Health

Summary

C complained about the care and treatment that their spouse (A) received during two admissions to hospital. C complained that the board had failed to provide A with adequate personal care during both admissions and failed to adequately manage their medication during their first admission. C also complained that A had been unreasonably discharged following their first admission and that there had been inadequate preparation for A’s second discharge.

The board apologised for failures in A’s care and for aspects of their communication. They also apologised for a failure to adequately prepare A’s medication prior to their second discharge. They identified learning from these failures. However, C remained unhappy and asked us to investigate.

We took independent advice from a consultant in geriatric medicine and an advanced nurse practitioner. We found that A was unreasonably discharged at the end of their first admission. Therefore, we upheld this part of C’s complaint. However, the board managed A’s medication reasonably and provided adequate personal care during A’s first admission. Therefore, we did not uphold these part’s of C’s complaint.

In relation to A’s second discharge, we found that there had been a failure to provide A with adequate personal care and that they had been discharged at the end of this without adequate preparation. We upheld these parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and 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/information-leaflets.

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

• Where a patient has a lack of bowel movements for several days, this should be highlighted and discussed with the relevant nursing, medical and allied healthcare teams.
• Where blood tests have been carried out, the patient’s results should be reviewed prior to their discharge.
• Where there is a delay in a patient being discharged, they should receive any medications they are due whilst waiting to be discharged. Patients should receive all appropriate prescribed medication when they are discharged. All relevant patient discharge documentation should be completed.
• Staff should obtain the precise details of a patient’s usual medication regime for Parkinson’s and act upon this to improve patient care.

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 failed to provide them with reasonable care and treatment. C was involved in a road traffic accident after they momentarily lost consciousness while driving. C had a phone and then a face-to-face consultation with a physician associate (PA, a healthcare professional who support doctors in the diagnosis and management of patients) who referred them to respiratory medicine to investigate possible sleep apnoea caused by hypersomnia (excessive daytime sleepiness). Another telephone consultation was held, during which the PA indicated their intention to refer C to the DVLA due to concerns that C was continuing to drive despite their advice to stop.

C was unhappy with their level of care. C disputed having been told that they must not drive, and complained that the referral was made on the basis of a suspected rather than confirmed diagnosis. They also said that they had not received fair warning of the consequences. C complained that it had not been made apparent that they were being seen by a PA rather than a GP. Lastly, C complained about the practice’s complaints handling, and the accuracy of their responses.

We took independent advice from a GP. We found that the questionnaire used to assess hypersomnia had been incorrectly completed by the PA which provided misleading results. C’s prescribed medication had not been followed up as a contributing factor in the accident and C’s significantly low pulse rate had not been identified or acted upon. We found that the PA appeared to have been acting without sufficient supervision from a GP, particularly once the complex nature of C’s situation became apparent. It would have been reasonable for C’s case to be transferred to a GP.

We also found that the referral to the DVLA had not been made in line with either DVLA or GMC guidance. Furthermore, the practice had failed to take appropriate steps to ensure that it was clear to C that they were receiving care from a PA and not a GP. Lastly, we found that there had been a failure to proactively update C on the progress of their complaint and that there were inaccuracies in the complaint responses. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. 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:

• A PA should be working within a defined scope of practice as determined by their employer. There should also be appropriate supervision and oversight from GPs when care and treatment is being provided by a PA. Supervision needs to take place in a timely fashion to ensure that complex cases are identified.
• The practice should ensure that all paperwork and IT systems are set up to allow for staff members to appropriately identify their job role.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS complaints handling procedure and all efforts should be made to ensure the accuracy of complaints responses. Complainants should be kept updated on their complaints and clearly signposted to the SPSO in all stage 2 complaints responses.

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.

Correction 4/3/2025

When this case was originally published on 22 January 2025, it incorrectly stated the organisation as 'A GP Practice in the Lanarkshire NHS Board area'. This was due to human error. The GP practice is based in the Forth Valley NHS Board area. We apologise for any inconvenience this may have caused.

