Health

Summary

Mr C complained about the care and treatment provided to his late brother, Mr A (who had a significant mental health condition), when he was admitted to University Hospital Ayr with internal bleeding. Following treatment, Mr A was transferred to East Ayrshire Community Hospital with a view to discharging him home a few days later. However, when Mr A's support workers came to the hospital to take him home, they raised concerns about his condition and he was readmitted to University Hospital Ayr. Mr A had further internal bleeding and several weeks later a scan showed that he had had a stroke. He was later discharged to a nursing home, where he became severely disabled and in need of constant attention before his death some six months later.

Mr C complained that if it were not for Mr A's support workers querying his discharge, he would have been sent home and died. Mr C also believed that the result of the stroke would not have been as serious if Mr A had received adequate care and treatment sooner. Mr C was also unhappy with communication from a stroke consultant about the possibility of stem cell treatment, and the board's response to the complaint, saying it was not an accurate reflection of what happened.

We took independent advice from one of our medical advisers after which we upheld Mr C's complaint. Our investigation found that Mr A was clinically unstable when he was transferred to the community hospital, that healthcare professionals failed to check a blood test before the transfer, and that the stroke consultant's discussion with Mr C unreasonably raised his hopes for curative treatment. However, we found that healthcare professionals had diagnosed Mr A's stroke within a reasonable time. In relation to Mr C's complaint about the board's response to his complaint, we found shortcomings in the board's response and made a recommendation to the board about this.

Recommendations

We recommended that the board:

• inform us of how they intend to ensure the safety of transfers to community hospitals, particularly for vulnerable adults with severe mental health problems such as Mr A;
• provide a copy of the latest audit of the appropriateness of admissions to the community hospital;
• feedback the failings identified in relation to checking a blood test and communication about stem cell treatment to the relevant healthcare professionals;
• bring the failures identified to the attention of relevant complaints staff; and
• apologise to Mr C for the failings this investigation identified.

Summary

Mrs A had been treated in the community for a urinary tract infection, confusion and dehydration, but the treatment did not address her condition and she went into Ayr Hospital for further treatment. Mrs A's daughter (Miss C) then complained on her mother's behalf about nursing care, prescribing of antibiotics (a range of drugs used to fight bacterial infection) and complaints handling.

During their complaints procedure, the board had already acknowledged some failings in the nursing care, and our investigation, which included taking independent advice from our nursing adviser, confirmed these failings. On balance, we upheld this complaint, although our nursing adviser explained that some of the nursing care and treatment was appropriate.

On one occasion during Mrs A's admission she required to be prescribed intravenous (directly into the vein) antibiotics and a medical review had been requested. There was a delay of four hours before a doctor attended to review her, and a further delay of seven hours before the antibiotics could be given as that doctor did not write up a prescription. We took independent advice from our medical adviser, who reviewed the evidence and was critical of these delays.

Miss C also complained that the board had not made a timely response to her complaint. Our investigation found that, while they did not respond within the 20 working days recommended in the NHS complaints handling procedure, there was no evidence of any avoidable delays and Miss C was kept informed. Although some of the communication with Miss C took place at her instigation, overall we found that the handling of her complaints was reasonable.

Recommendations

We recommended that the board:

• take action to ensure that all staff involved in this complaint are reminded of the need for effective communication with patients, relatives and carers;
• review their discharge procedures and documentation to ensure that relevant information is passed on to those involved in a patient's ongoing care; and
• issue a written apology for the additional failings identified during this investigation.

Summary

Mr C complained to the practice that he was concerned that his daughter (Miss A) had been inappropriately prescribed medication for bladder problems. He felt that this was not clinically indicated and was for convenience only, and that Miss A was at risk of side effects from the medication. The practice believed that the medication was appropriate for the symptoms Miss A presented with.

We took independent advice from one of our medical advisers, an experienced GP. Our adviser was satisfied from the medical records that, given Miss A's reported symptoms of urinary frequency and medical history, the medication was appropriate. We found that the practice's actions in prescribing the medication was appropriate and we did not uphold Mr C's complaint.

