Health

Summary

C is an advocate who complains on behalf of A. A has a brain injury which impacts on their daily living tasks and functioning. C complained that A received poor treatment from their GP practice and that there were delays in making referrals for specialist input following a fall down stairs which made A’s existing health conditions worse.

We took independent advice from a GP adviser. We found that A's treatment had been reasonable. We noted that A had come to the practice with a number of previous unresolved problems. We considered that A's new GPs were right to be mindful that A's neurological symptoms had already been assessed as 'functional', meaning they had no known physical cause.

C also complained about repeated prescription of antibiotics. We found that this did not seem excessive given the poor general state of A's health and that referrals for specialist input had been appropriate. Therefore, we did not uphold C's complaints.

Summary

C complained about the treatment of their spouse (A) by the Scottish Ambulance Service (SAS). A became unwell at home and whilst on route to hospital in an ambulance they experienced a cardiac arrest and later died in hospital. C complained that the ambulance took a long time to arrive; that the care and treatment A received in their home was poor; that there was a delay in transporting A to the hospital; that C was asked to commence cardiopulmonary resuscitation (CPR) on A whilst on route to hospital and that C was not assisted by the ambulance technician and that they alone performed CPR on A until they arrived at hospital.

C was dissatisfied with the way in which their complaint was investigated. It was initially investigated by the SAS, however, when contacted by SPSO, SAS requested to reinvestigate the complaint in light of an error that they identified in their initial response. C remained unhappy after receiving the SAS's further response and asked us to consider the matter.

We took independent advice from an emergency and retrieval medicine adviser. We found that the way in which the dispatch of the ambulance was handled was unreasonable, that the initial care provided to A in their home was reasonable, nevertheless it should have been clear to the ambulance crew that A was seriously unwell and that the time spent on scene was unreasonable and that the decision to ask C to perform CPR in the ambulance was not reasonable.

We found that the initial investigation was not sufficient, although we acknowledged the proactive steps taken by SAS to address this issue and acknowledge failings, including asking C to commence CPR. We also found that in this case the full crew should have been interviewed. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified that have not already been acknowledged in previous responses including the length of time taken to assess A in their home and the delay in transporting A to hospital, the failure to follow clinical guidelines appropriately and the failure to handle C's complaint appropriately. 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:

• Complaint investigations should be thorough and accurate in the first instance.
• For patients suffering cardiac arrest out of hospital such as in this case, relevant clinical guidelines should be followed by ambulance crew. Ambulance crew should accurately record what treatment was performed to demonstrate adherence to the clinical guidelines.
• When it is clear from initial assessment that a patient is seriously unwell, their transfer to hospital should be expedited and delays should be avoided.

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 board's decision to discontinue the prescription for gluten free foods for their adult child (A). The board explained that as A did not have a confirmed diagnosis of coeliac disease, that they would not be expected to prescribe gluten free foods. To make a diagnosis, a patient would be required to include gluten in their diet for a number of weeks prior to testing. C said that due to A's additional needs and the distress that they would suffer from the symptoms associated with taking gluten, it would be reasonable for the board to take a flexible approach when applying their policy on the matter.

We took independent advice from both a GP adviser and a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). It was noted that it was agreed by all parties that it would be distressing to A to require them to include gluten in their diet in preparation for testing. We considered that a more flexible approach should be taken to the application of the relevant policies and guidance and that a diagnosis could be made by probability. We found that principles of realistic medicine and patient-centred care should be applied and we recommended that consideration is given to other means of non-invasive tests to determine the presence or absence of coeliac disease in A's case. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should explore and discuss with C other means of non-invasive testing to determine the presence or absence of coeliac disease in A's case.

Summary

C has Asperger's Syndrome (a form of autism, in which people may find difficulty in social relationships and in communicating) / Autistic Spectrum Disorder and a diagnosis of chronic fatigue and Functional Neurological Symptom Disorder (symptoms in the body which appear to be caused by problems in the nervous system but which are not caused by a physical neurological disease or disorder). They were referred by their GP to neurology (specialists in the nervous system) to explore a possible neurological basis for their pain symptoms. C raised a number of concerns about this consultation. C complained that no meaningful assessment took place, that the conclusions were unreasonable and that the consultant neurologist wrongly stated a psychiatric opinion by stating that they had a complex personality disorder. C also noted that there were inaccuracies in the board's response to their complaint.

The board responded to C's individual concerns and concluded that overall, they considered the assessment was reasonable.

We reviewed the relevant medical records, evidence provided by C and took independent advice from a consultant neurologist adviser. We found that there were not any significant failings and that the assessment was of a reasonable standard, consistent with General Medical Council guidelines and that the reasons for the referral were reasonably addressed. We did not uphold the complaint.

