Health

Summary

C complained about the care and treatment that they received during an admission to hospital. C attended A&E and the Acute Medical Unit for symptoms that were later diagnosed as an acute ischaemic stroke.

We took independent advice from a consultant physician. We found that some aspects of C’s care were reasonable, particularly the communication between the board and C and their partner.However, we found that C’s assessment in A&E was unreasonably delayed in relation to their triage category. In addition, no structured stroke assessment was carried out.

We also found that there was a delay in senior medical review and a lack of specialist stroke input. Furthermore, a prescription for aspirin was not made timeously after a CT scan excluded bleeding. Therefore, we upheld C's complaint.

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.

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

• Patients presenting to hospital with symptoms potentially indicative of stroke should receive timeous assessment, investigation and 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 that the practice unreasonably failed to take the appropriate action in response to C's elevated prostate-specific antigen (PSA, a protein in the blood) test result. C requested a PSA test due to having a family history of prostate cancer. C complained about the failure to refer them to urology (specialists in the male and female urinary tract, and the male reproductive organs) based on the test result. The practice had said it was appropriate to advise C to repeat the test in one month’s time. This did not happen and C was diagnosed with prostate cancer 13 months later.

We took independent advice from a GP. We found that the practice failed to follow Scottish Referral Guidelines for Suspected Cancer. According to the guidelines, due to C’s age, their family history and the test result, the GP should have referred C to urology for further investigation. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow the Scottish Referral Guidelines for Suspected Cancer and to refer C to urology in light of their PSA test result. 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:

• Practice staff should be familiar with Significant Event Analysis (SEA) guidelines: https://learn.nes.nhs.scot/984.
• The GP involved should be informed of the findings of this case.

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 their sibling (A) about the cancer care and treatment that A received and the handling of C’s subsequent complaint about this.

We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs) and a consultant oncologist (specialist in cancer).

We found that there was a delay in arranging an MRI scan and a ureteroscopy (a procedure that uses a thin telescope with a camera on the end to look inside the ureters and kidneys) for A. We also found that it was unreasonable that A had to involve their GP to prompt urology treatment and that there was no evidence that A’s scan results were revealed or discussed with them.

We found that the board’s investigation of the failings were inadequate. The board should have carried out a local significant adverse event review and there appeared to have been no process changes to prevent similar failings in future. The board also failed to keep C updated on the reason for the delay in issuing their complaint response. We upheld C's complaints. However, we considered that it is unlikely that earlier treatment would have changed A's prognosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to advise C that a named member of staff was available to clarify any aspect of the complaint response. 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:

• Staff should discuss scan results with patients and record this in the patient’s records.
• The board should ensure that where events meet the definition of a Category 1 adverse event (events that may have contributed to or resulted in permanent harm), as set out by Healthcare Improvement Scotland, they carry out a local SAER.
• The board should have systems in place which adhere to the Royal College of Radiologists recommendations on cancer imaging alerts and a robust system for booking procedures in theatre that does not rely on email.

In relation to complaints handling, we recommended:

• The board should keep complainants updated on the reason for any delay in issuing their complaint response and when the response is issued, advise complainants that a named member of staff is available to clarify any aspect of the complaint response. [In response to a draft copy of this decision notice that was issued to both parties, the board indicated that since this complaint, they had implemented a new complaint system that provided a facility to monitor when holding letters were due.]

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 parent (A). A suffered a heart attack and was treated with increased levels of digoxin (heart medication) in hospital. Over a two-week period A became increasingly paranoid and agitated and needed to be medicated. A was then transferred to a nursing home.

A’s digoxin levels were found to be very high and this medication was reduced. C believed that A was suffering from digoxin toxicity. C felt that A’s digoxin levels were not properly monitored or controlled and that A's outcome might have been different with better monitoring.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s digoxin was not appropriately monitored. However, it is difficult to assess whether A was suffering from digoxin toxicity. The board acknowledged this failing and provided information on the action taken by individual staff members as well as the board as an organisation to reflect on A’s experience and improve the delivery of care and treatment in the future. We upheld C's complaint and made recommendations to ensure these changes were taken forward.

