Health

Summary

C complained about the care provided to their late parent (A).

The practice visited in the morning and found them to be coherent and capable of declining a full examination. A's carers left around midday and did not have any specific concerns about A. By the evening, A's condition had deteriorated and they were taken to hospital. A died two days later.

We took independent advice from a GP adviser. We found that there was evidence of appropriate communication between the GPs and other professionals and agencies involved in A’s care. Therefore, we did not uphold the complaint.

Summary

C complained about the care and treatment provided to their late adult child (A). A had been admitted to hospital from police custody due to cellulitis in their hand. A was monitored overnight and discharged the following day. A was readmitted several days later following a cardiac arrest. On resuscitation, a cannula (a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples) was found in A’s arm dated the day of their initial admission. A’s condition deteriorated and they died a few days later.

C was concerned that A’s mental health issues were not taken into consideration and that it had been unreasonable to discharge A without these being assessed. C also believed it was unacceptable for A to have been discharged with a cannula in place given A’s known drug misuse. C believed that these failings led directly to A’s death as they had used the cannula to administer drugs immediately before suffering a cardiac arrest.

The board had carried out an Adverse Event Review (AER) following C’s complaint. This found a number of failings in A’s care. It made recommendations to try and address these.

We took independent medical advice from a consultant in emergency medicine. We found that there had been a full investigation of the case. The key learning points had been identified and actions were being taken to reduce the likelihood of a similar incident occurring in future. There was no evidence of failings which had not been addressed by the AER.

We upheld C’s complaints due to the acknowledged failings in A’s care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in the care and treatment, and discharge processes, in relation to A’s admission to hospital. 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 to the board about the care and treatment provided to their late parent (A) regarding hip problems they suffered.

A was admitted to hospital with worsening mobility having suffered a number of recent falls. Under the care of older people’s services they were reviewed by occupational therapy and received physiotherapy, before being moved to another hospital for rehabilitation. A month after being discharged, A was readmitted and underwent an X-ray CT scan. A was initially diagnosed with a broken femur. A underwent hip replacement surgery and passed away a month later.

C complained that despite being informed by the board that A had sustained a fracture of their right femur, possibly present some years prior, they were later told that A had not sustained a fracture. Nevertheless, A’s death certificate had recorded a fracture of the right femur as one of the causes of death. This confusion caused the family significant anxiety. In their complaints response the board concluded that junior medical staff had been responsible for misdiagnosing A and apologised for the miscommunication. They also apologised for the misdiagnosis having been included on A’s death certificate.

We took independent advice from a medical adviser with expertise in orthopaedics (treatment of diseases and injuries of the musculoskeletal system), and further advice from a radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that while A did not have a broken femur, the board had failed to act upon a CT scan taken some years previously that showed A was suffering from significant arthritis which therefore went untreated over the subsequent years. Additionally, the board had emphasised the role of a junior doctor in misdiagnosing the fractured femur despite the involvement of more senior management in signing off on this diagnosis. In view of these specific failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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:

• Care should be taken by staff to ensure that patient records are correct and as full as they can be. Where discussions have taken place what was said should be documented. A’s case should have been discussed at the board’s Radiology Events and Learning Meeting (REALM). If this had not happened they should happen in order to highlight the importance of reporting significant osteoarthritis as an incidental finding, if it has not been depicted on prior imaging.
• The board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement.

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 a close family member (A) had received from the practice. A was admitted to hospital having suffered a heart attack and stroke. On further investigation masses were found on both of A’s ovaries, later confirmed to be ovarian cancer. A died a short time later.

C complained to the practice that they had not given proper consideration to A’s presenting symptoms and had missed opportunities to identify A’s cancer and start treatment sooner. C also complained that the practice had not given appropriate consideration to the family’s history of breast cancer or undertaken CA125 testing (blood test to check for raised levels of a protein called CA125, which is linked to ovarian cancer).

The practice apologised for being unable to detect A’s cancer at an earlier stage, noting ovarian cancer often only presents at a very advanced stage which had been the case for A. They explained a CA125 test had not been checked as the clinical information available at that time had not suggested malignancy. They also noted that a family history of breast cancer would not directly predispose to a risk of ovarian cancer in the absence of evidence of BRCA gene (specific mutations to this gene increase lifetime risk of cancer) positivity. They did not identify any substantive failings in A’s care and treatment, but agreed to use A’s case for reflective learning.

