Health

Summary

Mr C's GP had referred him to the board in November 2014 as he required the removal of his gallbladder. Although Mr C was not a resident in the board area he had received previous treatment there and his daughter lived nearby. The plan was that Mr C would stay with his daughter on his discharge following the surgery and the board had indicated that they were willing to accept him for surgery on this basis. Mr C emailed the board three times in January 2015 as he had heard nothing more. He was then advised that the board could not accommodate the GP's referral, and that the board had referred him to the health board where Mr C was resident. Mr C complained about the delay by the board in responding to his GP referral.

The board apologised for the delay in responding to Mr C's emails and explained that the reason they could not carry out the surgery was due to pressure on their services and that to accept a referral from another health board would put added pressure on an already pressured system. We upheld the complaint and found that between November 2014 and January 2015 there was no action taken regarding the GP referral as two staff members thought the other was dealing with the matter.

Recommendations

We recommended that the board:

• ensure that the staff members who considered whether to action the GP referral reflect on their actions and discuss the complaint at their next appraisal.

Summary

Mr C complained to us that the board had unreasonably refused to give him braces when he entered prison. The prison dentist originally told Mr C that he could not have braces because his oral hygiene was poor. He gave Mr C advice about improving this. When Mr C's oral hygiene had sufficiently improved, the dentist took impressions of Mr C's teeth for study models in order that the models could be scored for the Index of Orthodontic Treatment Need (IOTN). However, both the dentist and an orthodontist considered that Mr C did not achieve the minimum score for orthodontic treatment on the IOTN and that he did not meet the criteria for NHS orthodontic treatment.

We took independent advice on the complaint from a dental adviser with experience in orthodontics. We found that if Mr C's oral hygiene had remained poor during orthodontic treatment, there would have been a risk of the development of decay and further damage to his teeth around the brace. Mr C was also given reasonable advice and the opportunity to improve his oral hygiene. Mr C's oral hygiene had subsequently improved, however, the impressions that were taken showed that he did not meet the criteria for NHS orthodontic treatment, as he did not achieve the minimum score for orthodontic treatment on the IOTN. Consequently, we found that it had been reasonable for the board not to give Mr C braces and we did not uphold his complaint.

Summary

Mrs C complained about the care provided to her late mother (Mrs A) by Forth Valley Royal Hospital. Mrs A had dementia and was admitted to the hospital suffering from a urinary tract infection and increased confusion; she was noted to be generally unwell. One evening, Mrs A fell out of bed just before 21:00 but Mrs C was not told about this until the following morning.

Mrs A had been reviewed by a doctor and her head and shoulder were x-rayed, but despite having pain in her leg this was not x-rayed. Three days later, after Mrs C pointed out to nursing staff that Mrs A's foot was at an odd angle and she was in severe pain, an x-ray was done and it was found that Mrs A had broken her hip. Remedial surgery was considered but due to Mrs A's on-going and recurrent infection and her general frailty, it was agreed with the family that only palliative (end of life) care was appropriate. Mrs A died less than a fortnight after her fall.

Our investigation included taking independent medical advice from two of our advisers, a doctor specialising in care of the elderly and a senior nurse. The advisers found some evidence of reasonable care, especially in Mrs A's initial care - but they were critical of the lack of communication with Mrs C about Mrs A's fall and later about what happens when a patient dies in hospital; the delay in diagnosing Mrs A's broken hip; that at one time Mrs A's notes were missing and later found in another patient's room - resulting in a delay in prescribing pain relief for Mrs A; and that when surgery was still being considered, Mrs A was found to have an incorrect identification wristband on.

Recommendations

We recommended that the board:

• ensure that all staff involved in this complaint are made aware of our findings and reflect on them to inform their future practice;
• consider the introduction of an information leaflet for relatives explaining the procedure when a patient dies in hospital;
• remind staff involved in this complaint of the requirements of the General Medical Council and Nursing and Midwifery Council guidance on record-keeping, and in particular with regard to protecting patients' confidential information;
• ensure that staff involved in this complaint are reminded of the importance of good, and timely, communication with relatives where patients have sustained a fall and/or injury while in hospital; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C complained about the poor communication by Victoria Hospital in relation to her father (Mr A), who had been receiving dialysis treatment (a form of treatment that replicates many of the kidney's functions). Following a discussion with Mr A's family, the medical team at the hospital decided to stop the treatment, but they did not tell Mr A's GP that they had done so. The GP didn't found out that Mr A required palliative care until a home visit three weeks later.

In response to Mrs C's complaint, the board said the consultant in charge was unable to locate the letter he dictated after meeting with the family. The board apologised for this and said that the consultant would try to ensure that in future information is passed on appropriately. Mrs C was dissatisfied with the response, as the board did not explain whether the letter was in fact dictated or typed, or whether the consultant had any recollection of signing it. Mrs C also considered that the board's response was not robust enough to prevent a reoccurrence of the situation, and she brought her complaint to us.

After taking independent medical advice, we upheld Mrs C's complaint. We found that the consultant had failed in his responsibility to inform the GP of Mr A's discharge (with the most likely explanation being that the letter was never dictated). We were also critical that the consultant did not give a clearer response to Mrs C's complaint, as this could have resolved it at an earlier stage. We noted that the board had already apologised to Mrs C and taken steps to improve their system for signing letters. As the failing in this case appeared to be caused by human error, rather than a system failure, we considered that asking the consultant to reflect on his practice was an appropriate and proportionate response.

Recommendations

We recommended that the board:

• bring the findings of our investigation to the attention of the relevant consultant, for reflection as part of his next annual appraisal.

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.