Health

Summary

Ms C complained about the care and treatment her mother-in-law (Mrs A) received while a patient in the Victoria Hospital in the days immediately before her death. Mrs A had a history which included, amongst other things, epilepsy and dementia.

Mrs A was admitted to the hospital after a fall from bed. She then fell a further twice from bed, and shortly after the second time, she sustained a serious injury and subsequently died. Ms C said that the hospital failed to protect her mother-in-law properly, particularly as Mrs A had been assessed as being at high risk from falls. She said Mrs A was not provided with the one-to-one care she should have been given nor was she given appropriate medical care after she fell from bed. Ms C was also concerned at the level of communication with the family because although they were advised of both falls, the second time there was no sense of urgency despite Mrs A's very serious condition.

We took independent advice from a consultant geriatrician and from our nursing adviser. We found that the medical care Mrs A received was reasonable, so did not uphold that aspect of her complaint. However, we found that nursing staff failed to provide Mrs A with adequate nursing care; there was a general lack of detail in some of Mrs A's records; and there was a similar lack of detail given to the family about Mrs A's condition, so we upheld all of Ms C's complaints about these issues.

Recommendations

We recommended that the board:

• formally apologise to Ms C for their shortcomings in nursing care;
• confirm to us that the recommendations they made, after a significant adverse event review, have been satisfactorily completed;
• ensure that all staff are reminded of their obligations to provide properly detailed notes and demonstrate to us that they have done so;
• apologise for their communication failures; and
• remind staff on the relevant ward of the necessity of good, clear communication with patients' families, particularly in circumstances where the patient is unable to make their own decisions.

Summary

Mrs C complained that the board failed to appropriately manage her late husband (Mr C)'s adverse reactions to chemotherapy. In 2010, Mr C developed a troublesome itch and his chemotherapy was stopped half way through. In 2013 he had a severe reaction to one of his chemotherapy drugs. He later developed thrombocytopenia (a reduced platelet count), which ultimately led to his death.

We took independent advice from one of our medical advisers, who considered that there was nothing else the board could reasonably have done to treat Mr C's itch. We were advised that the cessation of chemotherapy was ultimately the only approach likely to resolve the problem. As Mr C's leukaemia had responded well to treatment, it was considered that the board's decision to stop this when they did was reasonable. We were also advised that the drug Mr C reacted to in 2013 was administered with appropriate caution and reasonable steps were taken to address the reaction when it occurred. The adviser considered that Mr C's development of thrombocytopenia could not have reasonably been predicted or avoided, noting that appropriate, but unfortunately unsuccessful, efforts were made to treat this. We concluded that Mr C's adverse reactions to chemotherapy were appropriately managed and we did not uphold the complaints.

However, we identified that the board's haematology day unit provided a poor service when Mrs C contacted them one Friday to express concern about some of the symptoms Mr C was displaying. There were no medical staff or blood analysing service available on the unit that day so they merely referred Mr C to his GP, without proper instruction. The adviser considered that this was a basic level of care that the board should have been in a position to provide. We, therefore, made some recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the identified failings in the care provided by the haematology day unit; and
• urgently review the identified failings, with a view to improving the service offered by the haematology day unit, and report back to us with their findings.

Summary

Mrs C complained about the palliative care provided to her father (Mr A) after his dialysis treatment (a form of treatment that replicates many of the kidney's functions) was stopped. Although this decision was discussed with the family, the hospital did not tell Mr A's medical practice about this, so they only found out three weeks later during a visit to Mr A's care home. At this stage, the GP began palliative care, including prescribing fentanyl patches (a type of pain relief similar to morphine). However, another GP stopped the fentanyl patches a few days later, and did not prescribe any other pain relief. Mrs C was concerned about this, and contacted the hospital consultant. The consultant tried to contact the practice, but the practice did not call back until the next day. After speaking with the consultant, the practice arranged an infusion pump of a painkiller and sedative for Mr A.

After taking independent medical advice from one of our GP advisers, we upheld one of Mrs C's two complaints. We found the practice could not have known that Mr A required palliative care earlier (as the hospital was responsible for telling them), and when they did find out, their care was reasonable, based on Mr A's symptoms at the time. It was also reasonable for the practice to return the consultant's call the next day, as there was no evidence that the message was given as urgent. However, we were critical that the GP did not discuss the decision to stop the fentanyl patches with Mr A's welfare attorney (his wife). We were also critical that the practice gave Mrs C misleading information, as they told her that, if they had known the dialysis was stopped, they would have referred Mr A to the community palliative care team, but they later told us that this wasn't necessary in Mr A's case.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings our investigation found; and
• bring the findings of our investigation to the attention of the doctor involved for reflection as part of their next annual appraisal.

