Health

Summary

Mrs C complained that communication from staff and the care provided to her husband (Mr C) in Caithness General Hospital were inadequate. Mr C had been taken to A&E after collapsing, and although Mrs C thought he had symptoms of a stroke, he was discharged. The board said that this was because Mr C did not want to stay in hospital overnight. He suffered a significant stroke shortly afterwards. Mrs C also complained about the nursing care after her husband was admitted to hospital, saying that when visiting him the next day she found him in a side room, lying on a mattress on the floor. She was distressed that Mr C's dignity was compromised, as he was not wearing pyjama bottoms.

After taking independent advice from one of our medical advisers and our nursing adviser, we upheld all Mrs C's complaints. We found that the junior doctor and the consultant physician involved did not give enough consideration to Mr C's diagnosis, particularly to the likelihood that he had suffered a minor stroke. Had they done so, it might have led them to have assessed the risk of this happening again and provided treatment if appropriate. However, our medical adviser pointed out that the outcome for Mr C might not have been different even had he been admitted to hospital at the start.

Although both the nursing staff and the doctors had indicated in the clinical records that Mr C did not want to stay overnight, there was no clear written information to show that they had recommended that he should be admitted before having an urgent scan in the morning. As the doctors had not indicated what they thought was wrong with Mr C, he would not have been aware of any potential risks in being discharged. We considered that the communication with Mr and Mrs C fell below a reasonable standard. We also found that the nursing staff should have told Mrs C before she visited that they were nursing Mr C on a mattress on the floor, to reduce the likelihood of him falling out of bed. The board had acknowledged that his care in terms of his dignity was unreasonable and had taken steps to address this with relevant nursing staff.

Recommendations

We recommended that the Board:

• draw to the attention of the junior doctor and the consultant physician our findings in relation to the lack of consideration given to Mr C's initial diagnosis;
• draw to the attention of the junior doctor and the consultant physician the importance of ensuring that communication about likely diagnosis is clearly explained to patients and their families where appropriate; and
• apologise to Mr and Mrs C for the failings we identified in Mr C's care.

Summary

Miss C has suffered from acne for a number of years. She complained to us that the medical practice had failed to offer appropriate support and treatment for her condition. She had asked to be referred to an endocrinologist (a specialist in a branch of medicine dealing with hormones) but the practice had refused and offered to refer her to a psychologist. We reviewed Miss C's medical records and found that over a prolonged period the practice had carried out appropriate assessments and had sought specialist opinions in an effort to manage her condition.

Summary

Ms C, who suffers from mild cerebral palsy and epilepsy, complained that when she attended the Western Infirmary Glasgow following a fall, staff failed to take her concerns seriously and discharged her without taking an x-ray of her left knee. Ms C says she was told to carry out exercises, which she did, but the pain worsened and she returned to the hospital three days later to be told, following an x-ray, that her left knee had suffered a fracture.

In response to Ms C's complaint, the board apologised for the delay in the diagnosis of a left knee fracture and told Ms C that the member of staff involved had been asked to reflect on her practice and attitude. We contacted the board and were told that they had upheld Ms C's complaint that staff had not carried out an x-ray when Ms C first attended the hospital and that advice should had been sought from a senior member of the medical staff. The board also said that the member of staff involved did not follow recognised protocol and that all staff are required to have an up-to-date Knowledge and Skills Framework and a Personal Development Plan, both of which are used to ensure that staff are kept up to date in their clinical practice. We found that the board's response to Ms C was lacking in specific detail and did not make clear that her complaint had been upheld. The board's response also failed to include information about what action had been taken to prevent a repeat occurrence.

Recommendations

We recommended that the Board:

• apologise to Ms C for failing to make clear that her complaint was upheld and that appropriate action had been taken to help prevent a similar situation occurring in future.

Summary

Mrs C complained on behalf of her mother (Mrs A) that staff at Inverclyde Royal Hospital provided inadequate care and treatment to her. Mrs C also complained that communication from hospital staff was not good enough. Mrs A had started taking antibiotics for a urinary tract infection two days before admission, and was admitted to the hospital with increasing confusion. Mrs C was particularly concerned about a fall her mother had in hospital, as well as treatment for Mrs A’s confusion.

