Health

Summary

C underwent a hysterectomy (surgery to remove the womb) and although the procedure was considered successful, C began to bleed from scar tissue soon after the operation. An ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) showed blood clots in C's pelvis and C was kept in hospital in case further surgery was required. C was given blood thickeners and a blood transfusion. C developed a chest infection and suffered from further complications.

C raised complaints about their care and treatment following their initial surgery with Greater Glasgow and Clyde NHS Board. C raised a number of specific concerns about their post-operative complications and their management. C was also concerned about the surgery, or that the post-operative complications had caused the nodule on their lung, which was subsequently identified as lung cancer.

We took independent advice from a gynaecology (medicine of the female genital tract and its disorders) adviser. We found that C's care and treatment was reasonable and that C had experienced significant post-operative complications, but that these were appropriately managed. We noted that there was no evidence that C received inadequate consultant input post-surgery, or that C's complications were as a result of the surgery being performed poorly or inappropriately. We found that the board were correct to say that there was no relation between C's surgery and the subsequent health issues that they faced. We also found no fault with the level of physiotherapy support offered to C.

We concluded that C's medical records showed that they were regularly reviewed by a physiotherapist and that the exercises that were provided to C were also reasonable and appropriate. As such, we did not uphold C's complaint.

Summary

C complained about the care and treatment that they received from Greater Glasgow and Clyde NHS Board. C was referred to the Early Pregnancy Unit (EPAS) by a private clinic on two occasions. C complained that EPAS took too long to declare the pregnancy non-continuing, that C was required to attend an unnecessary number of scans and that their care was not escalated to a doctor. C also complained that the advice and care that they received by phone, and the fact that they were contacted and invited to a reassurance scan, was unreasonable. C further complained that EPAS asked them for distressing information rather than gathering this from the private clinic and that EPAS did not gather consent from C for surgical management as they ought to have done. C also complained that the care and treatment that they received as an inpatient was unreasonable.

The board noted that they apologised for the delay in the time C waited to be seen, that during their admission C fainted and was lowered to the floor by a nurse who then called a doctor, that all options were not discussed and that on reflection there was a missed opportunity to obtain a second opinion. The board also noted, however, that this would not have changed C's management plan.

We took independent advice from a consultant obstetrician (the medical specialism for pregnancy, child birth etc) and gynaecologist (medicine of the female genital tract and its disorders). We found that a second opinion should have been sought, which may have allowed miscarriage to be diagnosed earlier. We also found that C should not have had to relay findings or be subjected to repeated examination when diagnosis had already been made by the private clinic and that the necessary documentation ought to have been obtained from the private clinic. We further found that during C's fainting episode, appropriate observations and actions were taken and the faint was well managed.

In light of the above, we found that whilst it was reasonable for EPAS to repeat some scans, a second opinion was not sought when it should have been. If this happened, C's miscarriage could have been diagnosed earlier, and therefore, the care and treatment provided to C was unreasonable. Additionally, the actions of EPAS asking C to relay findings and requiring C to undergo a further scan was unreasonable. We found that C's faint was well managed and the care and treatment provided to C during this time was reasonable.

We also considered the way in which the board handled C's complaint. We found that it does not appear that the board's complaint investigation took account of the clinical notes made by the doctor to ensure a full and accurate response was provided.

We partially upheld C's complaint and made recommendations to the board as a result.

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/informationleaflets.

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

• Patients attending EPAS should not be required to undergo unnecessary scans.

In relation to complaints handling, we recommended:

• When carrying out an investigation, consideration should be given to ensuring the response takes into account any relevant clinical notes so that the complainant receives a full and accurate response.

