Health

Summary

C had concerns about the care and treatment that their late parent (A) received from the practice. At the time the care and treatment took place, the practice was being managed as a GP partnership arrangement. By the time C had submitted their complaint to the practice, the previous partnership arrangement had ended and a medical group took over the running of the practice. The named GP Partner who C had raised concerns about had also left the practice. C was concerned that the practice, under its new management, refused to respond to their complaint and did not follow the complaint handling procedure.

GPs are independent contractors who deliver general medical services to patients on behalf of the health board. If a complaint is received about care given by a practice and the practice still has an active contract, then the practice will deal with the complaint accordingly. However, if the complaint relates to a closed practice or a partnership arrangement that no longer exists, as is the case here, this means that the contract with the health board would no longer be active. The practice’s position is that they had no involvement in the care and treatment provided to A because this took place under the dissolved partnership arrangement.

We found that the practice should have advised C to contact the NHS board at the earliest opportunity, in line with the complaints handling procedure.

The board could have facilitated, where possible, communications between the former partner(s) and C. If the former partners were not able to provide a response, the Primary Care Service department within the board could then have considered either providing a response, or commissioning an external review and/or signposting to another appropriate body if applicable. We upheld this aspect of C’s complaint.

Additionally, C considered whether the practice should have carried out a Significant Event Analysis (SEA) or similar review in line with the Healthcare Improvement Scotland national framework. Given the particular circumstances, we found that it was reasonable that the practice, under its new management, did not carry out a SEA when the complaint was brought to their attention. As such, I do not uphold this aspect to the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not advising them to contact the NHS Board about their complaint at the earliest opportunity given that it related to the care and treatment provided under a dissolved partnership arrangement. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• If someone complains about the service of another Primary Care service provider, and the practice has no involvement in the issue, the person should be advised to contact the relevant board or service provider directly.

Summary

C complained that they had received substandard care across a series of surgeries to their nose. They said that the board inaccurately stated that C was suffering from a recognised complication and that the board failed to provide C with sufficient information about the possible complications of surgery. The surgery had left C with a deformed nose, significant impairment to their breathing, constant pain and affected their ability to work. C was seen for a second opinion by another Health Board in Scotland and had received surgery in England from a surgeon with expertise in this area. C believed that their medical records had been deliberately falsified or altered to conceal mistakes in their care.

The board had responded to a series of complaints from C, but their position was that C was suffering from recognised complications, which treatment had been unable to resolve. They did not accept C had been misled about their treatment, or that C’s records had been altered or falsified.

We took advice from a consultant surgeon, with expertise in the type of surgery C underwent. We found that C's complications were ones associated with the type of surgery that they had undergone. Therefore,we did not uphold this aspect of the complaint. Parts of C's records were not well maintained, although there was no evidence of falsification or alteration. Consequently, it could not be demonstrated that C had given informed consent to some of the procedures, and board staff failed to have full and frank discussions with C about their surgeries and the condition of their nose. We upheld this aspect of the complaint around providing sufficient information on the complications of surgery.

We found that C was suffering from a recognised complication of surgery, but that the consent process had fallen below a reasonable standard. There were errors in C's medical records, particularly around the first surgery C underwent, but overall, we found that C's care and treatment was reasonably documented. Therefore, we did not uphold this aspect of C's complaint.

There was not, however a clear enough treatment plan for C, and some aspects of the complications C was experiencing were not being addressed. We also found that the board's own complaint investigations should have identified the errors in C's records. Therefore, we upheld this aspect of the complaint around ongoing treatment plans.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should confirm that they have considered whether there are additional referrals required to manage the issues caused to C by their surgeries and that staff have reflected on whether these should have been made earlier as part of C’s treatment plan.

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

• Patients should be given complete and accurate information during the consent process for surgery to enable them to make informed decisions about the planned procedure. Discussions with patients should be fully documented in the medical record and include key areas of discussion in relation to the pros/cons of the procedure, the risks associated with the procedure generally, and with reference to any specific risks for the individual patient.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that concerns raised are appropriately investigated, failings, and good practice, are identified and that learning from complaints is used to drive service development and improvement. There should be a review of complaints by senior staff during the board’s investigative process.

Summary

C complained to us that the board failed to provide them with reasonable care and treatment during an appointment for a cataract procedure. We took independent advice on the complaint from a consultant ophthalmologist. We found that the scratch on the lens was not caused by the doctor but rather by the folding process of the lens in the lens introducer. However, it was unreasonable that a large scratch on the lens had not been identified after it had been inserted during the procedure. Had the issue been noticed at the time of the procedure, C would have been put into an informed position regarding the issue, of the symptoms that they would likely experience and the plan to remedy the issue. It could have been resolved much sooner, thereby lessening the pain and discomfort C endured over an extended period of time and the subsequent effect this had on their life.

