Health

Summary

Mrs C complained about the care and treatment she received in relation to a range of unexplained neurological (relating to the nerves and nervous system) symptoms. During our consideration of the complaint, Mrs C advised that she had decided to pursue the matter by other means. We decided, in the circumstances, and under the provisions of the Scottish Public Services Ombudsman Act 2002, that we would not consider the matter further.

Summary

Mr C complained about aspects of the medical and nursing care and treatment provided to his brother (Mr A) during four admissions to Glasgow Royal Infirmary. Mr A was diagnosed with lung cancer. His deterioration was sudden and significant, and he died within four weeks of diagnosis. Mr C said that Mr A's cancer was not diagnosed within a reasonable time, and that his various discharges and the management of his pain was not reasonable. Mr C was particularly concerned about an attempt to resuscitate Mr A when they had agreed with nursing staff the night before that, as he was at the end of his life, he should not be resuscitated. Mr C also said that communication with nursing and medical staff was not reasonable, and that the family had explained to staff that they should be present when staff talked to Mr A because he had a fear of hospitals.

After taking independent advice from one of our medical advisers, we found that the treatment decisions and discharges were reasonable, as was the time it took to diagnose Mr A's cancer. Also, we could not reconcile the different accounts of the level of pain Mr C said Mr A experienced in light of the evidence from the medical records. However, in relation to the attempted resuscitation, we found that there were significant failings which resulted in a serious injustice to Mr A and his family, who were traumatised by the attempt. We also found communication failures between nursing and medical staff, which then affected communication with the family.

Recommendations

We recommended that the board:

• bring to the attention of relevant staff the medical adviser’s comments in relation to senior clinical review for distressed patients at the end of their lives;
• review their process in relation to end of life care to ensure that inappropriate CPR (cardiopulmonary resuscitation) attempts are avoided;
• bring the shortcomings in record-keeping to the attention of relevant staff;
• ensure the failures around the attempted resuscitation are raised with relevant nursing staff in the annual appraisal process;
• ensure the failings in communication are raised with relevant staff in the annual appraisal process;
• take steps to ensure the involvement of senior clinicians with seriously ill patients and their families in light of the medical adviser’s comments; and
• apologise for all the failings this investigation identified.

Summary

Mrs C complained that her mother (Mrs A) had received inadequate medical supervision and nursing care whilst in Stobhill Hospital. Mrs C said there were not enough medical staff available on the rehabilitation ward Mrs A had been placed on and that Mrs A's consultant had been uninterested in her case. She said Mrs A had been fed inappropriate food, and treated without dignity or respect. Mrs C said the family had fought to have her discharged into their care and they were unhappy about the board's failure to take their complaint seriously. Mrs C noted that it had taken months for the board to produce minutes of the meeting held with the family to discuss the complaint.

Our investigation took independent medical and nursing advice. The medical advice noted that the specific complaints raised by Mrs C were mostly nursing issues. The level of clinical supervision was adequately documented, and showed regular and appropriate recordings of medical review. The nursing advice received was that the level of nursing care overall was reasonable, although the board had admitted there were deficits in the care. The nursing adviser suggested that the board should provide evidence of the actions taken to improve nursing care.

The board provided a comprehensive and detailed action plan, showing improvements to patient care following the complaint. We found that the board had apologised appropriately and taken reasonable steps to improve patient care, and that no further action would be appropriate.

Summary

Ms C, who is an advice worker, complained on behalf of Mrs A's family about the care and treatment provided to Mrs A by Southern General Hospital when her life-support machine was switched off. Mrs A was admitted to hospital after sustaining a severe injury at home, and put on a life-support machine. After being told by hospital staff that she could not survive, the family agreed to switch off the life-support machine. However, unexpectedly, Mrs A continued to live for a further 20 days. During this period, the family said there were communication failures; they did not know what was being done and what to expect in terms of care. They were also concerned that staff failed to provide appropriate care, particularly in relation to pain relief, fluids and nutrition. At the end of Mrs A's life, she was transferred to another hospital (Glasgow Royal Infirmary). The family said that her medical records were not transferred with her which meant that appropriate care could not be provided within a reasonable time at the second hospital. Finally, the family complained about the way the board had handled the complaint.

