Health

Summary

Ccomplained that their late parent (A) called the practice and was given a prescription without being seen in person. C also complained that an appointment or home visit wasn’t arranged when C called three days later and reported that A's condition had worsened.

We obtained independent advice from a general practitioner adviser. We found that the actions taken by the practice at the time of the initial call were reasonable and considered it reasonable for A not to have been seen in person at that time. We also considered that reasonable action was taken when C called three days later, based on what was documented in the records. However, it was acknowledged that there were differing accounts of what had been discussed, and that the symptoms C said they communicated would reasonably have prompted A to be seen in person. Based on the evidence available and the advice obtained, which we accepted, we concluded that A received reasonable medical care and we did not uphold this complaint.

However, we noted that the level of documentation could have been improved. This includes recording when safety netting advice is given (when patients are advised to return if their symptoms don’t improve, advice which the practice said was given to A during the first call but was not documented); reasons why a patient is not spoken to directly (as was the case when C called); and reasons to see or not to see a patient in person, particularly for a repeat caller. We fed this back to the practice for their reflection and learning, along with feedback on their handling of the complaint.

Summary

C complained about the care and treatment provided to their parent (A) when they were a patient at Glasgow Royal Infirmary. C raised concerns that they had to alert staff to the fact that A had become unresponsive. C complained that A was stepped down from critical care to a medicine for the elderly ward when A was still unwell and suffering from delirium. C also complained about changes made to A's death certificate, which had been amended by a consultant, following the initial certificate prepared by a junior doctor. The death certificate was updated to fully reflect A's underlying condition, including the possibility of an underlying cancer diagnosis. However, it was subsequently amended again to remove the reference to cancer in light of C's upset over this.

We obtained independent medical advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A's condition was monitored appropriately and reasonable action was taken in a timely manner when it was noted they had deteriorated. We were satisfied that the board had already acknowledged and apologised for not keeping C updated while they dealt with A's care. Therefore, we did not uphold this complaint.

In relation to the second complaint, we considered action was appropriate as A was no longer in need of critical care, and confirmed delirium would not have been a reason to delay the transfer. We, therefore, did not uphold this complaint.

With regard to the complaint about changes to A's death certificate, we were satisfied that the board had provided an appropriate explanation and apology, and had demonstrated learning. We had no concerns about the accuracy of the death certificate. However, we noted that it would have been good practice to offer a post-mortem examination in light of the clinical uncertainty, and C's concerns, surrounding a possible underlying cancer. While we fed this back to the board, on balance, we did not uphold this complaint.

Summary

C's baby (A) was born with a rare genetic disorder and died four days after their birth. C complained about the board’'s failure to identify A's condition during prenatal scans. C complained that despite A's face not being visualised in two abnormality scans, a further scan was not arranged.

We took independent advice from a consultant obstetrician and gynaecologist (a specialist in pregnancy, childbirth and the female reproductive system). We found that the board had appropriately followed national and departmental guidance in relation to the scans. We found it reasonable that A's condition was not detected during C's pregnancy. Although imaging of A's face was not possible during the second scan, we found there was no requirement to carry out a further anomaly scan or take any further action in relation to this. We therefore did not uphold this complaint.

Summary

C complained about a delay in diagnosis of cancer due to insufficient investigations undertaken by a number of GP's at the practice. C was later diagnosed with stage 4 lung cancer. C said the signs of cancer were missed, which was likely due to seeing different GP's at each consultation. In addition to this, C had a history of kidney cancer and considered their history was not adequately taken into account. C attended the practice on several occasions, reporting a number of concerns. C said that considering their history of cancer, the early signs of lung cancer were evident. It was only following a CT scan for C's kidney cancer that the oncology team found evidence of stage 4 lung cancer.

