Health

Summary

Mr C was Mrs A's carer, and complained on her behalf that a community health partnership did not identify that she had an infected leg wound. Mr C said that district nurses did not maintain the dressings appropriately, and an ulcer became infected. He also said that Mrs A's GP failed to diagnose the infection. Mrs A was later admitted to hospital, where she developed sepsis (a serious blood infection).

We took independent advice from two advisers; one a GP and the other a specialist in district nursing. Our GP adviser noted the condition of Mrs A's leg ulcer when she was examined by the GP, and said there was no evidence at the time of the examination, or when Mrs A was admitted to hospital, that her ulcer had become infected. Our adviser also clarified that the source of Mrs A's sepsis was never identified when she was in hospital.

Our district nursing adviser reviewed the care and treatment Mrs A was given by district nursing staff prior to her admission to hospital. This adviser explained the expectations around treatment of leg ulcers, and said that it was appropriate for staff to replace Mrs A's dressings every two days. She said that Mrs A's care and treatment was in line with national guidance and good clinical judgement, and our decision reflected this advice.

Summary

Mr C complained about the treatment he received at the Victoria Hospital over a period of months. He was admitted there suffering from stomach pains. He had an operation to treat a blockage in his bowel and was discharged, although he was readmitted soon after and operated on again. Mr C remained in the hospital and his condition deteriorated further, resulting in two more operations and a series of significant complications. He said that this had a substantial effect on him, including memory loss, mood swings and depression. He now struggles to work, and felt these complications could have been avoided had his care and treatment been of a higher standard.

As part of our investigation we took independent medical advice from an experienced surgeon. He acknowledged how serious Mr C's complications had been but said they were not due to medical or surgical failings. He said there had not been a delay in Mr C's operations and explained that one of them had only become necessary following Mr C's sudden deterioration. In addition, he explained that surgery prior to this sudden deterioration would have been inappropriate.

Although we recognised how significant this matter had been for Mr C and his family, our role was to consider whether the evidence available indicated that his treatment was unreasonable in the circumstances at the time. Importantly, this did not include the benefit of hindsight. Although we took Mr C's concerns into account, we did not find that there had been any failing in care, or unreasonable treatment.

Summary

Mr C had concerns that, when his late mother-in-law (Mrs A) was discharged from hospital to a nursing home, staff failed to inform the family about the existence of the NHS continuing healthcare procedure and that as a result there were financial implications for Mrs A. The board maintained that Mrs A's medical records contained details about communication with Mrs A's family about her discharge from hospital and that the family were satisfied that placement in a nursing home was appropriate. We upheld the complaint as we found that, although the records showed that there were frequent discussions with Mrs A's family about the plans for her discharge, there was no specific mention of the NHS continuing healthcare procedure.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to advise the family that there was an appeals procedure where there is a disagreement about the decision to provide NHS continuing healthcare;
• issue a written apology to Mr C for the failure to specifically record at discharge that consideration had been given to NHS continuing healthcare; and
• remind staff of the requirement to communicate with patients and carers about the procedure for NHS continuing healthcare and ensure that decisions are recorded in the medical records.

Summary

Mr C complained that the prison health centre were failing to prescribe appropriate pain medication for his knee. He was due to start a detox programme and because of that, the decision was taken to stop the pain medication he was being prescribed and to provide an alternative.

We examined Mr C's medical records and we took independent medical advice from one of our GP advisers. They explained that the steps taken by the prison health centre in Mr C's case were appropriate because the effects of the pain medication he was being prescribed would have been blocked by the effects of the detox programme. Our adviser also confirmed that the alternative pain medication prescribed to Mr C was appropriate. We accepted the view of our adviser and we did not uphold Mr C's complaint.

Summary

Ms C had a complex medical history including extensive long-standing urological (urinary tract) problems dating back to childhood. She had her left kidney removed, with a segment of the tube that carries urine from the kidney to the bladder (ureteric stump) being left in place. In October 2012, Ms C's GP referred her to a urologist at Ailsa Hospital for recurrent urinary tract infections and to a consultant surgeon because of gastroentology (digestive system) symptoms including abdominal pain, bloating, variation in bowel habit, diarrhoea and intermittent rectal bleeding. Following investigations, the ureteric stump was removed in March 2013 and Ms C's urological problems improved. However, her gastroenterology symptoms continued and in October 2013 she was diagnosed with irritable bowel syndrome.

Ms C complained that her urological symptoms were not investigated within a reasonable time and that there was an unreasonable delay in removing the ureteric stump. She also believed that her urological and gastroenterological symptoms were related and was concerned about her continuing severe gastroenterological symptoms, which she said worsened after the surgery to remove the ureteric stump and were not properly investigated. Finally, Ms C complained that she had not been told about the diagnosis of irritable bowel syndrome.

