Health

Summary

Mrs C complained that psychiatric staff in Stratheden Hospital treated her son (Mr A) unreasonably while he was a patient there. Our investigation considered a number of individual issues that she raised in relation to this, and in doing so we took independent advice from our mental health adviser.

Mrs C said that staff had failed to check whether Mr A had any dangerous items in his possession when he was being admitted to the hospital, which meant that he was able to start a fire in a room. We found, however, that he had not been formally admitted to the hospital at this point. Staff had not completed his admission assessment, as they had been called away to deal with a medical emergency involving another patient. Had this assessment (which would have included a risk assessment and a plan to minimise risk) been completed, any potentially dangerous articles would have been removed from Mr A's possession. In the circumstances, we did not consider that staff acted unreasonably, but we said that the board should treat this as a learning point.

Mrs C also said that staff delayed in arranging for an injury to Mr A's hand to be treated. We found that Mr A had initially refused to allow staff to carry out an examination, and that once he had consented to being examined and treated, staff had acted appropriately. Mrs C also complained to the board that Mr A was assaulted and molested by staff in the hospital. We found, however, that an adult protection investigation had been carried out into these matters, led by the local council, and that the board had also satisfactorily considered and investigated these allegations. In addition, we found that staff had acted reasonably in relation to getting Mr A an advocate, and were entitled to decide that Mrs C could not use a camera in the hospital to take photos. We also found that Mr A had been prescribed medication in line with the relevant guidelines and that staff had acted reasonably in relation to this.

That said, we found that Mr A had been transferred to another ward in his underwear and without shoes, which we found inappropriate. We also found that staff had failed to adequately observe or supervise him when he was moved into a seclusion room, and there was no evidence of a plan to ensure that he had appropriate access to food, fluids and a toilet during seclusion. This was not acceptable and, in view of these specific failings, we upheld Mrs C's complaint. However, we noted that the board had apologised to her for what happened when her son was transferred, and had acknowledged that there were failings when he was put in the seclusion room. This had prompted a review of seclusion practice and procedures in the hospital. The board sent us evidence of this review and we were satisfied that they had taken action to address these failings. We did, however, draw their attention to some failings in relation to a significant event review carried out in relation to the matter.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings identified in relation to putting her son in a seclusion room.

Summary

Mr C complained that when he attended his medical practice the GP who saw him did not tell him that he could stop his diabetic medication. As a result, he had continued to take it for a year, and he wondered whether this was detrimental to his health. The practice apologised and explained that the GP recalled discussing the matter with Mr C at the time but forgot to amend the repeat prescription list. They said that by continuing with the medication, Mr C did not come to any harm.

After taking independent advice from one of our medical advisers we found that, although we could not establish exactly what the GP and Mr C discussed, it was the GP's intention to stop the medication at that time. However, human error prevented the medication from being removed from the repeat prescription list. Because of this, we upheld Mr C's complaint. However, as the practice had already apologised to Mr C and reminded staff about properly documenting conversations with patients, we did not make any recommendations.

Summary

Mr and Mrs C were not satisfied with the board's investigation of their complaint about the behaviour of staff at clinic appointments at Ayr Hospital. The board told them that the relevant staff had been interviewed, and their recollection of events was different from that of Mr and Mrs C. Staff had said that it was Mr and Mrs C who exhibited unacceptable behaviour. Mr and Mrs C then complained to us that the board did not respond appropriately to their complaint.

It appeared that Mr and Mrs C and the staff had interpreted events differently, and we could not say which version of events was more accurate. We did find evidence that the board had treated the matter seriously and had thoroughly investigated the complaint. We were satisfied that they took Mr and Mrs C's concerns into account along with the evidence from the staff involved and had provided a reasonable response, including explaining the main issues involved.

Summary

Mr C complained that the board failed to provide him with appropriate ongoing psychiatric treatment and support after he was admitted to a hospital psychiatric unit. After taking independent advice from one of our medical advisers - a consultant psychiatrist - we found that Mr C was treated appropriately whilst he was in the hospital. However, several months after he left there, he was diagnosed with borderline personality disorder. We found that psychiatrists had failed to adequately document a detailed medical history, and that the diagnosis was not adequately founded or justified. It was not made with sufficient rigour and was not reviewed appropriately.