Summary

C complained that the board failed to provide them with reasonable care and treatment in relation to their breast cancer care. C raised concerns that that the board failed to carry out necessary scans and failed to offer neoadjuvant chemotherapy (treatment given before the primary course of treatment to reduce the size of the tumour). C also complained about the waiting times in relation to surgeries and the mastectomy report; and that the board failed to adhere to the relevant local and national guidelines.

We took independent advice from a consultant breast surgeon. We found that the care and treatment provided to C was reasonable. In particular, we found that C did not meet the requirements to receive neoadjuvant chemotherapy prior to surgery and, accordingly, it was not unreasonable that the board did not perform further scans. We found that the waiting times were reasonable. We also found that the board’s medical team had followed relevant local and national guidelines and C had been provided with reasonable care and treatment based on the information available to the clinicians at the time. Therefore, we did not uphold C’s complaint.

In relation to complaint handling, we found that C was provided with updates on the progress of their investigation and the reason for the delay. However, C was not given a revised timescale for completion so we provided feedback to the board on this point.

Summary

C complained about the care and treatment provided to their parent (A) by the practice. A was described as fit and well but had developed severe diarrhoea. Although the diarrhoea subsided, A continued to feel unwell and breathless. A was seen by an advanced nurse practitioner (ANP) and referred for an electrocardiogram (ECG) as an outpatient a few days later. A attended for these tests, but was not seen by a doctor, and returned home. A suffered a stroke that afternoon and died in hospital the following day.

C complained that although A spoke with a doctor by telephone, they were not seen in person by a doctor over a series of appointments. C believed that A should have seen a doctor much sooner and that A should have been considered for hospital admission at their appointment with the ANP. They also said that A’s ECG results were abnormal, had been misinterpreted by the practice and should have resulted in A’s admission to hospital as an emergency. C believed that had the practice provided a reasonable standard of care, A’s death could have been prevented. Although C met with the practice and received two responses to their complaint, they continued to believe the practice’s response was inadequate and brought their complaint to this office.

We took independent advice from a GP. We found that A’s care prior to their ECG was of a reasonable standard. It was noted that C disagreed with A’s medical records, but it was not possible to determine precisely what was said at A’s appointments. We did not uphold these parts of C’s complaint.

We found that A’s ECG was highly abnormal, indicating A’s heart was lacking in oxygenated blood flow. This should have resulted in a face-to-face appointment, followed by an immediate hospital referral. Therefore, we upheld this part of C’s complaint. However, it was not possible to determine whether A would have survived with an earlier admission as the cause of A’s death was a bleed on their brain. This was an unfortunate but recognised side effect of the medication given to A to treat the stroke they had suffered.

Finally, C complained about the practice’s complaint handling. We found that the practice failed to handle C’s complaint reasonably and upheld this part of their 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.
• Apologise to A’s family for the failure to provide A with a reasonable standard of care on the day of their ECG. 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:

• ECG results should be accurately interpreted, taking into consideration the condition of the patient and their medical history.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure.
• The practice’s complaint investigations should ensure that failings are accurately identified.

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 standard of medical care and treatment provided by the practice. C attended the practice with a lesion on their back which was diagnosed as a seborrhoeic wart (a harmless growth on the skin). C underwent cryotherapy treatment (the use of extreme cold to freeze and remove abnormal tissue) but this was unsuccessful. Therefore, the practice made a a routine referral for an outpatient hospital appointment to have the lesion removed surgically. C opted to be see a private consultant dermatologist (skin specialist) and was diagnosed with cancer. C felt that the practice misdiagnosed their skin cancer which led to a delay in receiving appropriate treatment.

