Health

Summary

C complained about the care and treatment their parent (A) received from district nurses in relation to the management of sores/ulcers on their legs while resident at a care home. In particular, C complained that district nursing staff had failed to adequately monitor and treat A's sores/ulcers to such an extent that dressings would become saturated in exudate (fluid), requiring care home staff to apply further dressings. C stated that this had led to A developing significant infection requiring admission to hospital, where they died a short time later. C further complained that district nursing staff had failed to identify the deterioration in A's legs and had not alerted A's GP nor made a referral to a specialist tissue viability practitioner (a specialist in aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration).

In response to C's complaint, the board stated that A had been reviewed frequently by district nursing staff, who had not identified any signs suggesting that A's legs had become infected. The board concluded that district nursing staff had delivered consistent and appropriate care and that referral to a tissue viability specialist had not been indicated.

We took independent advice from a district nursing adviser. We found that there were a number of failings in relation to how A's sores/ulcers had been managed, specifically that wound assessments carried out were incomplete and not carried out at the required frequency and that the wound dressings used were inappropriate, often contradicting the findings of examinations, and contrary to current guidelines. We noted that district nursing staff had failed to carry out baseline observations and tests to check for the presence of infection or sepsis (blood infection) despite noting that A was as “flat” and “lethargic”. We also found that the district nursing staff's record-keeping was poor and not in accordance with relevant professional standards given there was no documented record of interactions with A on certain dates.

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.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement. The board should comply with their complaint handling guidance when investigating and responding to complaints.

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 after they were diagnosed as having a tumour in their bowel.

C underwent surgery to remove their tumour. Following the procedure, they experienced a number of complications that led to extended hospital treatment and the need to be fitted with a stoma (a surgically made pouch on the outside of the body). It was ultimately established that their surgery failed to heal properly, possibly due to a fault with an item of equipment used to staple their bowel. C complained that the issues resulting from their surgery had life-changing consequences.

C raised a number of concerns regarding the care and treatment that they received from the board at the time of their surgery and once they had been discharged. They also did not consider that the board adequately took responsibility for the issues that affected them.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). It was evident from C's complaint that they went into surgery expecting a straightforward procedure. The procedure was complicated by C's high body mass index (BMI, a measure for estimating human body fat) and took several hours longer than they had anticipated. Whilst we were critical of the board for not explaining to C that their BMI was a potentially complicating factor, overall we were satisfied that the surgery was carried out reasonably. During the procedure, the surgeon made reasonable adaptations when issues arose and there was no indication at the time of the issues that would later affect C. We were also satisfied that there was no indication at that time that there was a fault with the equipment being used during the procedure. Therefore, we did not uphold this aspect of C's complaint.

Following their surgery, C experienced a significant amount of pain. We were largely satisfied that the board's staff took this seriously and took appropriate action when it became apparent that the pain was not resolving as expected. C was ultimately found to have a leak from the site of their bowel surgery. We found that this was treated appropriately with further surgery once it was identified. That said, we found that C's symptoms should have led staff to suspect a potential leak sooner than they did. Whilst we found nothing to suggest that the outcome would have been any different for C, had staff considered a leak earlier, an earlier diagnosis could have been made and C's pain may have been relieved sooner. We upheld this aspect of C's complaint.

We found that, four months after C's surgery, the board proactively identified and investigated a cluster of patients (including C) that had experienced bowel leaks following surgery. The board concluded that there was no common factor linking these cases. Two months later, the board were advised by a medical equipment manufacturer that an item of equipment that was used during C's surgery was faulty and should be withdrawn from use. We found that there was no clear link between the faulty device and the leak that C subsequently experienced. However, we were critical of the board for not going back and reviewing the cluster of cases in the presence of the new information regarding the faulty medical device. We also found that the board could have done more to address C's questions about the situation. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in diagnosing the leak. 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 board should share this decision with the staff involved in C's care with a view to identifying any aspects of their care and treatment that could have been improved.
• The clinical team should review C's case with a view to ensuring their protocols for considering and diagnosing anastomotic leaks take account of all relevant risk factors.

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 regarding treatment provided to their late spouse (A) at the end of their life. C was concerned that the board had failed to provide A with reasonable care and treatment, and failed to manage their diet appropriately. C was also concerned about the board's recording of an incident where A fell and broke their hip, as well as that the board refused to allow A to attend a relative's funeral.

We took independent advice from an appropriately qualified clinician. We found that the board had provided reasonable care and treatment throughout, including managing A's diet appropriately and keeping a reasonable record. There was no record in the clinical notes that the board had refused to allow A to attend a relative's funeral.

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

Summary

C complained to the practice about a delay in prescribing them with medication for high blood pressure, and as a result C suffered a heart attack. C said that they had attended the practice on a number of occasions within a few months with recurring chest pains, breathlessness and dizziness. C had their blood pressure read and electrocardiograms (ECGs) taken a number of times. C saw a GP and reported chest pain and dizziness. The GP put this down to muscle spasm and arranged another ECG and blood pressure reading. C was then given tablets for their blood pressure. The following day, C was admitted to hospital to have a stent inserted as they had suffered a heart attack.