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 https://www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• Complaints should be investigated fairly and fully and in line with the requirements of the NHS Scotland Complaints Handling Procedure. Complaint responses should be accurate, complete and address all the points raised in line with the NHS Scotland Complaints Handling Procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 parent (A). A was admitted to hospital with a suspected stroke, confusion and poor mobility. A CT scan was performed but the results were not reviewed until a few days later. The result was discussed with other specialists and a further scan was requested. A’s warfarin treatment (blood thinning) was reversed because A’s condition had deteriorated. C was concerned that A’s condition was not properly recognised as a stroke and that imaging of A’s head was not reviewed. Consequently A’s blood thinning medication was not stopped promptly.

The board carried out a Significant Adverse Event Review (SAER) which identified delays in reviewing A’s scan, and a lack of clarity between medical staff over who was responsible for organising tests for A, as well as poor communication. C felt the SAER lacked rigour and failed to address all the issues in A’s care.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the SAER lacked detail and did not contain sufficiently clear recommendations to ensure the failures in A’s care did not reoccur. It also did not adequately address the decision making around A’s scan or the level of awareness amongst clinicians of the scan being performed.

During our investigation the board provided further evidence of the feedback provided to staff, and the actions taken in response to the incident involving A. We found that these were reasonable and proportionate. The board accepted that the SAER had not adequately explored all the issues in the case. Therefore, we upheld C's complaint but did not make any further recommendations.

Summary

C complained about the care and treatment of their late spouse (A). A had a history of multiple myeloma (a type of blood cancer). C raised concerns about the board’s response to A’s symptoms, including a delay in carrying out a CT scan (a type of medical imaging) and a potential misdiagnosis of pancreatic cancer. The board said that A received prompt and appropriate management.

We took independent advice from a consultant haematologist (specialist in blood disorders). We found that the board’s use of CT scanning to explore A’s symptoms was reasonable, and the investigation of a mass near A’s pancreas was reasonable and consistent with National Institute for Health and Care Excellence (NICE) guidelines. Therefore, we did not uphold this aspect of the complaint.

We also investigated the board’s communication regarding A. We found no significant failings in communications in this case, and we did not uphold this aspect of the complaint.

Additionally, C complained about the handling of their complaint. We found that the board reasonably investigated A’s complaint. Therefore, we did not uphold this aspect of the complaint.

Summary

C complained about the care and treatment provided to their adult child (A). A has hereditary haemorrhagic telangiectasia (HHT, a rare genetic disorder characterised by abnormal blood vessel formation, leading to frequent bleeding, with potentially severe complications). A attended A&E as they had previously been bleeding from the left eye. A was triaged within 30 minutes and seen by a senior nurse within 90 minutes. The senior nurse discussed A’s presentation with a senior doctor. A was advised that they could await clinical review by a doctor, with a likely wait of up to two hours. A decided to leave and see an optician the next day. A was subsequently referred to the ophthalmology department (eye specialists) for further review and then to the oculoplastic clinic (specialists in surgical procedures around the eye) to consider cauterisation of a lesion inside the left, lower lid.

C complained that triage and initial review were unreasonable, as no-one examined A’s eyes or nose, staff had little understanding of the condition, on-call ophthalmology were not consulted and A felt pressured to leave. Overall, C was concerned that A could have lost their sight without timeous, specialist intervention.

The board considered that A had been appropriately managed in A&E. They noted that the discharge letter advised A had no active bleeding and no visual disturbance. A was offered to wait for medical review but decided to make their own optician appointment.

We took independent advice from a consultant in emergency medicine. We found that triage and staff understanding of A's condition was reasonable. We found that it was reasonable to give A the opportunity to await clinical review and not to have ophthalmology input prior to clinical review. No harm came to A and no adverse event review was required. We did not uphold C's complaint.

Summary

C complained about the care and treatment their late spouse (A) received for a bowel perforation. A died in hospital following a cardiac arrest. C complained that the conservative, non-surgical approach taken to A’s treatment led to a deterioration in their condition, leaving them unfit for surgery.

C also complained about the standard of A’s medical records, which made it unclear whether clinical advice and treatments had been followed.

Furthermore, C complained that the board’s complaint response contradicted information given at the time, particularly regarding the healing of the abdominal leak and plans for discharge. Instead, the board’s response stated that the treatment had failed, A’s condition was non-survivable, and the leak persisted. Given this, C questioned the board’s decision to attempt cardiopulmonary resuscitation and the lack of palliative care for A.