Summary

A was admitted to A&E at the Royal Hospital for Sick Children with symptoms including retching, a purple rash on their leg and feeling agitated. A had a diagnosis of quadriplegic cerebral palsy (form of cerebral palsy in which all four limbs are affected), was non-verbal and received PEG feeding (passing a thin tube through the skin to give food, fluids and medicines directly into the stomach). A was subsequently admitted to hospital after assessment.

A was observed in hospital and underwent a number of investigations. A gastrojejunal tube (when a thin, long tube is threaded into the jejunal portion of the small intestine) was inserted to address concerns about A's nutrition. A became increasingly distressed following the procedure and their condition deteriorated. A underwent emergency surgery where a caecal volvulus (obstruction of the bowel) was diagnosed.

C complained to the board that they had missed several opportunities to diagnose and treat the bowel obstruction which was causing A's symptoms. The board produced a report detailing the history of A's care and decision making during the period. The main finding was that there were no identified failings in the care provided to A and that there was no misdiagnosis of A's condition.

Dissatisfied with the board's response to the complaint, C brought their complaint to our office. We took independent advice from a paediatric gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) and a paediatric radiologist (a specialist in the analysis of images of the body). We found that the investigations and treatment provided were appropriate. There was a delay in obtaining a CT scan, however the delay was relatively small in the context of the period of A's admission. As such, we found that the care and treatment provided to A was reasonable and we did not uphold the complaint.

There were some aspects of care which we identified as being suitable to feedback to the board for reflection and consideration.

Summary

C made a complaint about the nursing care and treatment that their late parent (A) received at University Hospital Wishaw. C was concerned that A was not nursed in an elevated position and was kept lying flat. C also said that A's nutrition was not taken seriously and that the food record charts were not completed properly to monitor A's intake.

We took independent advice from a nursing adviser. We found that it is not usual to document a patient's position in bed (whether they are upright or lying flat). Therefore, we were not critical of the board's record-keeping in this regard. We found that the monitoring of A's nutrition and fluid intake was unreasonable because the Malnutrition Universal Screening Tool (MUST) assessment was not completed within 24 hours of A's admission to hospital, the food record chart and the fluid balance chart were not completed appropriately during A's admission and A's personal centred care plan was not updated to reflect their condition. We upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not completing the MUST within 24 hours of A's admission, not appropriately completing the food record chart and fluid balance charts during A's admission and not updating A's person centred care plan to reflect their condition. 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:

• Patient intake of fluid should be accurately and timeously recorded.
• Person-centred care plans should be reviewed and, where necessary, updated to reflect the needs of 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 complained about the care and treatment that their parent (A) received during an admission to a community hospital.

A had a degenerative condition which affected their mobility and was latterly diagnosed with a form of vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain). A was admitted to hospital following a fall. C told us that A had a number of falls in hospital and suggested that one of these falls led to an injury to A's leg. C raised a number of general concerns regarding the nursing care and implied that A was allowed to become dehydrated, only drinking when assisted by family members or when family members prompted the ward staff.

C also raised concerns about the clinical aspects of A's care. C said that A became lethargic and unresponsive during their admission to hospital. Family members expressed their concern to staff that this may have been the result of sepsis (blood infection) or a urinary tract infection. However, they were reassured that A's symptoms were likely caused by antibiotics.

A suffered a heart attack. Staff performed cardiopulmonary resuscitation (CPR) and revived A. A was then transferred to a general hospital for care where A died five days later. C explained that A was uncomfortable and agitated during their final days. C said that staff there had expressed concern that no Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) had been signed for A. C complained that the additional five days of suffering that A experienced could have been avoided had a DNACPR been discussed with family members.

We found that A's condition and medical history meant that clinical staff should have considered DNACPR each time that they reviewed A. Whilst we were critical of the board for failing to do so in A's case, we acknowledged that they had already taken action to improve their procedures and ensure that the consideration of DNACPR is not left until an emergency situation develops.

We found that A had developed sepsis, likely as a result of the leg injury sustained during their admission. We noted an apparent delay of several days before the cut to A's leg was identified. However, once the nursing staff were aware of this, they appropriately escalated the situation to the clinical team. We found that no clinical review was carried out and that the nursing staff instead consulted NHS24 for advice as to how to treat A's leg. A was treated with oral antibiotics. We found that had A been reviewed in person by a member of the clinical team, the severity of their infection may have been recognised and intravenous (into a vein) antibiotics may have been prescribed. We noted an overall lack of clinical input into A's care during their admission and concluded that this led to a failure to diagnose A's sepsis.

With regard to the nursing care that A received, we found that there was a four day delay to A's falls risk being assessed and mitigated after their transfer to hospital. The number of falls A had and the severity of the harm caused increased during this time and we found that this was a clear failure to adapt to a patient's specific needs. We were critical of the board for failing to record and monitor A's leg wound in a wound chart.