We received Mrs A’s medical records from the board, and took independent advice from our nursing adviser. There was no dispute that Mrs A fell; what was disputed was the reason for the fall. In this case, we could not resolve the dispute given the differing accounts of what happened, although that did not mean we believed one version over another. In Mrs C’s view, the fall was not addressed properly. The medical records showed that Mrs A was assessed after the fall, and no major injuries were found. Our adviser’s view, which we accepted, was that the care provided to Mrs A was reasonable in the circumstances. Based on the available evidence, we concluded that hospital staff provided adequate care and treatment to Mrs A.

The board said they should have phoned Mrs C earlier to tell her about Mrs A’s fall, and they apologised for this and reminded staff of the importance of keeping patients and relatives informed. We found evidence in the medical records that staff spoke to Mrs C regularly during Mrs A’s stay in hospital, and that they were aware Mrs C was unhappy. Our adviser observed that staff could have tried to offer more support to Mrs C when she was visibly upset. However, we decided that, on balance, communication from hospital staff to Mrs C was adequate in the circumstances.

Although we did not uphold Mrs C’s complaints, we made recommendations to address specific concerns raised by our adviser.

Recommendations

We recommended that the Board:

• reflect on this case, as part of ongoing improvements, to ensure that an appropriately detailed approach is taken to care planning to help manage delirium; and
• reflect on this case, as part of ongoing improvements, to ensure that staff provide support to relatives of patients with delirium.

Summary

Mrs C complained to us on behalf of her husband (Mr C), following a consultation at the A&E department of the Royal Alexandra Hospital. Mr C went to A&E a few days after a fall, as he was suffering from back pain. He was examined by a consultant in emergency medicine, who concluded that the back pain was an exacerbation of a pre-existing problem. The consultant told Mr C to continue with pain relief and return if symptoms persisted or got worse. Mr C was eventually diagnosed with a fracture to one of his vertebrae.

We took independent advice from a consultant in emergency medicine, who considered the examination that Mr C had at his consultation to be reasonable, though he noted that it did not consider Mr C’s range of movement or any associated pain. Our adviser said that, when examining older people, doctors should have a low threshold for considering whether an x-ray is necessary, but that the decision should still be based on clinical judgement. However, he concluded that the decision not to x-ray Mr C had been reasonable in this case, given the findings of the consultant's examination.

The board apologised to Mr and Mrs C that an x-ray had not been requested, and said that they had raised this issue with staff, and reminded them of the need to particularly consider whether an x-ray is needed when an older person is examined.

On the basis of the advice we received, we considered that Mr C’s care and treatment had been reasonable. The board had already taken action, and there was nothing further we could achieve.

Summary

Ms C complained that, during a consultation at her medical practice, her GP asked her whether she was paranoid. She found this distressing and the GP's approach to be blunt and unprofessional. The GP had discussed referring her to the local community mental health team, but Ms C indicated that she did not want this. The police contacted her three days later and she was admitted to hospital under a compulsory treatment order (an order that allows professionals to treat a person's mental illness). Ms C then complained to us that her GP had referred her to psychiatric services against her wishes.

After taking independent advice from one of our medical advisers, we found that, although Ms C's GP had discussed a possible referral to psychiatric services, no referral was actually made and no confidential information was shared with the community mental health team.

Summary

Ms C was admitted to Leverndale Hospital under a compulsory treatment order (an order that allows professionals to treat a person's mental illness). She was assessed by a consultant psychiatrist as suffering from paranoid psychosis (a form of delusional disorder). Ms C disagreed with this assessment and was concerned that the psychiatrist had rushed to a judgement based on little evidence. She believed he was reluctant to be seen to disagree with one of his senior colleagues who had assessed Ms C at home before her admission. Ms C was also concerned that the psychiatrist's assessment was based, in part, on incorrect information the police gave him, which he failed to challenge. Ms C said that she later learned that the psychiatrist had intended to discharge her around 11 days earlier than he eventually did.