We took independent advice on this case from two of our medical advisers. Turning first to the care and treatment in relation to Ms C's gastroenterology symptoms, our adviser said that Ms C was appropriately investigated and treated for her symptoms. In relation to her urology symptoms, the advice we accepted was that this too was reasonable. Both our medical advisers pointed out that Ms C had a complex medical history and that, in relation to her urological condition, her case was rare and unusual. However, we found that the board appropriately arranged for further follow-up for her gastrointestinal problems. Ms C felt strongly that both sets of symptoms were directly linked, but our medical advisers said there was no evidence that this was the case. We were concerned that there was no direct evidence in Ms C's medical records that the diagnosis of irritable bowel syndrome was discussed with her, but we noted that the board had taken steps to address this. We were satisfied by the evidence from the medical records that, with the exception of this, the standard of care and treatment was reasonable.

Summary

Miss C complained to us on behalf of her son (Mr A). She said that the board had failed to provide reasonable care and treatment to him after he injured his nose. Mr A had several appointments in the board's ear, nose and throat (ENT) and maxillofacial (the specialty concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) departments after he sustained the injury.

We took independent advice on the complaint from one of our medical advisers, who is an experienced ENT surgeon. We found that the board had initially taken reasonable action to investigate Mr A's problems. However, we found that staff in the ENT department had failed to identify that an x-ray that had been carried out suggested a disease in one of his sinuses. They had then not taken action to investigate this further, and in view of this, we upheld this aspect of Miss C's complaint.

Miss C also complained about the way in which the board handled a complaint from Mr A's representative about the matter. We found that they had delayed in issuing a response, and had failed to keep Mr A's representative updated when the response was delayed.

Recommendations

We recommended that the board:

• apologise to Mr A for the failure to adequately investigate the condition affecting his sinus;
• take steps to arrange an urgent ENT appointment for Mr A in order that the matter can be investigated;
• review the reporting of images in the ENT department to ensure these are appropriately reported;
• make the staff involved in Mr A's care in the ENT department aware of our finding on this matter;
• remind the staff involved in handling the complaint that they should keep complainants updated when there is a delay in a response being issued; and
• apologise to Mr A for the complaints handling failures.

Summary

Mr A had suffered a morphine overdose and become unwell. An ambulance was called and the crew assessed Mr A. He was nauseous and vomiting, had abdominal (stomach) pains and was unable to keep down food or drink. He was taken to Perth Royal Infirmary, where he was triaged and sent to the out-of-hours service. He was assessed there by a primary care nurse, and deemed fit to be discharged.

His niece (Mrs C) complained on behalf of Mr A. She said that when Mr A had been discharged he had phoned her and was confused and disorientated. Mrs C complained that her uncle was not reasonably assessed at the hospital and should not have been discharged.

During our investigation we took independent advice from both a GP adviser and a nursing adviser. Both advisers expressed concerns that the assessment of Mr A was not thorough. The nursing adviser was concerned that Mr A's recent morphine overdose history was not noted and that his abdomen was not examined, in light of the pain reported to the ambulance crew. The GP adviser was also concerned that Mr A was not assessed for dehydration due to his inability to keep down liquids. In light of the advice we received, we upheld Mrs C's complaints.

Recommendations

We recommended that the board:

• share the outcome of this investigation with the practitioner concerned to reflect on assessment and record-keeping; and
• apologise to Mr A for the failings identified.

Summary

Mrs C had an operation at Perth Royal Infirmary, after which she experienced complications and was transferred to Ninewells Hospital for more surgery. Her husband (Mr C) complained on her behalf about how clinical and nursing staff responded to her pain levels and other concerns. He also complained that, after Mrs C was transferred, there was a delay before she was taken to an operating theatre. Finally, he said that the risk of the complications (perforation of the uterus and damage to the bowel) were not included in the information leaflet sent to her before the surgery.

During our investigation, we took independent medical advice from a consultant obstetrician and gynaecologist, and nursing advice from a nursing adviser. Our medical adviser said that Mrs C had an appropriate operation in Perth Royal Infirmary, and experienced a recognised complication of the procedure, for which she received appropriate treatment.

We did, however, uphold Mr C's complaints. There was no written record by doctors at Perth Royal Infirmary, so our medical adviser could not say whether there was a delay in diagnosing the perforation or whether a consultant should have been contacted earlier. Because of this lack of records, we also could not confirm whether there was a delay in transferring Mrs C. We were concerned that her consent for the procedure had not been properly obtained. The board explained that their consent process for hysteroscopy (a procedure that lets the doctor look inside the womb) was being reviewed to ensure that it follows guidance from the Royal College of Obstetricians and Gynaecologists.

