Health

Summary

C's late partner (A) tested positive for COVID-19. A's condition worsened over time and C called 111 as they were concerned A's breathing was becoming laboured. C had to wait around 20 minutes before the call was answered. Once connected, the call lasted around 30 minutes. The call handler contacted the Scottish Ambulance Service (SAS) and said that they were 'looking to arrange an immediate response for a patient'. A's condition deteriorated further and C made a 999 call around ten minutes after ending the call to 111, as assistance had not yet arrived. However, by the time paramedics arrived, A had stopped breathing and could not be resuscitated.

C complained about the length of time it took for an ambulance to arrive. They complained that paramedics did not arrive in personal protective equipment (PPE), and considered that they wasted time getting dressed outside when it was an emergency call. C also queried whether a defibrillator (an electronic device that applies an electric shock to restore the rhythm of a fibrillating heart) had been used as they could not hear any shock being administered.

We took independent advice from a paramedic. With regard to the initial call from NHS 24, we found that this had been dealt with appropriately. The call taker had assigned the request for an ambulance the correct level of priority, in terms of the SAS coding system in place at the time. Therefore, we did not uphold this aspect of the complaint. However, we noted weaknesses in the NHS 24-SAS service interaction and suggested that SAS review the process and consider making improvements if necessary.

We found that the response to the 999 call was reasonable, proportionate and timely. We noted that it would not have been appropriate to provide shock to A, given their clinical condition. We also accepted SAS' explanation as to why crew required to put on PPE when they arrived at the scene, which was necessary for infection control. We did not uphold this complaint.

Summary

C complained about the Scottish Ambulance Service (SAS) after calling an ambulance for their spouse (A). The ambulance crew that initially attended C diagnosed that A's condition was not sufficiently serious to require hospital attendance and instead requested that a GP attend instead. C considered that this was unreasonable as, when the GP did later attend, they requested a further ambulance to take A to hospital. C was also concerned about the SAS' handling of their subsequent complaints.

We took independent advice from an emergency medicine clinician. We found that the original ambulance crew had carried out a detailed diagnostic investigation and reasonably concluded that requesting a doctor to attend the home was the best option. Therefore, we did not uphold C's complaints in that respect.

However, our investigation did raise concerns about the SAS' complaints handling. We found that there were unexplained inaccuracies in their response and also that they had failed to clarify the nature of C's complaints when this was not clear from the complaint correspondence, leading to a misunderstanding of the nature of the complaint. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

In relation to complaints handling, we recommended:

• Where a complaint is not entirely clear, clarification should be sought from the complainant to ensure a full and accurate response.

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 to us about the care and treatment that they had received from their GP practice. C told us that the practice had failed to carry out appropriate prostate specific antigen (PSA) testing after they found out that C was at increased risk of prostate cancer genetically. They told us that after an initial test, which was normal, there was a delay of around four years in carrying out a further test, at which time the test showed elevated results and they were subsequently diagnosed with cancer. C considered that this delay had a considerable impact on their prognosis, as their cancer had by that time spread, which they had been told was unlikely to have been the case had they been diagnosed earlier.

C also complained that the practice had failed to appropriately respond to their concerns about this, both in the way that they had investigated the concerns, and the manner in which they had responded, which C had found to be uncaring.

We took independent advice from a GP adviser. We found that the practice had failed to handle C's testing appropriately. In particular, that they unreasonably assessed that regular testing was not required based on guidance intended for those not at increased genetic risk and that they unreasonably failed to seek further advice and clarity from specialist services on the request to consider regular testing. We also noted that when the test was subsequently agreed as part of other blood tests, this was missed in error, and they then failed to identify this had been missed or notify C, leaving them with the impression that this had provided normal results.

Therefore, we upheld C's complaint that their testing had been mishandled.

Our investigation also found that the practice had not responded reasonably to C's concerns, as the Significant Event Analysis (SEA) they carried out was not of a reasonable standard, and they had failed to provide appropriate apologies for the failures that were identified by their own investigations.

On this basis, we also upheld C's complaint that the practice had not responded reasonably to their concerns.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide appropriate PSA testing. 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 for failing to respond reasonably to their concerns. 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 practice should appropriately consider the results of any tests requested to ensure that they are fit for the purpose they were requested for.
• The practice should ensure that there is clarity around any request received from secondary care services that they choose to accept.
• The practice should provide appropriate screening for any patient at increased risk of developing cancer.

In relation to complaints handling, we recommended:

• All complaints should be processed in line with the Model Complaints Handling Procedure and any apologies offered in complaint responses should meet the terms of the guidance on apology.
• All SEA (Significant Event Analysis) investigations should include an assessment of whether the treatment provided was of a reasonable standard, and a consideration of the root causes of any failings 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 care and treatment provided to their late parent (A) when they were admitted to hospital for investigations of lung cancer. A had an out-patient appointment for a CT scan, however, the day before this appointment, A was admitted to hospital due to increased haemoptysis (coughing up of blood). There was a delay in performing the CT scan due to miscommunication between the clinical team and radiology, which the board have acknowledged. When A was taken for the scan, they suffered a massive haemoptysis and a subsequent cardiac arrest and died.