During our investigation, we took independent advice from one of our medical advisers, who is a psychiatric specialist. We accepted their advice that Ms C's assessment, diagnosis and treatment were all reasonable. We also found the timing of Ms C's discharge to be appropriate and that she was allowed out of hospital on a limited basis before this, in line with accepted practice. We found no evidence to suggest that an earlier discharge date had been considered.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), whose late brother died during an investigative procedure in Glasgow Royal Infirmary. The complaint was about the way the board investigated Mrs A's complaint about her brother's care and treatment.

Mrs A complained to the board in July 2012 and two weeks later she and a friend met with members of the clinical, nursing and complaints team staff to discuss her concerns. Mrs A expected to receive a copy of the meeting notes shortly afterwards, but this did not happen. She chased this up over the next few weeks but did not receive the notes until October that year.

When Mrs A reviewed them, she found several inaccuracies and omissions according to her recollection of the meeting and sent the board a list of these in early November. She asked them for a final written response, so that she could escalate her complaint to us if necessary. This did not happen, although she had several more contacts from the board. Mrs C eventually complained to us in October 2013. The board eventually, and only after our intervention, provided an amended copy of the notes. Mrs A still thought that there were inaccuracies and omissions, and was confused by conflicting information about the board's process for investigating significant clinical incidents and how they are reported on the NHS system (known as Datix).

In response to our enquiries, the board said that the complaint file was closed in error after the meeting, so no automatic reminders were sent to the complaints team or the clinical staff involved in the complaint about the outstanding meeting notes.

Our investigation found that the board had not complied with the timescales in their own complaints handling procedure. We were concerned at the time taken, firstly to produce the meeting notes, and then to correct them. We were particularly concerned that we had to intervene before the amended notes were issued. It was also of concern to us that when Mrs A contacted senior members of staff because she had not received any response from the complaints team, they did nothing to progress this or assist Mrs A. We noted that the members of the clinical team that Mrs A contacted did not respond to her because they assumed the complaints team would do so.

Recommendations

We recommended that the Board:

• issue a written apology for failing to notify Mrs A of her right to complain to this office and the inconsistent explanations she received about the significant clinical incidents policy;
• take steps to review their procedures for preparing and issuing notes of complaints meetings to ensure they are issued to complainants as soon as possible after the meeting and that they address any concerns about accuracy appropriately at the time; and
• review the current Datix form and consider how best to reflect the outcomes for incidents which, following initial review, do not escalate to full investigation.

Summary

Ms C and her partner (Mr C) complained to us about the failures in communication from staff at Aberdeen Maternity Hospital following the death of their baby. The failures included a lack of postnatal checks; being given a damaged keepsake memory box; a failure to inform their GP of the circumstances; appointment letters for baby checks sent following the baby's death; and delayed contact by the community obstetric team.

The board had apologised to Ms C and Mr C and had taken action in an effort to prevent a repeat occurrence happening to another family. We gave the case considerable consideration and upheld the complaint. However, we were satisfied that as the board had apologised and had taken appropriate action following the complaint by amending procedures, no additional recommendations were required.

Summary

Mr C, who is a prisoner, complained that the prison health centre had unreasonably failed to explain why his complaints were being managed in line with NHS Scotland's policy for dealing with habitual and vexatious complaints. In response to our enquiries, the board confirmed that the prison health centre inappropriately applied the incorrect version of a national policy and said that the decision to manage his complaints in line with that policy had now been revoked.

In addition, Mr C said the board failed to respond appropriately to his complaint about the decision to manage his complaints in line with the policy. In response to our enquiry, the board said that they were not in a position to confirm that the steps taken by the prison health centre in responding to Mr C's complaint were appropriate, given that the prison health centre had implemented the incorrect policy.

In light of the information available, we upheld Mr C's complaints.

Recommendations

We recommended that the Board:

• take steps to ensure staff within the prison health centre are fully aware of the correct complaints policy and its procedures.