Summary

Mr C complained to the board that a decision had been taken inappropriately to reduce the number of gluten-free foods available on prescription for his mother (Mrs A) who suffers from a coeliac condition. Previously Mrs A was prescribed 18 units and this had been reduced to 14 units. The board maintained that Mrs A had been appropriately assessed in accordance with national guidelines and in view of her medical condition. We took independent advice from one of our medical advisers, and found that the dietitian had carried out a thorough assessment and that the prescribing of 14 units was appropriate.

Summary

Miss A is profoundly deaf and uses British Sign Language (BSL). Ms C, an advocate, complained on her behalf that the board did not arrange a BSL interpreter for her. We found that Miss A was left in Ninewells Hospital without an interpreter for nearly three days, which was unacceptable. The board had initially tried to get an interpreter, but it was then left to Miss A's family to do so. When they could not, the board arranged for an interpreter to attend. There were also problems in ensuring that interpreters were there at the same time as doctors.

The board agreed it is their responsibility, not that of the patient's family, to try to secure an interpreter. In responding to our enquiries, they told us that staff had been made aware of the complaint and knew the process for booking interpreter services. They had added phone numbers for five interpreters to staff guidance. Ward staff had been reminded to escalate to senior staff if they experienced difficulties securing an interpreter out-of-hours. The board also apologised for not providing an interpreter to support Miss A. After Ms C complained to us, they entered into a legal agreement with the Equality and Human Rights Commission and committed to trying to ensure that every patient with additional communication requirements receives the same level of services as those without such requirements. In view of this, although we upheld the complaint, we did not make any recommendations.

Ms C also complained that wards did not display a poster advertising BSL interpreter services. The board told us that all wards are required to display this, but could not confirm that it was displayed in the wards Miss A was in when in hospital. Because of this, on balance we upheld this complaint. However, we did not make recommendations, as the board now carry out a weekly audit of posters, ensuring that they are displayed in every clinical area.

Summary

Mr A suffered from advanced cancer, and was admitted to Ninewells Hospital for treatment to control his pain. While there, he fell and a fractured hip was suspected, although it was established this was not the case. He was transferred back to a palliative care centre (a place providing care to prevent or relieve suffering only), but was semi-conscious on arrival, and died shortly afterwards.

Mr A's daughter (Ms C) complained that her father had not received adequate care. She said Mr A's mobility problems had not been properly addressed, which had contributed to his fall. His pain had not been properly controlled and staff had failed to communicate properly with the family. The family felt Mr A was not properly assessed after his fall and should not have been transferred.

The board accepted that there were failings in Mr A's care, and apologised for these, explaining that changes had been made to procedures as a consequence. They said the decision to transfer Mr A was appropriate, although he had deteriorated during the transfer. They also said that he was properly assessed after his fall and his pain had been adequately managed. The board told the family they had an action plan to improve care, and this would be shared with them.

We took advice from a palliative care adviser, a nursing adviser and a geriatric medicine adviser. The palliative care adviser said Mr A had suffered a reaction to his medication. His dosage had been reduced, but it had later been increased again. She was also critical that Mr A was not medically reviewed before transfer. Our nursing adviser criticised the standard of nursing care, but noted that the board had taken action to remedy the majority of the failings. The geriatric medicine adviser agreed that the decision to transfer Mr A was appropriate, but was critical of the failure to review him immediately prior to transfer, or to discuss the decision with the family.

We found the decision to transfer Mr A was reasonable, but that he should have received a medical review immediately before being transferred. The transfer should also have been discussed with the family before it took place. We found serious failings in the nursing care provided to Mr A, noting that the board had addressed these, although they had failed to evidence this to the family. We upheld Ms C's complaints, and made several recommendations.