Whilst we were satisfied that there was evidence of the nursing staff monitoring A's food and fluid intake, we noted that their focus was on the weekly variations in A's weight. This meant that A's significant weight loss over a longer period was not identified. Had it been, staff may have taken proactive steps to increase A's intake and increase their weight. We upheld all aspects of this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family 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:

• That the board conduct a review of the nursing care provided on A's ward and take steps to ensure that they are compliant with the relevant standards for falls risk assessment, nutritional assessment and wound care.
• The board conduct a review of the medical provision available to patients on dementia wards at the hospital and take steps to ensure that they meet the standards of inpatient care set out in the guidance from the Royal College of Psychiatrists.
• The board share this decision with the nursing staff.

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, an advocate, complained on behalf of their client (B). B's spouse (A) died of advanced lung cancer.

A started experiencing pain between their shoulder blades and was referred by their GP practice to University Hospital Hairmyres for a chest x-ray. A attended A&E at University Hospital Hairmyres on three different occasions and received further x-rays. A was admitted to University Hospital Wishaw and after undergoing further investigations, they were diagnosed with advanced lung cancer.

C complained about the clinical assessment of A's symptoms when they attended A&E. C complained that A had signed a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form during a hospital admission when they did not have capacity to understand it. B was unhappy that they had not been consulted about the DNACPR.

C also complained that communication about A's diagnosis was very poor. They complained that A was not informed that their cancer was life limiting or terminal. According to B, they were unaware of the prognosis or that A only had a short time to live.

We took independent advice from an emergency medicine adviser. We found that A's symptoms were appropriately assessed and treated during each of their attendances at A&E. We considered that A was appropriately referred for further investigation and we did not uphold this aspect of the complaint.

We also took advice from a consultant physician. In relation to communication regarding the DNACPR, we found that A's capacity was appropriately assessed and that their consent was reasonably obtained. We considered that there was no obligation for staff to discuss the DNACPR with A's family and we noted that A's admission was during the initial weeks of the COVID-19 outbreak when restrictions for visits were in place and hospitals were under considerable pressure. We did not uphold this aspect of the complaint.

We noted that there was a disparity between what clinicians thought that A's family understood regarding A's condition and what their understanding actually was, although it was not possible to say whether this was due to a communication failing on the clinicians' part or whether the family had failed to grasp what they were being told. We took into account that B said that they did not realise how ill A was until they found the DNACPR form on which it was noted that they were not expected to live more than 28 days. In recognition of the impact that this must have had on B and taking into account that A's family did not feel sufficiently informed about A's condition throughout their illness, on balance, we upheld the complaint that the board's communication regarding A's condition was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the communication failings our investigation has 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:

• This case should form part of the annual appraisal for staff involved in communicating A's condition, with training undertaken where any gaps are 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 to the practice about a failure of their GP to offer them a face to face consultation when they reported being concerned about a breast lump. C was given a telephone consultation only. C was not seen for a further three months and when they attended the breast clinic, C was diagnosed with breast cancer.

We took independent advice from a GP. We found that the GP had acted reasonably in that the plan was to review C two weeks following the telephone consultation should the symptoms not have resolved. C did not contact the practice for a number of months and when they did, appropriate referrals were made to specialists for further consideration. We did not uphold the complaint.

Summary

C complained about the board after suffering wound care complications following a caesarean section (an operation to deliver a baby. It involves cutting the front of the abdomen and womb) during the birth of their child. They considered that a number of factors meant that the board had failed to provide reasonable treatment in relation to the birth of their child.

We took independent advice from a consultant obstetrician (specialist of pregnancy, childbirth etc) and gynaecologist (specialist of the female genital tract and its disorders). We found that the board had failed to provide reasonable treatment. In particular, we found that the board failed to follow up on a phone call to ensure C's safety when a full triage could not be completed; that they had failed to ensure a timely review by a senior doctor when complications occurred; that they failed to keep reasonable records of C's care; that they failed to identify that a Significant Adverse Event Review (SAER) should have been carried out, meaning that the staff in question were unable to clearly recollect events by the time the complaints investigation was completed and additionally, that the board made insufficient attempts to establish a cause for the complication, which may possibly have been operator error or the result of faulty sutures, either of which would have required further action to ensure wider patient safety and avoid a repeat. 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 reasonable treatment relating to the birth of their child. 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 know when to suspect complications in post-caesarean wound care and escalate for review by a senior doctor as soon as possible, if indicated.
• If a triage is unable to be completed for any reason, the board should have robust procedures to ensure the safety of the patient in question.
• Sufficiently detailed records should be made of all operations carried out.
• When a wound has ruptured following surgery, the board should ensure reasonable steps are taken to invsetigate the cause of this.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

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.