C also complained that the board failed to provide reasonable follow up care and treatment following the appointment. We found that early follow up and intervention by the board would have allowed for a relatively straightforward lens exchange. Better information and communication throughout this process would have allowed for smoother patient care. Therefore, we upheld both of C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaints considered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients should receive appropriate follow up care and treatment and a review appointment should be promptly arranged at the hospital when this is appropriate.
• Surgical staff should routinely inspect the intraocular lens post insertion.

Summary

C complained that the practice failed to provide them with reasonable care and treatment. C attended the practice with symptoms of an ear infection. C said that they were not prescribed appropriate medication and were unreasonably diagnosed with an outer ear infection. C felt that a swab that was taken damaged their ear.

We took independent advice from a GP. We found that while their communication could have been better, the practice provided reasonable care and treatment in line with the history and information available at the time, and the relevant guidance. The evidence does not suggest that the ear swab caused C’s hearing loss and the practice's rationale for performing the swab was in line with local guidance. We found that the treatment provided was reasonable. We did not uphold C's complaint.

Summary

C complained about the treatment provided to their late parent (A) when they attended hospital with shortness of breath and abdominal distension (swelling). Following assessment, A was prescribed a blood-thinning medication and was discharged with a plan to return for a scan within 48 hours to look for blood clots in the lungs. A deteriorated within hours of returning home. They were taken to hospital by ambulance and admitted for treatment. Their condition deteriorated significantly. Investigations revealed worsening heart failure and they died within a few days. The board initially considered sepsis to be A's cause of death but a post mortem later established this as congestive heart failure.

We took independent advice from a consultant cardiologist (specialists in diseases and abnormalities of the heart). We found that it was reasonable for A to have been prescribed blood thinners and referred for a CT scan when they first attended hospital. However, on the basis that A’s clinical observations were abnormal, in particular their blood gas results, we found that A should have been admitted as they required oxygen. Therefore, we upheld this part of C's complaint.

C complained that the board failed to provide appropriate care and treatment in response to A's deterioration. We were critical of the board for gaps in A’s records, meaning we were unable to establish what nursing checks were carried out on the day A deteriorated. However, we found that medical staff acted appropriately in response to A’s deterioration. A’s deterioration was a result of heart failure, leading to multi-organ failure. A’s family felt that there was a lack of clarity regarding A’s condition and what they were being treated for. The board recognised that there had been communication failings, apologised and confirmed that learning had taken place. We found that the plans for investigation and treatment were appropriate. It was reasonable for clinicians to suspect sepsis when A’s condition deteriorated, and to commence treatment with broad spectrum antibiotics. There was no evidence that the outcome in this case could have been avoided. We did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for not admitting A when they attended hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and C’s family for the poor complaints handling in this case. 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:

• Clinical staff are confident about when to admit patients with respiratory failure who do not have a specific diagnosis.

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 on behalf of a family member (A) about the care and treatment that A received during two presentations to hospital following a fall at their home. Prior to their fall, A was fit and well and independent for activities of daily living.

During our investigation the board had accepted that there were failings and had taken action to address these. This included using this case as a case study to ensure any training and development requirements were implemented, delivering training sessions on significant adverse events review and carrying out a review of the duty of candour arrangements which would include training.

We took independent advice from a consultant in emergency medicine and a trauma and orthopaedic consultant. We found serious failings in A’s care and treatment and that a number of red flags (specific symptoms or signs that indicate a potentially urgent or serious underlying condition requiring immediate medical attention) had been missed in this case. In particular, we found that there was a failure to take into account relevant national guidance and to perform imaging which meant that the fractures of the vertebrae in A’s thoracic spine were undiagnosed. There was also a failure to take account of the National Institute for Health and Care Excellence guidance which the board had accepted.

We found that it had been unreasonable that A had been left to sit during their second visit to hospital for a prolonged period before being assessed given their symptoms. There were also missed opportunities to complete a more thorough neurological examination with a failure to appreciate the presence of a spinal injury and to realise the significance of the signs of limb weakness and incontinence. We also found that the board failed to immobilise A while awaiting the results of a CT scan and during their transfer between hospitals. In view of the failings identified, we upheld C's complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidance on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients attending the emergency department should be appropriately assessed and thoroughly examined, taking into account relevant guidance and, where appropriate, imaging performed. Account should also be taken of presenting symptoms, for example where a patient is presenting with ongoing back pain and new incontinence they should be laid flat and where appropriate immobilised, for example during patient transfer.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. When an incident occurs that falls within the Duty of Candour legislation, the board’s Duty of Candour processes should be activated without delay. Staff should be aware of the board's adverse event review processes and ensure they are appropriately applied.

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, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's late family member (A) during their admission to hospital. In particular, in relation to pain management, standard of care and communication.