There was no evidence that assessment for psychological treatments was carried out so that Mr C could be offered treatment promptly. His care and management were not coordinated and there was no evidence that his care plan had been reviewed. In addition, it was not clear whether the findings of a scan were adequately communicated to him. We found that this delayed Mr C's treatment for a number of months. In view of all of this, we upheld the complaint. However, we found that a psychiatrist who had later taken over Mr C's care had been following an appropriate plan of further investigation in collaboration with Mr C's GP.

Mr C also complained that staff had failed to admit him to the psychiatric unit when he was discharged from another hospital after attempting suicide. The discharge letters from the other hospital, however, did not say that Mr C should be admitted to the unit. We found that it had been reasonable for the board not to readmit Mr C at that time and did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the delay in providing him with appropriate psychiatric treatment and support;
• review his current treatment to ensure that it is appropriate;
• take steps to ensure that clinicians are more rigorous in the way that they diagnose personality disorders and that appropriate treatment is provided; and
• take steps to ensure that care management for psychiatric patients is co-ordinated.

Summary

Ms C complained that the board failed to diagnose a large volume of fluid on her lungs when she was treated in hospital in Scotland. She said that when she was treated later in another country a large amount of fluid was drained from her lungs.

We obtained independent advice on this case from one of our medical advisers. Our adviser explained that the records showed that the board did diagnose fluid on the lungs but that it was a small amount. Having looked at Ms C's chest

x-rays our adviser said that this was the correct description and there was no evidence of the litres of bloody fluid that Ms C told us she had drained later. The adviser said the difference might have been due to progression of her condition over a period of time, which is not uncommon. Based on the advice received, we were satisfied that the board's care and treatment of Ms C was reasonable.

Summary

Mr C had suffered prostate problems since his forties and his prostate health was regularly monitored. Until 2011, the tests had shown that although his prostate was enlarged, he was not suffering from cancer. Early in 2011, Mr C's blood test results began to indicate that he might have prostate cancer. Tissue samples were taken but these showed no sign of cancer. Mr C was given an appointment for a review within 12 weeks. However, this was cancelled and Mr C was not seen again until December that year. Following this appointment Mr C was diagnosed with advanced prostate cancer, which was incurable.

Mr C complained that the delay in rescheduling his review appointment was unacceptable. He felt that this happened because staff did not follow departmental procedures properly and because the board failed to appropriately implement a new appointment management system. Mr C said he believed the delay had adversely affected his treatment options and that when he complained the board did not handle his complaint reasonably or appropriately.

We took independent advice from a medical adviser on the clinical aspects of Mr C's case, and upheld most of his complaints. We found that the delay in rescheduling the appointment was unreasonable. The board did not give a reason for the delay and our adviser said that they should have explained why he needed the review appointment. Their failure to do so meant that Mr C did not pursue a rescheduled appointment after the original was cancelled. We did not uphold the complaint that his treatment was adversely affected, however, as our adviser said that it was likely that the cancer had already spread outside the prostate and the delay in rescheduling the appointment did not affect Mr C's prognosis or the available treatment.

We upheld Mr C's other complaints. The board could not show that they had implemented their appointment management system correctly, or that they had identified learning from the failures in Mr C's case. Their handling of his complaint was inadequate and there was no evidence that they had since introduced robust complaints handling procedures to stop these mistakes happening again.

Recommendations

We recommended that the board:

• review the urology department procedures, to ensure that patients are informed of the reason for a follow-up appointment and the timescale for this;
• provide us with evidence that they have identified the causes of the delay in manually transferring appointments during the introduction of the Patient Management System to prevent a reoccurrence, including the checks carried out to ensure that all patients were manually transferred at the time;
• provide evidence that the new Patient Management System will alert medical staff when appointments are cancelled;
• provide evidence of the steps they have taken to improve the accuracy of complaint responses;
• provide evidence that all staff have been reminded of the importance of using appropriate language when corresponding about patients;
• audit their new complaints process to ensure complaint investigations are conducted with appropriate rigour and that adequate records of the investigation are be maintained; and provide us with a copy of the findings; and
• apologise in writing for the failings our report identified.

Summary

Mr C complained that his former medical practice did not keep correct medical records and failed to give him the correct care and treatment. He also complained that the practice dealt inappropriately with urine samples presented for testing.

We obtained independent advice on the complaint from one of our medical advisers, who is a GP, and considered all the relevant information, including Mr C's medical records and the complaints correspondence. Our investigation found no evidence to suggest that the practice had failed to keep correct records and the records showed that Mr C had been appropriately treated for his symptoms. We also found that five urine samples were taken, all of which were presented for results which were also recorded.

