedures for risk assessing pregnant women in remote locations, to determine the most appropriate mode of transfer to the obstetric units.

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 they received in relation to an alleged failure to promptly identify and treat developing symptoms of cauda equina syndrome (CES, compression of the nerve roots in the lower back affecting various neurological functions). C was initially admitted to hospital within another health board area before being discharged the following day on the basis that there was no evidence of CES at that time. However, C re-presented to the emergency department at the same hospital four days later with new symptoms thought to be CES. On the basis of advice provided by NHS Greater Glasgow and Clyde’s neurosurgical department at the Queen Elizabeth University Hospital (QEUH) to clinicians at the health board, C was fasted and underwent an MRI scan the following morning, which showed a large disc protrusion compressing the cauda equina nerve roots. C was thereafter taken by emergency ambulance to the QEUH where they underwent surgery the same day.

In order to investigate the neurosurgical advice provided by NHS Greater Glasgow and Clyde to the other health board, we took independent advice from a consultant neurosurgeon. We found that the advice provided had been reasonable given that it was well accepted practice that surgery to decompress the cauda equina nerve roots should be performed within 24-48 hours of a patient presenting to hospital, which had occurred in this case. Therefore, we did not uphold C's complaint.

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.