We took independent advice from a consultant surgeon. We found that there were aspects of A’s care which were reasonably managed including timely administration of intravenous antibiotics and a CT scan on admission. However, we found that there was a lack of urgency and clarity following the CT scan, and an absence of documented clinical reasoning such as treatment purpose, an escalation plan, and consideration of palliative care. High dependency care was not provided early despite signs of deterioration.

Communication with A and C was inadequate, with no documented discussions about the severity of A’s condition or care decisions. We also found failings in fluid resuscitation and monitoring, with delayed reviews of A’s response to treatment. We upheld C's complaint.

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/meaningful-apologies.

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

• Patients should receive reasonable surgical care at a level appropriate to their condition. In particular, patients should receive timely assessment and have a clear management plan in place. This should include appropriate monitoring, planned follow-up reviews, and repeat tests and investigations to assess the response to treatment. Fluid resuscitation should be adequate and fluid balance carefully monitored. Medical records should be comprehensive and completed in line with local and professional standards. Communication with a patient and their family about their care and treatment should be timely and transparent.

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 their spouse (A). The first of C’s complaints was that the board had failed to reasonably and accurately record and report an alleged incident between A and a member of staff. They also complained about the board’s investigation, and future references in records to the incident. We identified a number of failings including that the incident referred to was not reliably recorded on the board’s incident reporting system, that the board did not properly investigate C’s concerns, and that medical record correction notices issued were inaccurate and inconsistent. We upheld the complaint.

C also complained about the care and treatment that A had received. We took independent advice from a psychiatrist. We found that the care and treatment was of a reasonable standard. We did not uphold this aspect of C’s complaint.

Finally, C complained about the board’s handling of their complaints. While acknowledging that the complaints were numerous and complicated, we were of the view that the board could have taken action at an earlier point to define the complaints. They also could have investigated to a higher standard and responded more promptly. We therefore upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for their failings in relation to recording and reporting of, future references to, and investigation into, the alleged incident; and for failings in relation to complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Place a new medical record correction notice in A’s records that accurately identifies the incorrect entries and corrects these.

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

• Where a patient raises concerns about accuracy of medical records, this should be properly investigated and responded to.

In relation to complaints handling, we recommended:

• Complaints should be responded to timeously and investigations should accurately identity failings.

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’s mental health services did not communicate information regarding C's adult child (A) reasonably. A, who had experienced various mental health issues, was taken to hospital after taking an unknown quantity of tablets. C and another family member were concerned about A's mental health. A did not wish to remain in the hospital and clinicians assessed that A had capacity to make this decision. A few days later, A agreed to go to the hospital for a mental health assessment. The board referred A to the community mental health team (CMHT) and did not admit them to hospital. A few weeks later, A took their own life.

C complained about the board's actions in the lead up to A's death. The board’s complaint response indicated that they had no concerns about the actions taken in relation to A's care. A significant adverse event review (SAER) concluded that communication between agencies (including within the board) could have been improved and an action plan based on the SAER recommendations was developed. The board acknowledged that A had died while in their care and apologised for this. C remained dissatisfied and raised their complaints with SPSO.

We took independent advice from a consultant psychiatrist. We found that, as the SAER concluded, there were failures in communication involving the mental health team, including failures to update risk assessments, failures to use the electronic case notes system and inconsistency in referral criteria across CMHTs. We concluded that the board did not take a partnership approach when communicating with Ass family and did not adequately take into account their concerns when assessing risk. Therefore, we upheld C's complaint.

During our consideration of the complaint, we gave the board the opportunity to comment on the adviser's views on the SAER Action Plan. The board reviewed and rewrote the SAER Action Plan and the proposed actions now relate directly to the recommendations in the report. However, we also noted that the board do not have the resources to undertake the proposed actions due to funding decisions. We noted that the revised SAER Action Plan could have included alternative actions that were not reliant on funding decisions. We have taken all of the above into consideration when making our recommendations.

Recommendations

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

• Board staff are mindful of the importance of communication with the family members of neurodiverse patients and adequately take the concerns of family members into account when assessing risk.
• The board develop a contingency plan to address failings in communication through training and team development of relevant staff that does not rely on external new funding, which could include building in awareness-raising and training within the development of revised CMHTs; and developing “Neurodiversity champions” within each team as sources of greater expertise to spread information and awareness.

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.