Summary

Mr C complained about the end of life care and treatment provided to his late mother-in-law (Mrs A) in Glasgow Royal Infirmary. Mr C said that the family found it distressing to see Mrs A in the latter stages of her illness, and that the board failed to provide reasonable pain relief and refer her to the palliative care (care provided solely to prevent or relieve suffering) team within a reasonable time. He also said healthcare professionals failed to take account of the views of Mrs A's daughter, who held welfare power of attorney (a legal document appointing someone to act or make decisions for another person), and that there were failures in communication and record-keeping, particularly around the provision of a morphine pump. Finally, Mr C complained about the the way the board handled his complaint, saying that they failed to carry out an objective and transparent investigation.

Having taken independent advice from a medical adviser and a nursing adviser, we upheld some of Mr C's complaints, as we found that while the frequency of communication between healthcare professionals and the family was reasonable, the board did not ask Mrs A's family about power of attorney (particularly in light of Mrs A's incapacity) or formally discuss the medical procedures in advance with Mrs A's daughter. Having said that, we found that the board's records of several conversations with the family about the provision of a morphine pump were reasonable in that they reflected the views of the clinicians concerned. We accepted advice that Mrs A's pain relief and end of life care were generally reasonable and that Mrs A's symptoms were adequately managed by the medication prescribed. We were not, however, satisfied that the board's complaint investigation was carried out in accordance with the NHS complaints procedure, as it appeared from the board's responses that it was done by the members of staff who were the subject of the complaint.

Recommendations

We recommended that the board:

• review their patient profile and documentation and its completion in light of our nursing adviser's comments;
• bring the failures our investigation identified to the attention of the relevant healthcare professionals concerned;
• ensure the relevant healthcare professionals appropriately consider referrals to the palliative care team at the earliest opportunity, in light of our medical adviser's comments;
• bring the failures identified in complaints handling to the attention of relevant staff; and
• apologise to Mr C for the failures this investigation identified.

Summary

Mr C complained on behalf of his wife (Mrs C) about the care she received from the maternity triage service at Forth Valley Royal Hospital immediately prior to the birth of her daughter. Mrs C had phoned the service twice for advice about coming into hospital as she was concerned about the progress of her contractions, and felt she was dissuaded from going to hospital after speaking to a midwife during her second phone call. Around an hour later, Mrs C gave birth to her daughter at home with the assistance of her husband. She suffered heavy blood loss, paramedics attended and she was transferred by air ambulance to another hospital.

We took independent advice on this case from one of our medical advisers, who is a specialist in midwifery. Our adviser was critical of the midwife's actions during the second phone call, as they should have asked Mrs C to attend hospital for assessment of whether or not she was in active labour, given that she had experienced complications during a previous birth. We also found that the maternity triage phone template did not prompt staff to ask women about their previous medical history. We, therefore, upheld Mr C's complaints about the advice Mrs C had received by phone, and the lack of adequate documentation of the advice given.

In responding to Mr C's complaints, the board agreed to make triage staff aware that patients should not feel as if they need permission to attend hospital, and acknowledged that the midwife had not documented any advice she had given Mrs C about coming into the hospital. They also took steps to introduce a new national maternity triage template to ensure that appropriate information is captured, and introduced peer review.

Although we took the view that the board made reasonable improvements to shortcomings in the triage process, we did not find that the structure in place at the time was inadequate. We also concluded that it was not unreasonable for the board to have staffed the maternity triage service with a labour ward midwife, given they are qualified to determine if admission is necessary or not. We did not uphold those aspects of Mr C's complaint.

Recommendations

We recommended that the board:

• ensure that the midwife reflects on our adviser's comments as a learning tool;
• ensure midwifery triage staff appropriately document advice they provide; and
• apologise to Mrs C for the failings our investigation identified.

Summary

Mr C complained that he was prescribed medication that caused an unpleasant side effect. He said he had not been fully informed of the possibility of experiencing this side effect.

We took independent advice from one of our medical advisers, who said that GPs are only required to mention the most common side effects. The adviser said that the patient information leaflet provided with the medication details all the other possible side effects and advises patients to report to their GP immediately if they experience any of these. The adviser also said that it was not certain that the medication Mr C complained about was what was causing the side effect. In light of the advice received we did not uphold the complaint.