C complained about the communication failures which led to a delay in arranging the CT scan and that insufficient efforts were made to resuscitate A. To investigate C's complaint, we reviewed the clinical records and sought independent advice from a consultant radiologist (a specialist in the analysis of images of the body).

Our investigation found that while there were communication failures in arranging A's CT scan on an in-patient basis, we did not consider the delay caused to be unreasonable as A's condition was stable and there were no further episodes of haemoptysis. We did however, uphold the complaint on the basis that there were communication failings. We made no recommendations due to action already taken by the board.

Our investigation also found that reasonable attempts were made at resuscitation when A suffered the cardiac arrest. We did not uphold this aspect of the complaint.

Summary

C complained that there had been an unreasonable delay in their late parent (A) receiving a prescription of antibiotics following a consultation with an out-of-hours GP from the unscheduled care service, operated by the board. During the consultation, the GP considered that A had developed a lower respiratory tract infection (an infection of the lungs), which should be treated with Co-amoxiclav (a type of antibiotic). However, the GP had attended the consultation without a prescription pad and did not carry the medication in their vehicle. The GP subsequently arranged for A's prescription to be faxed to a pharmacy on their return to base to be provided to A the next day. However, the pharmacy to which the prescription had been faxed was closed the following day due to a public holiday, which resulted in a delay of 48 hours before the prescription could be provided to A.

In response, the board apologised that the GP had attended the consultation without a prescription pad and for the distress that this had caused A and their family. The board stated that it could not explain why the GP had attended without a prescription pad but had reminded staff in a monthly update to ensure that prescription pads were checked prior to carrying out home visits and that prescriptions were only faxed to pharmacies that could provide medication in a timely manner. The board also confirmed that it was in the process of developing a checklist system and a written policy and protocol specifying the checks that staff were required to complete at the start of each shift prior to commencing home visits.

We took independent advice from a GP. We found that it had been unreasonable for the GP to attend the consultation without a prescription pad and to fail to ensure that the antibiotics A required were available to them sooner based on A's presentation at consultation. We also considered that the reminder provided by the board to staff was insufficient to ensure that a similar occurrence did not happen again. However the checklist system and written policy and protocol the board had indicated it was developing was likely to be appropriate to address the issues arising in this case.

For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. 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:

• Out-of-hours GPs should be in possession of all required equipment prior to the commencement of each shift. In addition, where a patient's clinical presentation requires medication to be prescribed, out-of-hours GPs should take all reasonable steps to ensure that there is likely to be no undue delay in the prescription becoming available to the patient.

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 and B complained about the care and treatment that their adult child (A) received from the practice. A had sought advice and treatment for a lack of energy, loss of libido and difficulty gaining weight. They were referred to the metabolic unit in hospital and, subsequently, to an adult eating disorders service. A had been diagnosed with a hormonal deficiency and a number of potential causes for their symptoms were considered. However, A and their family were concerned about the practice's clinical management of A's condition and the lack of a clear diagnosis or effective treatment plan.

A subsequently completed suicide. Following a meeting and written correspondence with the practice, C and B remained dissatisfied with a number of aspects of the treatment A received.

We took independent advice from a GP. A's case was complex and whilst with hindsight it was clear that A had an underlying mental health condition, a physical cause for their symptoms could not be ruled out. We were satisfied that the practice arranged numerous tests and investigations to explore a physical cause of A's symptoms. Additional tests were carried out by third parties and we found that the practice appropriately reviewed these and communicated clearly with A as to the results, their significance and the next steps in terms of finding a clear diagnosis.

We found that the practice considered at an early stage that there may have been a mental health element to A's condition. However, A was not keen to pursue this. We were satisfied that it would have been inappropriate in the circumstances for the practice to push further investigations into A's mental health. We were also satisfied that the practice communicated well with secondary care specialists and managed A's overall diagnostic pathway reasonably. Therefore, we did not uphold these aspects of C and B's complaint.

However, we were critical of the practice's communication with C and B. It was A's clear intention that they be included in conversations regarding their health. Although the practice were not able to communicate via C and B's preferred medium, they did not take reasonable steps to ensure clear communication between all parties and the communication broke down as a result. We also found that the practice failed to instigate an internal review following A's death and, having completed a review following C and B's complaint, they failed to provide them with a copy of their findings. Therefore, we upheld these aspects of C and B's complaint. We did not make any recommendations due to the appropriate action already taken by the practice.

Summary

C complained about delays in treatment that was meant to be provided to their late spouse (A). They told us that A had been referred to the board from another area for heart surgery, but that this took so long to arrange, A's condition deteriorated to a point that surgery was no longer viable and they subsequently died. C was also concerned about the board's handling of their complaints about the matter.

We took independent advice from a cardiology consultant (a specialist in diseases and abnormalities of the heart). We found that, while there were delays in arranging scans, these were the responsibility of the board in A's home area, so Lothian NHS Board could not be said to be responsible for this.