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 provided to their late parent (A) by Dr Gray's Hospital. C complained that A's colorectal symptoms and weight loss were not properly investigated and that a planned scope investigation wasn't arranged on an urgent basis. C also complained that a head injury A sustained in a fall was not properly investigated and that A was inappropriately discharged when they were unfit to return into C's care. A was re-admitted the following day and died in hospital around two and a half weeks later. C complained about the standard of medical treatment provided during this admission. Furthermore, C complained about the nursing care provided during A's final admission. They complained that visits did not take place in an appropriate location to ensure A's comfort and privacy, and in particular that A was not transferred to a side room in light of their condition. C also considered that A was denied adequate nutrition and hydration. Finally, C complained of difficulties obtaining information from the ward and more generally about communication with the family and the lack of visiting opportunities that they were afforded.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there was no evidence to indicate the need for urgent investigation. We did not uphold this aspect of the complaint.

We found that A's care surrounding the head injury was reasonable and that they did not meet the criteria for a head scan. However, we noted that there was a lack of care and attention to A's confusion and falls risk and that they should have been kept in hospital. On balance, we upheld this aspect of the complaint.

We noted that A received an appropriate medical review and treatment, apart from a delay in initially being reviewed by a consultant and a lack of attention to A's deterioration prior to their death. We also noted a failure to communicate the DNACPR process to C, but noted that the board had acknowledged this and outlined appropriate steps to address it. Taking communication and the lack of consultation together, in careful and close balance, we upheld these aspects of complaint.

In relation to C's complaint about the nursing care provided during A's final admission, we took independent advise from a nursing adviser. Other than an identified omission where nursing staff failed to sign for prescribed dietary supplements, which the board acknowledged, we found that A received a reasonable standard of nursing care. Therefore, on balance, we did not uphold this aspect of the complaint.

In relation to communication, the board acknowledged that the family weren't afforded the opportunities that they should have been following a change in guidance. We asked the board to provide evidence of the steps that they were taking to ensure staff are kept updated on changes to visiting guidance. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the lack of care and attention to A's level of confusion and the unreasonable decision to discharge them, for the lack of consultant review after A's later admission, for the failure to communicate the DNACPR process to C and for the lack of recognition of A's deterioration and failure to inform C of this. 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 findings of this investigation should be fed back to relevant staff for reflection and learning including, staff reflection on the decision making surrounding A's discharge, the level of consultant input in the days following their readmission and the care and attention given to A's deterioration and lack of communication with C. The consultants concerned should include the findings of this investigation as part of their annual appraisal 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 care and treatment provided by the board to their late spouse (A) who was diagnosed with muscle-invasive bladder cancer. C complained about various aspects of the care that A received. These included delay, and ultimate failure, to carry out surgery to remove A's bladder, inappropriately high and missed doses of medication, and initial refusal to offer chemotherapy (a treatment where medicine is used to kill cancerous cells). C also complained about a failure by an out of hours doctor in identifying a deep vein thrombosis (DVT, a blood clot in a vein) that A developed and subsequent provision of insufficient information on medication used to treat the DVT. C further complained about various failures of communication as well as concerns about arrangements for visiting A due to the Covid-19 pandemic and end of life care.

We took independent advice from medical advisers with expertise in oncology (cancer specialist), urology (a specialty in medicine that deals with problems of the urinary system), general practice and community nursing. We found that A's pain medication regimen was reasonable and that the timescale for the scheduling of A's bladder removal surgery had been appropriate. We also found that decisions made about the timing of chemotherapy and communication with A had been reasonable. This included communication about A's end of life care and how rules relating to visiting A during the pandemic had been applied.

However, a number of failings in the treatment provided to A were also identified. We found that A had not been given appropriate information on the extent of their cancer, the prognosis and the potential treatment options. We also found that there had been an unreasonable delay in the discussing of A's case by the board's multi-disciplinary team, which also understated the extent of A's cancer. Furthermore, we found that A missed doses of regular medication when attending for palliative chemotherapy, that the DVT A developed was unreasonably not initially identified and, once diagnosed, insufficient information was given to A about medication given to treat the DVT.