The practice agreed that some of C's symptoms during this time could explain developing cancer. However, they also considered that the symptoms reported could be caused by a wide range of diagnoses. The practice evidenced that multiple x-rays were taken along with blood tests and vital sign checks, and there was nothing to indicate that cancer was developing. Due to these findings, the practice say that they had no medical reason to request a CT scan or refer C to a specialist team. We took independent advice from a GP adviser and reviewed the relevant medical records. We found that C did not present with any symptoms suggestive of lung cancer but a variety of unrelated problems, some of which were long standing. It was noted there was a lack of red flag symptoms of lung cancer, and as such, there was no requirement for a CT scan or to be referred to a specialist team during this period.

In light of this, we found that the overall care and treatment provided to C was reasonable. We therefore did not uphold this complaint.

Summary

C complained about the care and treatment provided to their elderly parent (A) during their admission to St Andrew’s Community Hospital for post-surgery rehabilitation. C complained about several aspects of A's care during their admission including in relation to their eating and drinking, management of their medicines, the discharge arrangements, and the general care provided to them as a person living with dementia.

We took independent advice from a senior nurse. We found that aspects of A's care in relation to their eating and drinking had been reasonable. However, the board had failed to undertake regular weight checks or re-assess A's risk of developing malnutrition. As such, we upheld this aspect of C's complaint and made recommendations for learning.

In relation to the management of A's medicines, their discharge planning, and the care provided to them as a person living with dementia, we found the care provided by the board to A to be reasonable. Therefore, we did not uphold these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to accurately assess or review A's MUST score or record their fluid output. 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:

• Assessments should be accurate and updated in keeping with care planning or when a change in the patient’s condition prompts a further review.
• Where poor food and fluid intake has been identified, there should be documentation of the necessary observations to enable full assessment and management of this (MUST scores, oral intake such as on a food record chart and urinary volumes measured and recorded on fluid balance charts).

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 to the board about an incident during which they were restrained by staff to receive emergency treatment when they experienced a life-threatening complication of their health condition.

At the time, C was being detained under a Compulsory Treatment Order by the board when the complication arose necessitating their transfer to the acute hospital site for further treatment.

C complained about several aspects of this episode including the conduct of the staff when restraining them, the failure by the board to contact or seek appropriate consent for the treatment from their court appointed welfare guardians, failure to maintain their privacy and dignity, and failure to tend to their comfort or basic hygiene needs. C also complained about the board’s suggestion that a pattern was emerging of them making unfounded complaints due to them previously complaining about a separate episode of care.

We sought independent advice from a senior mental health nurse on the care and treatment provided by the board to C. We found that C's treatment was of a reasonable standard. We noted that the emergency nature of C's condition allowed treatment without their guardians’ consent, and the steps taken to ensure their privacy, dignity and comfort had been reasonable in the circumstances. On considering the conduct of staff during the episode of care, the likelihood of having to restrain C for treatment had been anticipated in advance and plans were made to do so in line with board-approved techniques. We did not uphold this aspect of C's complaint.

In respect of the board suggesting that there was a pattern emerging of C making unfounded complaints, we referred to the rights of patients outlined within The Patient Rights (Scotland) Act 2011 and the Charter of Patient Rights and Responsibilities. As this legislation ensures the rights of patients to complain or give feedback about their healthcare encounters, we considered the board's response to C to be unreasonable and we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

In relation to complaints handling, we recommended:

• The board should have policies and procedures in place to support the management of problem complainant behaviour.
• Where problem behaviour is suspected or identified, this should be handled in line with the NHS Model Complaints Handling Procedures and in reference to other associated policies and procedures.

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 to the board about the treatment provided to their late relative (A) who died of a ruptured bowel. A had been in University Hospital Ayr two weeks previously with symptoms of severe pain. Staff had carried out tests and a scan, and discharged A home without follow-up. C believed that the board should have carried out more intensive investigations, which may have discovered A was still having bowel problems and provided additional treatment. The board believed that appropriate treatment had been provided.