In response to the complaint, the board apologised for the failings identified in nursing care and communication. As a result of the failings the board had taken action. This included reiterating the importance of following the National Early Warning Score (NEWS) policy, reminding nursing staff of their obligations to comply with their code of professional conduct in the workplace, and reflecting on A’s care for the purpose of improving person centred care. B was dissatisfied with the board’s response and brought their complaint to the SPSO.

During our investigation, the board accepted that aspects of A’s care and treatment should/could have been better and explained that reflection had taken place, and learning had been taken forward for the purpose of improving the level and standard of person-centred care provided to other patients. In addition, relevant staff had been given the opportunity to reflect on their communication with A’s family.

We took independent advice from a consultant general and colorectal surgeon (specialist in in conditions in the colon, rectum or anus). We found that there had been a number of failings in the care and treatment A received. In particular, we found that there had been a delay in carrying out a CT scan and in diagnosing that A had a bowel obstruction. We found that this may have impacted on their management, including giving consideration to conservative/non-surgical intervention. We also found that A’s pain management had been unreasonable and that an adverse event review should have been conducted, particularly around a diagnosis of bowel obstruction and its management. In view of the failings identified, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for these failings. 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 appreciation and awareness of analgesic requirements in patients with suspected mechanical bowel obstruction and on long term medications for chronic pain.
• There should be appreciation and awareness of a diagnosis of mechanical bowel obstruction and its timely management including the use of Gastrograffin (ASGBI guidelines) and NELA score.

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 that the board failed to carry out their sibling (A)'s hip replacement surgery within a reasonable time. C said that A had made no progress with their surgery since their pre-assessment appointment.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that A's surgery was Category 2 (urgent) which meant it should have been carried out within 90 days. Given A's significant mobility issues and difficulties with day-to-day living, it was unreasonable to leave their case for more than 90 days. We were concerned that A waited 15 months for their surgery and that the surgery only took place after intervention from this office.

Although the board apologised for the delay in A's surgery, we found that the reasons given were unreasonable. The board had a contract with another health board to provide the type of surgery A required during the time period under consideration and as A met the criteria for acceptance, it was unreasonable that the board did not explore this avenue of care. We noted that the board could also have explored an out of area and exceptional referral for A to another health board and considered the use of non-NHS providers who specialised in filling gaps where there were staffing issues due to staff absences.

We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• The board should put in place a short/medium term solution, in the form of a recovery plan, to prevent this failing from happening to other patients, whether that be three session day operating or six day a week operating, potentially supplemented by other providers if the staffing issues persisted. [In response to a draft copy of this decision notice that was issued to both parties, the board provided some evidence of action they have already taken in relation to this matter.]
• In cases such as this, the board should explore alternative pathways to manage urgent cases in a timely manner.

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 them by their dental practice. C complained about a tooth extraction and the potential failure to fully remove the root of the tooth. The dentist performed an x-ray and examined C’s mouth but did not identify any evidence of infection or retained tooth or bone.

We took independent advice from a dentist. We found that there were insufficient records relating to the tooth extraction. Based on the limited evidence available, we concluded that the care and treatment was reasonable. However, the standard of record keeping fell below the required professional standards. This was likely an isolated incident as other records provided were completed to an appropriate standard. We upheld C's complaint based on the poor record keeping but did not make any recommendations as we were satisfied the dentist had appropriately reflected on their practice.

Summary

C complained that the board unreasonably failed to provide appropriate care and treatment to their late parent (A). A attended A&E with an injured arm after a fall at home. A was treated and sent home but was admitted to hospital a few days later with low sodium and anaemia. A was discharged after a short stay but re-attended A&E a few days later. An abdominal x-ray showed dilated loops of bowel and blood tests taken showed acute kidney injury. A’s condition deteriorated and they died later that day.

We took independent advice from a consultant in emergency medicine and a consultant geriatrician (specialist in medicine of the elderly). In relation to A's first admission, we found that the management of A’s sodium levels was reasonable. However, there was a lack of accurate charting of A’s bowel movements. We also found that medications to address A’s constipation were not provided at discharge. Therefore, we concluded that the care and treatment with respect to A’s constipation was unreasonable and upheld this part of C's complaint.

C also complained that the board failed to provide A with appropriate care and treatment during their second attendance at A&E. We found that there was an unreasonable delay in A being seen by a doctor on arrival. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in the investigation. This should also include the apologies that were included in the correspondence to our office in response to our enquiries. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Bowel charts should be routinely and accurately completed for patients admitted to hospital. Patients should receive appropriate treatment including assessment and relevant examinations to assess known symptoms.
• Patients should receive appropriate treatment including triage and medical assessment in accordance with their symptoms, when attending A&E. The board should have appropriate staffing to allow timely assessment and treatment of patients in A&E, and escalation plans to address instances where patient numbers become unmanageable. The board should have an escalation plan for instances where overcrowding / patient numbers reach critical levels.

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.