Summary

Mr C has a history of back problems. He complained that he was only given an x-ray for his back pain and had to arrange for a magnetic resonance imaging (MRI) scan privately because a clinician at Dumfries and Galloway Royal Infirmary refused him one. Unlike an ordinary x-ray, MRI shows the soft structures in the spine such as disc, nerves, ligaments and muscles.

In response to the complaint, the board said that Mr C had an increase in back pain with no new symptoms and there was no indication that an MRI scan would be needed in accordance with national guidance on the early management of persistent non-specific low back pain.

We took independent advice from our medical adviser who said that Mr C's presentation was not straightforward and did not properly fit with the diagnosis of non-specific low back pain or any existing spinal guideline. The medical advice we received was that Mr C should have been assessed for the possibility of spinal cord compression and either have had an MRI scan or his case discussed with a spine specialist given he had a pre-existing deformity of his spine and had several red flags (symptoms that are likely to indicate a particular serious illness). We only found records to show that an orthopaedic specialist had interpreted the x-ray but no evidence to show that the specialist was aware of the red flags and the pre-existing deformity.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• review their local guidance with a view to including information on spinal presentations, such as spinal deformity and myelopathy pathologies;
• ensure the clinician reflects on the shortcomings in their next appraisal; and
• consider reimbursing Mr C for the cost of the private MRI scan on provision of appropriate receipts.

Summary

Mrs C's mother (Mrs A) was admitted to Dumfries and Galloway Royal Infirmary following a fall at home. She had previously been diagnosed with Alzheimer's disease and was noted to be confused upon admission. Staff found no evidence of bone fractures, but kept Mrs A in hospital until her mobility improved. A few days following her admission, Mrs A began vomiting. Medical staff suspected a bleed in her stomach and proposed an endoscopy (a camera inserted into the stomach to find the source of the bleed). Mrs A was fasted for the procedure, but it was delayed on several occasions due to a lack of patient consent.

Mrs C complained that her mother was fasted unnecessarily on a number of occasions in preparation for the procedure. She noted that staff had been informed that she had power of attorney for her mother (a legal document appointing someone to act or make decisions for another person) and complained that she was not asked to provide consent for the procedure. She also complained about Mrs A's hygiene, the monitoring of her fluid intake and poor communication from staff.

We were critical of the board's handling of the consent for Mrs A's procedure. There are clear guidelines for obtaining consent from patients who lack capacity to discuss their own treatment and these were not followed. The record-keeping in Mrs A's case was very poor and suggested a lack of consultant review over a number of days during her admission. We were critical of this, and the lack of discussions with Mrs C regarding Mrs A's treatment plan. We also found the staff's communication to be poor with no proactive plan to discuss Mrs A's care with Mrs C. This led to impromptu discussions in open corridors which we found to be inappropriate.

Recommendations

We recommended that the board:

• conduct an audit of the relevant ward's compliance with malnutrition universal screening tool, falls risk, and adults with incapacity responsibilities;
• review the standard of record-keeping in Mrs A's case and identify any requirements for additional staff training;
• provide us with details of the outcome of the Endoscopy User Group's review and the action taken to prevent further consent issues;
• apologise to Mrs C for the inadequate level of care and treatment Mrs A received during her admission at the hospital; and
• ask senior staff responsible for the relevant ward to review how staff communicate with family members to ensure regular, proactive, communication with particular emphasis on complying with the national standards for care of dementia patients.

Summary

Ms C had cognitive and communication problems. Following poor experiences with her GP practice, she asked to be deregistered. However, she subsequently found it difficult to register with a new practice. Before registering with a new GP, Ms C sought reassurance that they would make reasonable adjustments in light of her disabilities to allow her to access the services she required. On each occasion, the local GP practices asked her to register first so that her needs could be assessed and adjustments put in place. Ms C was reluctant to do so and asked the board for help. Whilst the board provided details of local practices, they also advised that she should register first to allow a needs assessment.

Ms C complained that the board did not make reasonable adjustments to help her access services in her community. She also complained about their handling of her correspondence and that they labelled her a vexatious complainant.

We were satisfied that the board acted reasonably by signposting Ms C to local GP practices and advising her to register. We found that equalities legislation requires practices to make such adjustments as are necessary, reassuring patients that adaptations will be made to allow them to access services.