We took independent advice from a consultant in acute medicine (a specialist in the immediate and early management of adult patients with a wide range of medical conditions who present in hospital as emergencies) and a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that staff at the hospital provided a reasonable standard of treatment based on A's reported symptoms. We also found that it was not unreasonable to discharge A home with antibiotics based on the diagnosis of pyelonephritis (kidney infection) following a CT scan. Although a subsequent CT scan carried out on readmission showed evidence of infarct (a small localised area of dead tissue resulting from failure of blood supply) which might have been evident on the original scan, it was not unreasonable to have diagnosed pyelonephritis following the original scan. We therefore did not uphold the complaint.

Summary

C is an advocate who complains on behalf of A. A has a brain injury which impacts on their daily living tasks and functioning. C complained that A received poor treatment from their GP practice and that there were delays in making referrals for specialist input following a fall down stairs which made A’s existing health conditions worse.

We took independent advice from a GP adviser. We found that A's treatment had been reasonable. We noted that A had come to the practice with a number of previous unresolved problems. We considered that A's new GPs were right to be mindful that A's neurological symptoms had already been assessed as 'functional', meaning they had no known physical cause.

C also complained about repeated prescription of antibiotics. We found that this did not seem excessive given the poor general state of A's health and that referrals for specialist input had been appropriate. Therefore, we did not uphold C's complaints.

Summary

C complained about the treatment of their spouse (A) by the Scottish Ambulance Service (SAS). A became unwell at home and whilst on route to hospital in an ambulance they experienced a cardiac arrest and later died in hospital. C complained that the ambulance took a long time to arrive; that the care and treatment A received in their home was poor; that there was a delay in transporting A to the hospital; that C was asked to commence cardiopulmonary resuscitation (CPR) on A whilst on route to hospital and that C was not assisted by the ambulance technician and that they alone performed CPR on A until they arrived at hospital.

C was dissatisfied with the way in which their complaint was investigated. It was initially investigated by the SAS, however, when contacted by SPSO, SAS requested to reinvestigate the complaint in light of an error that they identified in their initial response. C remained unhappy after receiving the SAS's further response and asked us to consider the matter.

We took independent advice from an emergency and retrieval medicine adviser. We found that the way in which the dispatch of the ambulance was handled was unreasonable, that the initial care provided to A in their home was reasonable, nevertheless it should have been clear to the ambulance crew that A was seriously unwell and that the time spent on scene was unreasonable and that the decision to ask C to perform CPR in the ambulance was not reasonable.

We found that the initial investigation was not sufficient, although we acknowledged the proactive steps taken by SAS to address this issue and acknowledge failings, including asking C to commence CPR. We also found that in this case the full crew should have been interviewed. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified that have not already been acknowledged in previous responses including the length of time taken to assess A in their home and the delay in transporting A to hospital, the failure to follow clinical guidelines appropriately and the failure to handle C's complaint appropriately. 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:

• Complaint investigations should be thorough and accurate in the first instance.
• For patients suffering cardiac arrest out of hospital such as in this case, relevant clinical guidelines should be followed by ambulance crew. Ambulance crew should accurately record what treatment was performed to demonstrate adherence to the clinical guidelines.
• When it is clear from initial assessment that a patient is seriously unwell, their transfer to hospital should be expedited and delays should be avoided.

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 board's decision to discontinue the prescription for gluten free foods for their adult child (A). The board explained that as A did not have a confirmed diagnosis of coeliac disease, that they would not be expected to prescribe gluten free foods. To make a diagnosis, a patient would be required to include gluten in their diet for a number of weeks prior to testing. C said that due to A's additional needs and the distress that they would suffer from the symptoms associated with taking gluten, it would be reasonable for the board to take a flexible approach when applying their policy on the matter.

We took independent advice from both a GP adviser and a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). It was noted that it was agreed by all parties that it would be distressing to A to require them to include gluten in their diet in preparation for testing. We considered that a more flexible approach should be taken to the application of the relevant policies and guidance and that a diagnosis could be made by probability. We found that principles of realistic medicine and patient-centred care should be applied and we recommended that consideration is given to other means of non-invasive tests to determine the presence or absence of coeliac disease in A's case. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should explore and discuss with C other means of non-invasive testing to determine the presence or absence of coeliac disease in A's case.