We took independent advice from one of our medical advisers. We found that the standard of care provided in relation to medication, nutrition and fluids was reasonable, and that sufficient information accompanied Mrs A when she was transferred to the second hospital. We were also satisfied that the evidence indicated that the family were kept fully informed of Mrs A's condition and prognosis. However, we found that the language the board used in their response to the complaint was inappropriate and insensitive, and that the response was overly technical and difficult for a layperson to understand.

Recommendations

We recommended that the board:

• take steps to ensure that Glasgow Royal Infirmary are complying with Records Management: NHS Code of Practice (Scotland);
• ensure that appropriate and sensitive language is used in complaint responses; and
• apologise for the failures this investigation identified.

Summary

Mrs C complained about the care and treatment her husband (Mr C) had received from the board in relation to brain tumours. We took independent advice on this part of her complaint from one of our medical advisers, who is a consultant neurosurgeon. We found that it had been reasonable not to give Mr C radiotherapy after a tumour had been removed at the Western Infirmary. However, Mr C had also been receiving other treatment that would have increased the risk of early or more rapid progression of a recurrent tumour. We found that it had been unreasonable for the board to wait eleven months before carrying out a follow-up scan. In view of this, we upheld this part of Mrs C's complaint. When the follow-up scan was then carried out, it showed a large recurrent tumour.

Mrs C also complained about the nursing care provided to Mr C whilst he was in the Southern General and Beatson Hospital. We took independent advice on this from a nursing adviser and we found that the care provided had been reasonable so we did not uphold this aspect of her complaint. Mrs C also said that the board had failed to adequately explain Mr C's condition and prognosis. Whilst the evidence in relation to this was not conclusive, the comments made by the consultant about the information given to the family were somewhat vague, and Mr and Mrs C had not fully understood what the consultant was trying to say. We found that, on balance, the information had not been satisfactorily communicated to Mr and Mrs C and so we upheld this aspect of the complaint. Finally, Mrs C complained about the board's handling of her complaint. We found that the board's response had been difficult to understand. It contained too much medical terminology and jargon that was not adequately explained. We upheld this part of her complaint for this reason.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings we identified;
• make the relevant staff involved in Mr C's care and treatment aware of our findings; and
• remind the staff involved in the handling of Mrs C's complaint that responses to complaints should be clear and easy to understand.

Summary

Ms C complained that the board failed to adequately manage her Von Willebrand Disease (VWD – an inherited bleeding disorder) when she was admitted to Aberdeen Royal Infirmary for gall bladder surgery. She said she had previously been given medication for her VWD before dental treatment and treatment for cancer, but said this did not happen for her gall bladder surgery. Ms C also complained that the board failed to communicate properly with her about her VWD when she was in hospital.

We obtained independent medical advice on Ms C’s case from a consultant haematologist with specific expertise in blood clotting disorders. Our adviser said that Ms C’s VWF levels (levels of a blood protein which helps blood to clot) were checked on the day of her surgery and found to be within the normal range. As a result, the board decided not to treat Ms C with a concentrated form of the clotting agent, but to have it ready in case any problems arose. Our adviser said that this approach was reasonable.

The board apologised for the lack of communication with Ms C about her VWD and said that staff should have explained and discussed her condition with her. Our adviser said that communication could have been improved by checking Ms C’s VWF levels the day before surgery, rather than on the day of her surgery, and making a decision on whether she required treatment with the concentrated form of the clotting agent at that time. This would have allowed more time for discussion with Ms C about VWD and the proposed treatment, and at a less stressful time than on the day of her operation. This would have increased the chances of Ms C understanding and accepting the apparently conflicting advice about the management of her condition. We were critical of the board in this regard.

Recommendations

We recommended that the board:

• feed back our decision on the complaint about the board's communication regarding VWD to the staff involved.

Summary

Mr C complained to us on behalf of his daughter (Mrs A) in relation to two assessments she had at Forth Valley Royal Hospital’s psychiatric services. Mrs A’s mental health was deteriorating, and her family initially sought help for her from a GP, who referred her for a psychiatric assessment. She was subsequently sent home, so her family sought GP assistance again. Following a home visit, Mrs A was again referred for a psychiatric assessment, with a very similar outcome. Mr C complained that the family were only given the opportunity to explain why they were so concerned about Mrs A after her second psychiatric assessment, when they insisted on speaking to the doctor.