Recommendations

We recommended that the board:

• apologise for the failings that our investigation identified;
• review their complaints procedure to ensure that where appropriate complainants are provided with copies of action plans drawn up in response to their complaints;
• remind staff of the inappropriateness of the use of the term 'cotsides' when discussing patient care;
• review their procedures for transfer of patients, to ensure that patients are appropriately reviewed by medical staff immediately prior to transfer;
• remind staff of the importance of reviewing a patient's clinical notes prior to prescribing opiates; and
• remind all staff of the importance of providing accurate information to relatives in relation to the medical care being provided.

Summary

Ms C complained that her daughter (Miss A) was incorrectly diagnosed with a viral infection when she was seen by a doctor at the Royal Hospital for Sick Children. Ms C explained that three days after they attended the hospital Miss A was diagnosed with bacterial pneumonia whilst on holiday abroad.

We took independent advice from one of our medical advisers, who said that the diagnosis of a viral infection was reasonable as there was no clear evidence of pneumonia when Miss A attended hospital. We identified that the doctor obtained relevant information about Miss A and that the examination carried out was in line with national guidance. On this basis, we did not uphold the complaint but we found that there were no records to show that Miss A's level of consciousness had been assessed using the Glasgow coma score (a scale for recording the conscious state of a person) or whether the doctor had given any advice to Ms C on what to do if Miss A's condition did not improve, or deteriorated.

Recommendations

We recommended that the board:

• ensure the staff involved in Miss A's care reflect on the adviser's comments regarding the Glasgow coma score and advice to patients and/or their relatives.

Summary

Mr C complained that there was an unreasonable delay in the prison health centre providing appropriate treatment for his chest infection. He said he submitted a number of referral forms to see a nurse but despite this, no one saw him. In addition, Mr C complained about the board's handling of his complaints.

The evidence available confirmed that nursing staff attempted to see Mr C regularly in response to his referral forms but because he was not always in the hall at those times, it was not always possible to see him. In addition, the prison health centre took sputum (mucus from the lower airways) samples from Mr C and sent them away for analysis. They also prescribed an antibiotic.

In response to Mr C's complaint, the board indicated that he should have remained in his hall to be seen by a nurse. We asked the Scottish Prison Service (SPS) if it was acceptable for a prisoner to do that and they advised us that prisoners are required to attend work or education each day and they would only be allowed to remain in the hall if they were clearly unfit to report for work or education. In addition, we took independent clinical advice from our medical adviser for their view on the treatment provided to Mr C. They noted that he had been reporting a persistent cough for some time, and because Mr C was an ex-smoker, our adviser questioned the appropriateness of the health centre only taking sputum samples instead of considering whether an x-ray of his chest was needed as outlined by national guidelines.

We were satisfied that appropriate attempts were made by nursing staff to see Mr C in response to his referral forms but in light of the comments we received from the SPS, we did ask the board to ensure that everyone was clear on the process in place. In addition, because Mr C continued to report a persistent cough, and because of our adviser's comments, we upheld Mr C's complaint about the treatment he received.

In looking at the way the board handled Mr C's complaints, we were satisfied it was reasonable and so we did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• ensure healthcare staff and prisoners are aware of the process that has been agreed with the SPS in relation to self-referral forms; and
• reflect on this case in light of our adviser's comments and provide feedback to us.

Summary

Mr C complained that the board unreasonably refused to prescribe him a specific type of medication, that his prescription was stopped without him seeing the prison doctor, and that the board had failed to respond to his complaints appropriately.

Mr C had fallen one evening and cut his head, which resulted in him attending hospital for stitches. When nursing staff attended his cell, Mr C had fewer tablets of his prescribed medication than he should have had but he said this was because the remaining tablets were in a safe in his friend's cell. Mr C said he had previously had his medication stolen and, to try to prevent this from happening again, his friend kept some tablets for him. Mr C provided the remaining tablets the next morning but said he was then told his medication would be stopped. Mr C felt this was unfair.