We were critical of the board's handling of Ms C's correspondence, so we upheld this aspect of her complaint. Her correspondence was treated as a complaint but was not progressed through the formal complaints process. However, we did not find that Ms C had been categorised as a vexatious complainant.

Recommendations

We recommended that the board:

• apologise to Ms C for the poor handling of her correspondence;
• review their handling of Ms C's correspondence and consider how best to progress matters that are addressed outwith the formal complaints procedure; and
• remind their staff of the importance of adhering to the NHS Scotland complaints procedure.

Summary

Ms C complained that staff at Borders General Hospital failed to diagnose and treat her ankle injury. During the course of our investigation, Ms C decided that she no longer wished to pursue her complaint with us, and so we closed the file and took no further action.

Summary

Ms C, an advocate, complained to the board on behalf of her client (Mrs A) about the care she received at A&E at Borders General Hospital after she had fallen at home. Mrs A had fractured a bone in her arm and was discharged home the same day. The following day, she returned to the hospital in significant pain and further tests showed that she had fractured her kneecap and had bone cancer. Ms C also complained about a delay in Mrs A being reviewed by an orthopaedic specialist and physiotherapy.

We took independent medical advice from a consultant in emergency medicine who considered that Mrs A did not receive a reasonable standard of treatment when she initially attended A&E. There was insufficient evidence to show that the emergency doctor had carried out a thorough examination of Mrs A's joints below the fracture or her lower limbs despite ambulance staff having documented bruising to the right knee. We also took independent medical advice from an orthopaedic consultant who considered that the one day delay in identifying the fractured kneecap was unlikely to have impacted on Mrs A's overall outcome. However, we also found that Mrs A's significant pain level was not reassessed prior to being sent home and had it remained high, then she may have required intravenous morphine and admission to hospital. There was also no evidence to show that any assessment had been carried out of how she might manage at home and who was able to care for her if required.

In considering Ms C's complaint about the delay in Mrs A being reviewed by an orthopaedic specialist and physiotherapy, our orthopaedic adviser told us the eight week delay in Mrs A being reviewed was unlikely to have had a detrimental effect on the healing of her arm fracture. However, given she was to be reviewed within three weeks we found the delay in this case to be unreasonable.

We upheld all of Ms C's complaints, although we noted that the board had apologised to Mrs A that the pain relief they gave her was inadequate and acknowledged that a mistake had been made in her not being referred to the orthopaedic clinic and physiotherapy for further review. They also arranged for the hospital's discharge procedure to be reviewed with a view to making improvements in order to prevent the matter recurring. However, we made recommendations which related to the treatment of Mrs A when she initially attended the A&E department.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings identified; and
• ensure that the emergency doctor reflects on the failings and confirm when this has been done.

Summary

Mr C complained because he said an addictions caseworker inappropriately shared information about him at an integrated case management (ICM) meeting. The board told Mr C that he had consented to information about him to be shared because he had signed a consent form. Mr C disputed that he had given consent.

We obtained a copy of the information sharing protocol (ISP) agreement drawn up between the Scottish Prison Service and the NHS. That document was prepared to support the regular sharing of personal information for patients who are in prison with a view to supporting their care and case management in prisons and their transition in and out of prison. The ISP confirms that the information being shared will be used to facilitate operational prison management, including ICM, and the ongoing management and review of a prisoner's health and social care. It confirms the information that can be shared includes clinical information and also states that, for the purposes of the protocol and the processes described in it, no consent will be required from service users. We also obtained a copy of the consent form Mr C signed which confirmed that he consented to participating in the ICM process and understood what the process involved and how the information gathered would be used and stored.

In light of the information available, we concluded that the caseworker shared information about Mr C in line with the ISP. In addition, Mr C signed a consent form. Therefore, we did not uphold the complaint.

Summary

Ms C complained that her dentist had failed to fit temporary crowns properly. As a result they had become detached shortly after fitting. Ms C said when she returned to the dental practice, she was made to wait for an hour, before being told to go home and come in later that day. When she attended again, she felt the dentist was unprofessional and unreasonable as she asked Ms C to leave the surgery and refused to provide her with the impressions that had been taken of her teeth.

We took independent advice from one of our dental advisers on the treatment provided to Ms C. We found that the treatment provided was well documented and complied with the appropriate national guidance. Our investigation found there was no evidence that Ms C had received inappropriate or unreasonable dental care.