We took independent advice from a GP. We found that the care and treatment C received when they first attended the practice was reasonable. However, the practice failed to record a clear description of the lesion in the medical records. This is essential to ensure that subsequent viewers of the lesion can assess whether there has been any significant change. Therefore, we could not say that subsequent care and treatment had been reasonable and upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing identified. 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:

• When managing and treating skin lesions, the medical records should contain all relevant information to ensure that subsequent viewers of the lesion can assess whether there has been any significant change in the lesion.

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 that their child (A) received from a dentist. A injured their front tooth and attended their dental practice for an emergency appointment. The dentist noted there was a 1mm extrusion (tooth displacement) but decided that no treatment was needed. C complained that the tooth wasn’t treated with a splint.

The dentist said that dentists are able to use their own clinical judgement to decide whether or not to follow the guidelines in each case. In this case, the dentist decided that the tooth would recover on its own and made the decision not to splint the tooth.

We took independent advice from a dentist. We noted that there are standards a dentist should follow. This includes providing patients with treatment that is in their best interests and keeping up-to-date with current evidence and best practices. If a dentist chooses to deviate from established practice and guidance, the reason why should be recorded. We found that the dentist did not record the reasons why they decided not to follow the guidelines and they did not inform C that there were guidelines that applied in this case. We also considered that the decision not to follow the guidelines in this case was unreasonable. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform them that the treatment recommended was not in line with the trauma guidelines, failing to inform them of the reasons why the guidelines were not followed, including the decision not to splint the tooth, and failing to appropriately record the reasons why in the clinical records. 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:

• The dentist should be aware of and familiar with the guidelines on how to manage traumatic dental injuries (https://iadt-dentaltrauma.org/guidelines-and-resources/guidelines). Dentists should follow the guidelines when managing traumatic dental injuries unless there is a specific reason to take a different approach. Dentists should be aware of how and when to record their reasoning should treatment offered deviate from the approach recommended in the guidelines.
• The dentist should be familiar, and act in line with the Standards for Dental Team (particularly standards 1.4.2, 7.1.1, and 7.1.2) as well as, the Professional Duty of Candour.

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 delays in the care and treatment provided to their spouse (A) who was diagnosed with lung cancer following an abnormal chest X-ray. C said that there was a delay in A being provided with a CT scan result by the respiratory consultant, and a further wait to be seen by the oncologist (cancer specialist) following A’s biopsy (a medical procedure that involves taking a small sample of body tissue so it can be examined under a microscope). C asked whether A’s diagnostic pathway influenced their treatment, in that patients with more curable grades of cancer were treated sooner.

We took independent advice from a consultant oncologist. We found that there was no formal pathway for lung cancer patients in place at the time. We also found that the diagnostic pathway being used, was inadequate for all patients, not just for A or other patients with high grade cancer.

We found that due to a shortage of respiratory physicians at the time, there was a delay in arranging a review with the respiratory consultant. This resulted in delays to the biopsy which delayed a treatment plan. The board have accepted that the pathway for A was delayed and have made improvements to enable patients to follow the optimal lung cancer pathway. We found that there was an unreasonable delay in carrying out a respiratory review and that this, and a lack of formal pathway, had a significant impact on A’s overall treatment plan and experience. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 reasonably assess their mental health condition. C had been receiving treatment for a number of years in England, before returning to Scotland. C said that the board’s assessment questioned C’s existing diagnosis and sought to remove this. C asked for a second opinion and a different consultant reviewed their notes. C felt that they should have been seen face-to-face and complained that the board failed to offer an independent second opinion.

We took independent advice from a consultant psychiatrist. We initially upheld the complaint. However, in response to our provisional decision, the board provided evidence showing that they had not sought to remove C’s diagnosis. We found that if C’s existing diagnosis was not being removed, then there was no need for a second opinion. Rather the board should offer C an opportunity to work with a different clinician to repair the therapeutic relationship. As C’s diagnosis was not being removed, the basis for C’s complaints no longer applied. Therefore, we did not uphold C’s complaints. However, we recommended that the board apologise to C given the extent of the misunderstanding, which was not clarified early enough by the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the misunderstanding arising from the assessment of their condition. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 provide them with reasonable care and treatment when they attended the emergency department with pain and swelling in their leg. C was advised that their symptoms did not indicate a pulmonary embolism (a blood clot that blocks a blood vessel in the lungs) and that they were on appropriate medication. C was also referred to the deep vein thrombosis (DVT, a blood clot in a vein, usually in the leg) clinic for further investigation.