The practice explained that C had had a number of contacts within a few months, and was seen by 11 GPs. Most of the contacts related to C's respiratory problems of Chronic Obstructive Pulmonary Disease (COPD). C's blood pressure was discussed with a GP and further readings were arranged either at the practice or read by C at their home and telephoned to the practice. It was when C reported chest pain a few months later that further investigations were conducted and the decision was taken to provide antihypertensive medication (used to lower high blood pressure).

We took independent clinical advice from a GP. We found that the practice had provided a reasonable standard of treatment to C. Their blood pressure readings were monitored both in the practice and at home and subsequently, arrangements were made to prescribe medication when it was appropriate to do so. We did not uphold the complaint.

Summary

C attended hospital for gastroenterology procedures (medicine of the digestive system and its disorders). Upon waking from the procedures, C reported experiencing a painful tingling sensation in their mouth, left hand and foot. C informed the nurses of their symptoms and a consultant carried out an assessment. Following the assessment, C was deemed fit for discharge as no clinical concerns were identified. However, C's symptoms persisted upon returning home. They attended an emergency GP appointment the following morning and the GP concluded that C had had a stroke. C was readmitted to hospital for further investigations. A CT scan confirmed that C had suffered a stroke.

C complained that the board's staff unreasonably failed to identify that they had had a stroke following their procedure. We found that, whilst staff identified that C's symptoms indicated they may have had a stroke and an assessment was carried out with this in mind, the assessment was insufficiently detailed and, in light of C's presenting symptoms, further investigation by a neurologist (specialist of the nerves and the nervous system, especially of the diseases affecting them) should have been arranged. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fully consider the possibility of a stroke prior to discharging them and for failing to seek input from the specialist stroke team. 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:

• Clinical staff involved should reflect on C's case and give consideration as to where improvements could be made in their practice to ensure that symptoms of stroke are adequately investigated as soon as possible and input from stroke specialists is obtained in clinically appropriate cases.
• The board said that they would be running education sessions for all staff to raise awareness regarding early signs and symptoms for stroke and the appropriate action to take.

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 was a patient of the practice for a number of years where they were treated for thyroid (a gland in the front inside area of the neck) problems and anaemia (a deficiency in the number or quality of red blood cells in the body). C began to experience changes in their behaviour. Following an incident, the police and social work became involved and C was admitted to hospital. C was discharged the following day after a psychiatric assessment. However, C subsequently had to attend court. When gathering information for their court appearance, C obtained a copy of their medical records from the practice. Upon reviewing these, C considered that there had been failures to diagnose deficiencies of vitamin B12 and vitamin D. C also considered that there had been issues with the practice's management of their anaemia and thyroid problems and the long-term prescription of a proton-pump inhibitor (a class of medications that cause a profound and prolonged reduction of stomach acid production).

C submitted a formal complaint to the practice regarding their care and treatment and their handling of C's medical records. C said that, whilst the practice responded to their concerns about the medical records, they did not address the complaints about C's care and treatment due to the time that had passed.

We took independent advice from a GP. We found that, whilst C did have some abnormalities in their blood tests, these were relatively minor and would not have caused the behavioural changes C experienced. We found that the long-term proton-pump inhibitor prescription was reasonable and that C's thyroid problem was routinely monitored and managed. We found that the practice failed to notify C of their low vitamin D results, but concluded that the implications of this oversight were minimal. We did not uphold this aspect of C's complaint.

With regard to the practice's handling of C's complaint, we found that that their decision to rule the complaint as outwith the time limit was reasonable in the circumstances and in line with their complaints handling procedure. We did not uphold this aspect of C's complaint.

Summary

C complained about the care and treatment that their adult child (A) received from the board over a two year period. A had previously suffered an acquired brain injury and since then had developed obsessive compulsive disorder, post-traumatic stress disorder and anxiety, as well as experiencing delusional thinking and periods of psychosis (a mental disorder in which thought and emotions are so impaired that contact is lost with external reality). C raised a number of concerns, including that the board claimed A was reviewed regularly when they were not, that no psychological support was provided for A, that there was a lack of support from the local mental health team, that there was no clear local treatment plan and that in the care programme approach, needs identified were not met, matters were not escalated and no solution was found.

We took independent advice from a consultant psychiatrist (a medical practitioner specialising in the diagnosis and treatment of mental illness). We found that A's records showed that they received regular reviews during the period in question and that the letters on these showed a high level of clinical input. However, the evidence showed that there was a delay of over five months from the date of A's discharge from psychiatric hospital and the issuing of the discharge letter, which we found was unreasonable and, for a patient with less clinical/multi-professional input and family interaction, would likely have resulted in significant clinical risk.