To investigate the handling of this complaint, we sought independent advice from a GP. We found that CA125 testing is not an effective screening tool for ovarian cancer. While A’s initial presentation at the practice had met the National Institute for Health and Care Excellence (NICE) criteria for considering checking CA125 levels, A had undergone further gynaecological review a few months later, which had suggested no evidence of an abdominal pelvic mass. Overall, we considered that the practice had not acted unreasonably in not identifying A’s malignant diagnosis prior to their presentation with a heart attack and stroke. Therefore, we did not uphold C’s complaint.

We did, however, provide feedback to the practice. We asked the practice to ensure relevant staff were familiar with the NICE criteria for considering checking CA125 levels, as well as the significant limitations of this test.

Summary

C complained on behalf of their spouse (A) regarding the care and treatment A received from the board. A has serious health issues and has had multiple surgeries over a number of years.

Following a scan of A’s abdomen, it was identified that they had staples attached to their bladder. A considered that these had been left behind following surgery to remove their J-pouch (a pouch made from part of the small intestine and attached to the anal canal to form a pathway for the passage of stool). C complained that A experienced recurring infections and other complications as a result of the staples being left in their abdomen. A said that these had a detrimental impact on their long-term health.

We took independent advice from a general and colorectal surgeon (specialist in conditions in the colon, rectum or anus). While it was not possible to establish exactly which operation the staples came from, we considered that the staples were a likely source of A's infections. We found that the staples were clearly visible on previous scans but that these had not been reported on by radiology and therefore the clinical team did not consider these when they were assessing A’s likely source of infection and future treatment. Therefore, we upheld this aspect of C's complaint.

C also complained about the handling of their complaint. Whilst we found that there were some delays to the board’s investigation, we recognised that many years had passed between the events complained about and the complaint being submitted to the board. This meant that some issues were reasonably time-barred and some parts of the investigation were delayed due to difficulties sourcing the records and staff comments. Overall, we were satisfied that communication was generally reasonable with C and A, and that the board’s complaints procedure was followed appropriately. Therefore, we did not uphold 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.

What we said should change to put things right in future:

• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when handling a complaint.
• The board should share this decision with their radiologists as a reminder of the importance of fully reporting on scans to reduce the chances of important omissions.
• The board should share this decision with their surgical team with a view to ensuring that the origin of infection is included when considering treatment of chronic infection.

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 medical and nursing care their late parent (A) received. A attended hospital for a bronchoscopy (a procedure to look directly at the airways in the lungs using a thin, lighted tube) and a biopsy (a medical test to determine the presence or extent of disease). A became unwell and was admitted. The biopsy result confirmed that A had cancer. It was considered A was not fit for treatment and a palliative approach to care was recommended. A’s condition worsened and they died in hospital.

C complained about aspects of A’s care and treatment. C also complained about the communication from medical staff. The board did not uphold C’s complaint but apologised because they felt that communication had been poor. C remained unhappy and escalated the complaint to us.

We took independent advice from a specialist in general medicine and in acute nursing. We found that A’s care and treatment was reasonable. We also found that the communication with C and A was reasonable. Therefore, we did not uphold C’s complaints. However, we did provide the board with feedback on telephone updates to patient’s families.

Summary

C complained about the care and treatment their spouse (A) received over a number of years by the board.

C submitted a complaint to the board expressing A’s concern that they did not take reasonable care when carrying out two surgeries. C and A were dissatisfied with the board’s investigation and response to their complaint.

A underwent surgery in their abdomen in an attempt to resolve recurring infections and said they suffered significant pain afterwards. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We were satisfied that this surgery did not cause the pain that A had linked to the procedure. However, we were critical of the board for failing to recognise that scans taken prior to the surgery had shown evidence of staples in A’s abdomen from previous surgeries. We found that the staples were a likely source of A’s infections and that this should have been identified prior to the surgery taking place. Had it been identified, A’s management plan may have been different. Therefore, we upheld this aspect of C’s complaint.

A also underwent a procedure on their reproductive organs. C complained that the procedure that was carried out, as described in the record of the operation, was not the one to which A had consented. We found that it had not been possible to complete the planned procedure due to an issue in the affected area, which had not been apparent until the procedure began. Whilst we were critical of the way that the procedure was described in the records, we found that the procedure itself was reasonable and appropriate in the circumstances. Therefore, we did not uphold this aspect of C’s complaint.