With regards to C's concerns about complaints handling, we found that the board's approach had been reasonable, with appropriately empathetic language used throughout and regular updates provided.

Given these points, we did not uphold C's complaints.

Summary

C, an advocate, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A had attended their GP practice complaining of pain between the shoulder blades and breathlessness on exertion and was seen by a nurse practitioner. The nurse referred A to hospital for a chest x-ray which they received the next day. A then received further x-rays throughout the month following attendances at A&E. They were referred to another hospital where they were later diagnosed with advanced lung cancer.

B complained about the about the nurse's assessment and that the practice failed to follow up on the chest x-ray they referred A for, and failed to follow up on their various attendances at A&E. Had they done so, B considered that A might have been diagnosed sooner.

We took independent advice from a nurse and a GP. We found that the assessment by the nurse practitioner was reasonable and the decision to refer A for chest x-ray and spirometry (a simple test used to help diagnose and monitor certain lung conditions) was appropriate.

In relation to the x-ray taken after the nurse's referral, the results recommended referral to respiratory medicine but the practice did not receive the report until after A's death. We found that it was the responsibility of radiology (specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) to send the x-ray report to the GP, which in this case had not happened and would not expect a practice to chase up records. We also noted that the practice now log all investigation requests and check that results have been returned, which is good practice and above the standard level of care.

In relation to the various attendances at A&E, we found that it is not expected of the practice to follow up on these attendances. There was no mention in the discharge letters sent to the GP of any action required.

Therefore, we did not uphold C's complaints.

Summary

C complained about the care and treatment that their parent (A) received from the board. Following surgery to remove bladder lesions, A experienced severe pain and urinary problems. It was established that they had a bladder perforation. C complained that, whilst A's consultant initially accepted and apologised for the fact that A's bladder was likely perforated during surgery, the board subsequently backtracked and suggested that there could have been a number of causes. C did not consider that their family had been given a clear explanation as to how A's bladder had been perforated.

A subsequent review of A's case established that they had cancer invading their bladder muscle. The cancer could not be treated with chemotherapy or radiotherapy and staff had discussions with A regarding the difficulties associated with attempting surgery in light of their other existing medical conditions. A was readmitted to hospital via A&E the following month, due to bladder spasms and catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) pain. A CT scan was carried out and A was admitted to a ward for ongoing monitoring and treatment. A's pain worsened and further scans showed that the cancer had spread to their lungs. Surgery was no longer an option and A died shortly afterward.

C complained that the communication from the urology staff (specialists in the male and female urinary tract, and the male reproductive organs) during A's hospital admissions was poor and that there was an unreasonable delay to A and other family members being told the extent of A's condition.

We took independent advice from a consultant urologist. We considered that, when responding to C's complaint, the board sought to provide a detailed description of events and a clearly set out explanation as to the potential causes of A's bladder perforation. That said, we found that information provided by C was not taken into account and, had it been, a clearer explanation could have been provided by the board. Therefore we upheld this aspect of C's complaint.

We found that A did not require routine input from urology. Their day-to-day care in hospital was managed reasonably by gastroenterology (specialists in the diagnosis and treatment of disorders of the stomach and intestines), with input from urology as required. We were satisfied that A's urology investigations took place in good time and a reasonable management plan was put in place for their ongoing urology input. Overall, we found that the communication from the urology staff to be reasonable. We did not uphold this aspect of C's complaint.

A had a rare and aggressive form of cancer. We accepted evidence from the board that earlier scans showed evidence of changes that were visible, but not identified. We concluded that, whilst the treatment options available to A may not have been any different, had the changes been identified earlier, they may have been given details of their cancer and prognosis sooner and this may have given A more time to prepare and make arrangements. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings identified in this decision. 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 about the care and treatment that they received from the board. C had experienced severe nausea but initial investigations found no definitive cause for their symptoms and a presumed diagnosis of irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation) was made. C said that they were provided with medication but this had little effect.

C developed severe abdominal pains later the same year which required immediate surgery and initially appeared to recover well. However, their abdominal pains returned a few months later and they required a hospital admission. Further surgery was carried out, establishing and resolving the root cause of the pain.

Whilst C's pain resolved following the second surgery, they raised a number of concerns regarding the care and treatment provided by the board, delays to diagnosing the cause of their symptoms and inaccurate documentation of the procedures that they had had.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that the initial view that C's symptoms were being caused by a bowel condition was reasonable and that IBS was a reasonable working diagnosis while tests were carried out to confirm or rule out other possible causes of their nausea. We were satisfied that the working diagnosis and the focus of investigations changed when C's symptoms escalated. We were also satisfied, following the recurrence of their abdominal pain, that the board followed a reasonable and recognised pathway to establishing the cause of C's pain. Therefore, we did not uphold these aspects of C's complaint.

We were critical, however, of a number of errors in C's medical records, including details of another patient's procedures being misfiled in C's notes. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. 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.