We found that the overall level of support A received was reasonable. However, we found that there was a lack of focus by the board on the organic elements of A's presentation and how these may have contributed to their psychosis and we were critical of the board's failure to utilise locally available specialist advice which resulted in a lack of psychology and neuropsychiatric input in A's case. We found that these failings were significant and, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to focus on the organic elements of A's presentation and failing to utilise locally available specialist advice on psychology and neuropsychiatry in A's case. 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:

• In cases such as this, the board should consider organic elements of patients' presentations and utilise locally available specialist advice on psychology and neuropsychiatry.
• The board's patient discharge letters should be issued in a timely fashion.

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 they had been unreasonably removed from the practice list without prior warning due to alleged verbal abuse.

We reviewed the guidance provided by the General Medical Council (GMC), British Medical Association (BMA) and the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018. We took independent advice from a GP. While we appreciated that C disagreed that their behaviour was inappropriate, this is how the staff at the practice perceived the behaviour. This was also supported by extracts from the contemporaneous records detailing that the practice found C's behaviour to be abusive and upsetting.

The Regulations and the guidance from the GMC and the BMA indicate that a warning should be given to the patient, giving the reasons for the possibility of removal from the practice list. The only exceptions to the requirement to give a warning appear to be on the grounds of violence where the police and/or the procurator fiscal are involved, or where the practice believes that issuing the warning would put the safety of members of the practice or those on the premises at risk or it is, in the GP's opinion, not otherwise reasonable or practical for a warning to be given.

The practice decided that a warning letter did not apply due to how upset a staff member was. We found that the practice appeared to have taken the view that issuing a warning to C would not be appropriate due to the impact of this incident on the member of staff. We found that the practice acted reasonably (by requesting C's immediate removal from the practice list) and within established rules for removing a patient from the list.

We did not uphold C's complaint.

Summary

C complained about the care provided by the board to their parent (A) whilst admitted at Glasgow Royal Infirmary. A had been admitted with low blood iron levels and a two-week history of back pain, queried to be a spinal fracture of osteoporotic (weakened bones) or pathological (caused by a disease) origin. Following A's admission, they suffered a “controlled fall”. Twelve days later, A complained of being unable to move their legs. An MRI scan of the spine was carried out, which confirmed that A had suffered a fractured vertebra causing spinal cord compression affecting A's ability to move their lower limbs and control bowel and bladder functions. A was subsequently treated conservatively due to their age and comorbidities.

C complained about the circumstances surrounding the fall A suffered and that staff had not recorded details of the incident under the Datix reporting system as required. C considered that A had sustained the spinal injury during this incident and that the lack of Datix report meant that there had been a delay in identifying the injury.

The board accepted that a Datix report had not been completed as required at the time of A's fall but that this had not prevented A from being assessed. The board also stated that a Datix report had been completed retrospectively and that the incident had been reviewed by the hospital falls team. The board stated that it was not believed that A's fall had caused the spinal fracture, which may have been present in advance of A's admission.

We took independent advice from consultants in emergency and general medicine. We found that despite A presenting to the A&E with a queried spinal fracture, no neurological examination was carried out nor was any consideration given to performing an X-ray of A's spine. This was unreasonable practice. In addition, the board's failure to complete a Datix record of the fall A suffered was also unreasonable although it was impossible to say with any certainty that this incident had caused A's spinal fracture.

We found that the board were unable to produce any evidence to show that a Datix record into A's fall had been completed retrospectively or that the incident had been reviewed by the hospital falls team.

In view of the above failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably failing to carry out a neurological examination of A, for not considering whether an X-ray of A's spine was required following their presentation to the A&E at Glasgow Royal Infirmary and for providing inaccurate information in their complaint response. 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:

• In patients who present to A&E with new onset back pain, a neurological assessment should be performed as part of baseline medical examinations. Where the cause of new onset back pain in patients is suspected to be an osteoporotic or pathological fracture, consideration should be given to performing X-ray imaging to investigate the possibility. Any decision not to proceed with X-ray imaging, should be documented in the clinical records.

In relation to complaints handling, we recommended:

• The board should ensure that information provided in response to complaints is factually accurate and that, where the board has confirmed specific actions have been taken in response to a complaint, evidence of this can be provided.

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 was concerned about the care and treatment that their late spouse (A) received at Inverclyde Royal Hospital following a surgery for a hip fracture. C complained that A did not receive appropriate post-operative rehabilitation and physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery). We took independent advice from a physiotherapy adviser. We found that the physiotherapy assessments and treatment were appropriate. Therefore, we did not uphold this aspect of C's complaint.

C also complained about the nursing care that A received. In particular, C was concerned that proactive steps were not taken to prevent A falling and that A was not supervised to take their medication. We took independent advice from a nursing adviser. We found that the board acted reasonably by implementing appropriate and proportionate actions to mitigate the risk of A falling. However, there was no record that A was supervised to take their medication and this was unreasonable given A's cognitive impairment and physical frailty.

In light of the above, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not supervising A taking their medication. 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.