C and A complained that despite the board’s complaints procedure stating that complaints could be submitted in writing, in person, or over the telephone, the board insisted that A’s complaint was submitted in writing. A explained that they found it difficult to put their complaint in writing and had specifically requested a meeting with the board to discuss their concerns. This request was denied. We found that although there were reasonable reasons for asking A to submit the complaint in writing, these were not explained clearly by the board, and A was given no explanation as to why their request for a meeting was refused. We were critical of the board’s communication with C and A regarding the complaint, and of delays in the early stages of the board’s investigation. 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 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.

What we said should change to put things right in future:

• The board should share this decision with the clinical staff involved in A’s treatment with a view to identifying ways of avoiding similar issues in the future.

In relation to complaints handling, we recommended:

• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when they make a complaint.

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 the board provided their late parent (A) with inadequate care and treatment when they were an in-patient in hospital.

C complained to the board that they had failed to provide A with adequate personal care, nutrition and hydration. C also complained that the board had failed to accommodate A’s disabilities. The board identified failures in A’s care and apologised for these. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that more consideration should have been given to A’s minimal fluid intake, and the impact of this in terms of delirium and escalation to medical staff. In addition, we found that it appeared that more could have been done to support A in relation to their toilet needs.

Therefore, we upheld the complaint.

Additionally, we found that the board did not provide C with sufficient explanations related to the learning and improvement taken from A’s experience. We also found that the board had delayed in providing C with copies of minutes from a meeting and that no appropriate apology had been made for this. We made recommendations in light of these failings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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:

• Where a meeting with a complainant is held to discuss their concerns, the meeting should try to ensure that full explanations of what occurred and of any learning and improvement action being taken as a result are provided to the complainant at the time. Following up on a meeting with a copy of the minutes of that meeting and the board’s final response letter should be issued to the complainant as soon as possible thereafter.

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 Scottish Ambulance Service (SAS) on behalf of A for whom they hold welfare Power of Attorney. A waited for an ambulance for nearly 21 hours. A has multiple sclerosis (a disease that affects central nervous system), lives in a care home and usually has a catheter (a thin tube used to drain and collect urine from the bladder). The catheter was not working and there was concern that A had an infection.

C was unhappy with the delay as A had a known history of sepsis (blood infection) as a result of urinary infections. C also said that A’s case had been incorrectly prioritised, that they had received only two calls from SAS during the wait, and that the overall time waiting for the ambulance had been unreasonable.

We found that A’s case had been correctly triaged and prioritised by SAS clinical support desk paramedics, however, we noted that SAS did not meet their own standards for the frequency of welfare calls but recognised that the service was under extreme pressure at the time. We upheld the complaint that the ambulance response time was unreasonable as it had taken nearly 21 hours to attend the patient, which significantly breached the 60-minute target for cases like A’s.

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 on behalf of their client (B) about the care and treatment provided to B’s late sibling (A). A had attended the A&E in mental distress, had attended their GP the same day, and had a hospital appointment with the crisis team a few days later. At this appointment it was considered that hospital admission was not required. A completed suicide a short time later. B felt that the board had failed to provide reasonable care and treatment to A.

We took independent advice from a mental health nursing adviser. We found that the board had carried out a detailed review of A’s care and had taken some action which was reasonable. However, we found that the risk assessment carried out by the board when A presented at A&E lacked transparency and rigour. The assessment carried out a few days later provided more detail, however, it lacked a structured risk assessment and the clinical reasoning behind not offering any ongoing planned follow-up and the weighing of current and historical risk indicators against protective factors was not fully transparent. The record keeping of the risk management decisions was also not sufficient to show the way in which risks factors and protective factors were balanced. We also found that it was unreasonable that the board’s administrative systems resulted in an erroneous early diagnosis of borderline personality disorder being recorded. We found that the Adverse Event Review process did not appear to attempt to establish why things occurred as they did, rather than simply establishing what occurred. Therefore, we upheld the complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for failing to provide reasonable care and treatment to A. 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:

• Processes for risk assessments should ensure that information is gathered from all professional and non-professional sources, and that decision-making is a transparent, structured process based upon best possible evidence.
• The AER process should explore the influence of factors such as systems and processes, supervision, team-working, management decision-making, patient factors, resources, training, and policies / protocols in order to establish why things occurred as they did.

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.