For these reasons, 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:

• Patients diagnosed with DVT should be given appropriate information on anticoagulants (drugs that reduce the body's ability to form clots in the blood), in line with relevant clinical guidance.
• Patients should be given a comprehensive assessment of their end of life care needs, including support for sleeping, which is then clearly recorded in their nursing records.
• Patients should be given timely, clear and accurate information about the extent of their cancer, prognosis and management options. Patients should also receive appropriate support from clinical nurse specialists, in line with relevant clinical guidance.
• Patients requiring urgent care should be referred to specialists within a reasonable timeframe.
• Patients should be appropriately referred to the multidisciplinary team within a reasonable timeframe.

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 provided to their late child (A) by their GP practice. A had attended the practice on several occasions over a five month period with persisting chest symptoms. C complained that the practice failed to recognise the severity of A's symptoms or recognise that symptoms were indicative of a serious cardiac condition until A's health had significantly deteriorated. A subsequently suffered a cardiac arrest resulting in them being transferred to another health board for surgery, where they later died.

We took independent advice from a GP adviser. Although we noted that there had been a delay of a few days in responding to A's x-ray report, we found that the practice's care of A was reasonable, with referrals and tests being timeously arranged and in keeping with A's presenting symptoms at the time. Therefore, we did not uphold the complaint.

Summary

C complained about the care and treatment provided by the board to their parent (A), who was admitted to hospital with severe back pain after suffering a suspected fall and later diagnosed with osteoporosis (a condition that affects the bones, causing become fragile and more likely to break). C complained about the physiotherapy and occupational therapy assessments carried out during A's admission, the communication by staff and a lack of recognition of A's cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). C also complained about the lack of written information about osteoporosis/fragility fractures and how they should be managed after A's discharge, and A's follow up care, in particular, the failure to carry out a DEXA scan (a special type of x-ray that measures the density of bones).

In order to investigate C's complaint, we took independent advice from a trauma and orthopaedics (conditions involving the musculoskeletal system) adviser. We found that it was reasonable, in light of cognitive assessments undertaken by A, for staff to have taken the information A provided at face value. It was also reasonable in light of current practice and guidance for the board not to have provided A with written information about the management of osteoporosis upon discharge. We also found that the decision not to offer a DEXA scan was appropriate given the diagnosis, and that the appropriate treatment for this type of injury (osteoporosis/fragility fractures) was conservative management and therefore follow up care was not a requirement.

However, we identified a number of failings including that the board unreasonably delayed in starting A's osteoporosis treatment and that there were also failings in communication. In view of these specific failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the delay in starting A's osteoporosis treatment. 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 a clear treatment pathway in place for patients starting osteoporosis treatment which is based on the relevant national guidance so as to avoid unreasonable delay in the start of their 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 about the care and treatment provided to their spouse (A) when they became unwell with severe lower abdominal pain and vomiting. A was visited and examined by an out-of-hours (OOH) GP, who administered an injection for vomiting and left some medication for A. A's condition worsened and a different OOH GP attended the same evening. A was taken to hospital by ambulance and was found to have a perforated bowel (hole in the large intestine) and kidney failure. Medical intervention was not considered appropriate and A's care was redirected to palliative care. A died in hospital two days later.

C complained that the first OOH GP missed important aspects of A's condition during their home visit. C further complained that when A was admitted to hospital, A was left in pain and discomfort for many hours and it was only when C raised concerns that A was given stronger pain relief.

We took independent advice from a GP adviser, as well as a registered nurse and a general physician in acute medicine.

We found that overall, the assessment and examination carried out by the first OOH GP was reasonable and appropriate. It was determined that there was nothing suggestive of an acute abdomen (sudden, severe abdominal pain) which would have necessitated admission to hospital. We did not uphold this aspect of C's complaint.

C also complained that A was given unreasonable care and treatment in the hospital, in relation to managing A's pain. We considered that overall, the approach to A's pain management by nursing staff was reasonable. Nursing staff identified A's level of pain from first admission and throughout and took appropriate action to try and address this.