We took independent advice from a consultant in emergency medicine. We found that the medical care and treatment provided to C in the emergency department was reasonable. Therefore, we did not uphold this part of C’s complaint.

C also complained about the care and treatment that they received when they attended the DVT clinic several days later. C was advised at the clinic that it was highly unlikely that they had a DVT. However, around two weeks later, C attended the emergency department again due to worsening symptoms. C was diagnosed with a pulmonary embolism.

We took independent advice from a consultant in general medicine. We found that an advanced nurse practitioner did not give sufficient consideration to C’s significantly high D-Dimer blood test result (a test used to check for blood clotting problems) and did not seek input from medical staff. In addition, the board’s DVT protocol at the time was too simplistic to take into account all of C’s risk factors. It did not mandate the recording of those risk factors and deviated from the national guidance at the time, which recommended a repeat scan six to eight days later. Therefore, we upheld this part of C’s complaint.

C also complained about the Significant Adverse Event Review (SAER) the board had carried out. We found that the SAER fully recognised the omissions in the board’s protocol and changes were subsequently made to this. However, when carrying out the SAER, the review team did not seek input from C in line with national guidance. 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 failings identified. 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:

• All relevant staff should be aware of the board’s revised DVT protocol.

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 elderly parent (A). A had a known history of high blood pressure and white coat syndrome (when a patient’s blood pressure rises in response to a stressful situation, such as, a doctor’s appointment or visit to the hospital). A had been prescribed a combination of two diuretic medications (types of drug that cause the kidneys to make more urine) to treat this. During an appointment with a locum GP, it was noted that A’s blood pressure was high so they prescribed a third diuretic medication. A became unwell and attended the practice a few days later. They were then admitted to hospital and diagnosed with hyponatraemia (a lower than normal level of sodium in the blood). C was concerned that the practice prescribed an unnecessary third diuretic that led to A’s admission to hospital and that they did not perform checks on A’s bloods before prescribing this medication.

The practice said that the medications were safe to be prescribed together with close blood monitoring. They explained that they have a system in place to monitor patients who are prescribed ‘triple whammy’ drugs (a combination of drugs of different types: non-steriodal inflammatories, diuretic, and ACE inhibitors). They also highlighted that they took bloods during the consultation before A’s admission to hospital.

We took independent advice from a GP. We found that the decision to prescribe the third diuretic was unreasonable and unsafe. The consultation that took place before the admission to hospital was reasonable and bloods were gathered. However, the practice’s procedure to monitor triple whammy drugs does not apply in this case as A was prescribed three diuretics and none of the other drug types. Therefore, A’s case would not be picked up by this monitoring programme. We found that the practice should have carried out a Significant Adverse Event Review and did not acknowledge any failings in their complaint response. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to carry out a reasonable consultation on their first visit, failing to ensure that the medication prescribed was necessary and safe, failing to acknowledge any mistakes and failing to carry out a Significant Adverse Event Review, when they should have done. 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:

• When serious significant adverse events occur that could have caused or did result in harm, reviews should be carried out in line with the national guidance: Learning from adverse events through reporting and review – a national framework for Scotland.
• Clinicians should ensure that medication prescribed is required and is safe to be prescribed in combination with other medications before a new medication is issued. If required, blood monitoring should be carried out before commencing a patient on new medication.
• Temporary staff such as locum GPs should be aware of relevant practice procedures and working practices so that they may act in line with them.

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.