Our nursing adviser said that, given Mrs C's level of pain, nursing staff at Perth Royal Infirmary should have increased the frequency of their observations, and should have told the nurse in charge. They did not follow guidance on the Scottish Early Warning Scoring System (a set of patient observations to assist in the early detection and treatment of serious cases and to support staff making clinical assessments). The board told us that staff had been reminded of the need to increase the frequency of observations in such cases, but did not explain how this would be monitored. The board had also accepted that more proactive observation of Mrs C's vital signs should have been undertaken, and had taken action on this.

In relation to Mr C's concern about delay, the board accepted that a senior doctor should have been alerted immediately after Mrs C arrived, and that better communication might have helped her reach theatre earlier. Our adviser said that there was no evidence that this had a detrimental effect on the eventual outcome, but we were concerned about a possible delay in carrying out surgery. We were also concerned that, when Mrs C was so unwell, her family were asked to leave as visiting times had ended. Finally, patients have the right to information about the treatment that is proposed and we noted that the board now include in their leaflet information about the risk of perforation.

Recommendations

We recommended that the board:

• apologise for the failings identified in this case;
• report back to us on the outcome of the review of the consent process for hysteroscopy;
• report back to us on how they will monitor the action taken to remind nursing staff of the need to increase the frequency of observations when there is unresolving pain;
• remind all staff in the gynaecology unit of the need to record their findings when reviewing patients;
• report back to us on the action taken to share this case with all medical staff in gynaecology, to ensure patients who require senior review are seen as a matter of urgency; and
• report back to us on action taken to discuss the issue of relatives and visiting times with nursing staff in the relevant ward.

Summary

Mrs C complained to us about aspects of her care and treatment by the gynaecology and obstetrics department at Ninewells Hospital. We began an investigation into her concerns, but did not complete it as Mrs C decided to take legal action against the board.

Summary

Mr C's father (Mr A) suffered from lung cancer, and was being treated with palliative erlotnib therapy (a drug used to treat some types of cancer) by a consultant at Ninewells Hospital. Mr A became ill while on holiday with his family and was admitted to hospital. When the family returned home, Mr A was transferred to Ninewells as he was too ill to go home.

At a meeting with Mr A and his family, the consultant decided to discontinue the erlotnib therapy and focus on symptom control. Medical staff recommended that Mr A be transferred as an in-patient for palliative care, but Mr A and his family decided that he wished to be discharged home. A package of care was requested to support this, but Mr A passed away on the morning of his planned discharge.

Mr C complained to the board that they had failed to arrange a care package in time to enable Mr A to die at home, as he had wished. Mr C also raised several concerns about Mr A's care, record-keeping and communication with hospital staff. The board responded four months later. Staff from the board then met with Mr C and his mother, and agreed what they would do in response to the complaint. In response to Mr C's enquiries, the board wrote to him about the outcomes of these actions. However, Mr C remained dissatisfied with their response, and their handling of his complaint, and complained to us.

After taking independent advice from our medical and nursing advisers, we upheld some of Mr C's complaint. We found that the board had handled his complaint poorly, and had not complied with their own complaints handling procedure or NHS guidance. We also found evidence of poor communication and record-keeping. However, we did not find evidence that Mr A's medical and nursing care was unreasonable. We also found that hospital staff had taken reasonable and timely steps to try to help Mr A achieve his wish to die at home, although this did not happen.

Recommendations

We recommended that the board:

• issue a written apology to Mr C and his family for the record-keeping failings our investigation identified;
• provide us and Mr C with a copy of the quality improvement loop developed for addressing issues with documentation, and details of the Nursing and Midwifery Council code of conduct and accountability sessions arranged to reinforce the need for accurate record-keeping;
• raise our findings in relation to record-keeping with the doctor concerned, for reflection;
• review their complaint management procedure and practices to ensure they comply with the NHS 'Can I help you?' guidance in relation to responding to complaints within 20 days of receipt of the complaint (including where the complaint is received by phone) and informing complainants that they may approach the SPSO if the final response is not provided within 20 working days;
• review guidance and/or template letters for acknowledging and responding to complaints to ensure that all letters include an accurate date (including year), acknowledgement letters provide accurate information on who will sign the final response, and letters for complaints which will exceed the 20 working day time-frame provide an updated time-frame and inform the complainant that they may now approach the SPSO; review processes for ensuring that they meet any commitments made to contact the complainant following the resolution of the complaint (for example, to advise when outcomes or agreed actions are completed); and
• remind complaints handling staff of the need to accurately record the date a complaint is received (including where the complaint is made by phone or in person), the requirement in the board’s procedures for a deputy to be appointed where staff involved in a complaint will be absent, and the SPSO guidance on apologies - in particular that apologies should identify and acknowledge what mistake has been made, as well as the impact on the person being apologised to.