As part of our investigation we took independent medical advice from one of our GP advisers. They said if the board had a policy about concealment of medication or patients not keeping their own medication - and Mr C had been made aware of it - then they could not say refusing to prescribe the medication was unreasonable. The board provided a copy of a contract Mr C had signed and it said he would neither give his medication to anyone else nor keep another person's medication in his possession. It also said if Mr C breached its terms then his medication would be reviewed and possibly stopped. Although Mr C outlined his concerns about his medication possibly being stolen, we considered the contract clear that he should not have given it to someone else. We did not uphold this complaint.

Despite this, our adviser said they would have expected additional records relating to the decision to have stopped Mr C's medication. They were concerned Mr C had to seek the reason for it being stopped (rather than him being told directly) and pointed to some inaccuracies in one of the prison health centre's responses to Mr C's complaint. That letter had said Mr C was admitted to hospital with a suspected overdose, yet there was no other record of this. We also took independent advice from our nursing adviser, who also saw no evidence that Mr C had been to hospital with an overdose. Although we did not consider these errors automatically meant medical staff had considered inaccurate information when reviewing Mr C's medication – his medical records did not mention a suspected overdose - the advice we received was that it was unreasonable Mr C had to seek the reason for the change to his prescription. We upheld Mr C's second complaint.

Finally, Mr C's complaints should have been acknowledged in three working days. The board's internal records were unclear as to whether this had happened and, as above, one response from the health centre contained factual inaccuracies. The board's responses were almost identical to each other, which we found particularly concerning in light of the apparent errors in the health centre's response. We felt that did little to evidence the thoroughness of the board's investigation and we upheld this complaint.

Recommendations

We recommended that the board:

• ensure that clinical staff are reminded of the relevant General Medical Council guidance for prescribing medication in terms of patient communication;
• review the matter so the prescribing GP, if inaccurate information influenced his decision to stop Mr C's medication (such as him having been admitted to hospital with an overdose), revisits that decision;
• ensure the health centre team reflect on the inaccuracies identified in their handwritten response to Mr C's complaint and take steps to prevent this happening again; and
• conduct a review of their handling of Mr C's complaints and confirm to us any areas for improvement identified for future complaints handling.

Summary

Mrs C complained that the board failed to take reasonable steps to mobilise her father (Mr A) during his stay in the Western General Hospital.

During our investigation, we took independent advice from three of our medical advisers, a consultant physician, a physiotherapist and a nursing adviser, after which we upheld Mrs C's complaint. The consultant physician said that the medical care Mrs C's father received was generally of a high standard and that the decision to discharge him had been reasonable. However, we were concerned that there was no reference in Mr A's medical records to the decision to prescribe him a second antidepressant. In addition, the physiotherapist said that Mr A did not appear to have received much in the way of mobility input during his first month in hospital and that physiotherapy care fell below what would be considered an acceptable standard. Physiotherapy treatment received later was, however, appropriate and acceptable.

There also appeared to be a lack of communication between physiotherapy, the medical team and the nursing team and a lack of coherent mobility planning involving the whole multi-disciplinary team. Our nursing adviser said that, while some aspects of Mr A's nursing care were reasonable, there were some failings in relation to record-keeping which made it difficult to establish some key aspects of the care provided, particularly in terms of his mobilisation and his confusion.

Recommendations

We recommended that the board:

• ensure that relevant staff members are made aware of our adviser's comments in relation to the use of a formal depression score to aid decision-making around antidepressant treatment, and given the opportunity to reflect on these for their future practice;
• bring the issues raised in this complaint to the attention of the physiotherapy staff involved to see if lessons can be learned and report back to us;
• consider including a section on mobility on the standard care plan;
• ensure that our adviser's comments about the lack of communication between physiotherapy and the medical and nursing team and a lack of coherent mobility plan involving the whole multi-disciplinary team are brought to the attention of the relevant staff;
• provide evidence of the systems in place to monitor the standard of record-keeping in relation to nursing and physiotherapy care, to ensure that assessment, care planning and evaluation of care delivery does reflect individual care needs; and
• apologise for the failings identified.