However, we found that given the very high doses of morphine administered, medical staff should have checked the medication prescribed to see if it was working, and review or prescribe something else. Furthermore, given that the medical team would have been aware that A was on the ward round for comfort care, a palliative care referral could have been made earlier. We considered that an earlier referral may have supported better comfort care for A in the final stages of life. As such, we upheld this aspect of C's 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:

• Pain medication prescribed for patients should be appropriately checked by medical staff to see if it is adequately working. Referrals to palliative care should be made in a timely way without delay.

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 their late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, the patient in the bay beside A was confirmed positive for COVID-19. A received a test for COVID-19 and was discharged home. A was then made aware that they had COVID-19. A's condition deteriorated and they died.

C complained about the placement of A within an amber zone, rather than a green zone at the hospital. C was also concerned that A was placed in a bay beside the other patient, who subsequently tested positive for COVID-19.

We sought independent advice from a consultant oncologist (a specialist in the diagnosis and treatment of cancer). We noted that the COVID-19 guidance in place at the time required NHS Boards to have COVID/Non-COVID areas and provided examples of pathways for how NHS Boards might separate patients. The guidance was not prescriptive and each NHS Board had to decide how to apply the guidance to the different hospital environments within their area. We found that the board’s internal pathways were consistent with the pathways set out in the guidance. Given that A did not meet the criteria for a low risk/green zone within the hospital, we found it was reasonable to place A in an amber zone based on the information known at the time. We therefore did not uphold this aspect of the complaint.

We recognised how distressing it must have been for C to learn that their parent had contracted COVID-19 while in hospital. To assess this aspect of C's complaint we obtained the relevant clinical records for the other patient and shared these with the independent adviser. We found that the symptoms the other patient was exhibiting were not thought to be due to COVID-19 and we did not identify any failure regarding the placement of A beside this patient. We therefore did not uphold this aspect of the complaint.

Summary

C, an advocate for A, complained about the way A was treated by the board for their chronic psychotic illness. A experienced a relapse when administration of their medication was changed from a depot injection (a slow release method) to an oral route. A subsequently required two in-patient admissions. C complained the second admission only occurred due to a failure by the board to manage A's medication properly, and to being discharged from their first admission when they were still experiencing psychotic symptoms.

We took independent clinical advice from a consultant psychiatrist on the board’s management of A's medication and the circumstances of their discharge from hospital during their first in-patient admission. In reference to the board managing A's transition back onto their medication by depot injection, we found that this had been managed appropriately, and in agreement with A. However, we noted that the documentation of this could have been better. While we did not uphold this aspect of the complaint, we gave feedback to the board in respect of record-keeping.

Regarding the timing of A's discharge from hospital, we found that this had been reasonable and person-centred in approach, noting there was no reference in the medical records to A experiencing psychotic symptoms at the time of their discharge. As such, we did not uphold this aspect of the complaint.

Summary

C, an advocate for A, complained about the actions of the board's paediatrics department in relation to child protection concerns raised about A's child (B). C complained that the board did not reasonably communicate with A about the concerns raised and that they took an unreasonable length of time to arrange a child protection conference. C also complained that the board failed to fully involve the family GP in the child protection process and to explain the rationale for proposing to reassess B's autism spectrum disorder (ASD) diagnosis.

To investigate C's concerns, we reviewed the relevant clinical records and sought independent advice from a consultant community paediatrician. Our investigation found that the steps taken to invite A to a meeting to discuss the concerns about B and to share a summary of the professionals meeting held were reasonable. We also concluded that from the time the concerns were noted to holding a child protection conference, it was reasonable to consult with other professionals, gather information and attempt to speak with A. As such, we did not consider there was an unreasonable delay in holding the child protection case conference.

We also found evidence that the family GP was invited to a professionals meeting by email, however, due to administrative errors outwith the board’s control, the email was not received by the GP. With regards to the reassessment of B's ASD diagnosis, we concluded this was explained both in writing and at a meeting. We therefore did not uphold C's complaints.