We took independent advice on this complaint from one of our advisers in psychiatry. The adviser was critical that Mrs A’s family were not expressly involved in either of the assessments. He said that this should be a standard part of such assessments. He also noted that insufficient weight was given to the GP’s concerns and findings. He noted that the first GP had done a detailed assessment and history, and this was not fully considered during either of Mrs A’s psychiatric assessments. The adviser noted that both doctors who assessed Mrs A were trainees, and expressed concern that there was insufficient documentation as to why Mrs A did not meet the criteria for detention at hospital. He also found that the plan for future follow-up was not practical and did not sufficiently involve her carers.

We considered the advice we received, and found that the psychiatric assessments had not been sufficiently robust. We therefore concluded that she was not given a reasonable standard of treatment. We also noted that the failings in this case potentially put Mrs A at significant risk, as her family no longer felt able to keep her safe.

Recommendations

We recommended that the board:

• review the training for those involved in emergency assessments to ensure it highlights the importance of a corroborative history from relatives and carers; the concerns and findings of GPs; full documentation of consideration of a patient for detention in hospital, including clear links to the legal criteria for that detention; and a practical plan when a patient is not detained, involving carers, and including advice and guidance on potential future action;
• remind existing staff involved in emergency assessments of the requirements specified above; and
• apologise to Mr C and to Mrs A for the failings identified, for the distress they caused, and for the risks that these led to for Mrs A.

Summary

Mr A was referred by his GP to the ear, nose and throat clinic at Forth Valley Royal Hospital with a swelling below his left ear. This was found to be cancerous and Mr A was referred to another health board for surgery. This surgery resulted in extensive facial disfigurement and Mr A's daughter (Mrs C) complained that the board failed to explain the extent of Mr A's cancer and the impact the surgery would have on him. Mrs C also complained about delays following surgery in arranging onward referrals for Mr A to various specialists.

The board apologised that Mr A and his family were not adequately prepared for the life-changing results of the surgery, and they developed an improvement plan to address the concerns raised. They noted that their consultations with Mr A occurred at a very early stage in the process of preparing him for major surgery. They indicated that their role was to provide an overview and the intention was for a more detailed explanation to be provided by the board who were carrying out the surgery.

We took independent medical advice from a consultant maxillofacial surgeon (doctor specialising in the treatment of diseases affecting the mouth, jaws, face and neck). The adviser confirmed that the board carrying out the surgery were responsible for explaining the procedure and obtaining informed consent. He considered that the board had appropriately carried out their duties in this case. However, he noted that the communication between the two boards appeared to be lacking. He found no evidence of a formal referral to the other board having been made and he considered there was a lack of clarity regarding the respective role of each board. This also applied to the handover between the cancer nurse specialists at each board, which meant that relevant patient information literature was not given to Mr A. The absence of clear lines of responsibility also resulted in a delay in arranging relevant onward referrals following surgery. We accepted the advice we received and upheld the complaints, recommending that the board further develop their action plan in light of our findings.

Recommendations

We recommended that the board:

• develop their action plan further to take account of the failings this investigation has identified and the adviser's suggestions for areas of improvement.

Summary

Mr C complained that the board failed to prescribe him specific medication for his drug addiction, and that his drug worker did not listen to his concerns.

We looked at Mr C’s medical records, and we took independent advice from one of our medical advisers. We found that the prison health centre kept detailed records of consultations with Mr C, and that they took his state of health into account when deciding not to prescribe him the specific medication he wanted. The records confirmed that assessments carried out by Mr C’s drug worker were appropriate. We concluded that the prison health centre’s actions were reasonable in the circumstances, and that the care provided by them was of a reasonable standard. We did not uphold Mr C’s complaint.

Summary

Miss C complained to the medical practice because she said the doctor had inappropriately told her mother (Mrs A) at a consultation that she had been diagnosed with dementia. Miss C said the doctor repeated the diagnosis of dementia to both herself and her father in further phone calls. However, it was confirmed that Mrs A did not have dementia. The doctor denied telling Mrs A and her family that she had been diagnosed with dementia. Instead, the doctor said she advised that there was a possible diagnosis.

Having reviewed the related medical information, the evidence available suggested dementia was being explored as a possible diagnosis and at no point was it confirmed as having been diagnosed. We did not see any evidence to suggest that the doctor, or any of the other clinicians involved in Mrs A's case, had confirmed a diagnosis of dementia. Therefore, we did not uphold the complaint.