Health

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.

Summary

C complained about the care and treatment provided to their late spouse (A) by the practice. A died due to invasive bladder cancer and urinary sepsis (blood infection). C complained that the practice unreasonably delayed referring A to secondary care for investigation despite presenting with recurrent urinary tract infections (UTIs) that did not respond to antibiotic treatment. C considered that A's bladder cancer may have been identified earlier, and that their death avoided, had the practice referred them for investigation much sooner.

The practice's position was that A had a long history of intermittent UTIs, which were usually treated with antibiotics. At one point, all of A's urine samples showed pus cells but a normal range of red cells, which was suggestive of simple UTIs. The early signs of bladder cancer such as blood in the urine were not apparent in A's case until a relatively late stage. The practice considered that abnormalities in A's blood results (increased platelet and white cell count) were caused by A's unrelated medical conditions.

We took independent advice from a general practitioner adviser. We noted that patients over a certain age with recurrent or persistent UTIs (i.e. three episodes in 12 months) associated with haematuria (blood in the urine) should be referred for urgent investigation in accordance with national guidelines. In A's case, they had attended the practice three times in four months with recurrent UTIs and haematuria found on dipstick testing. At this point, we found that A should have been referred on an urgent basis in line with the guidance but that the practice did not do so for a further ten months. We found that the practice had failed to identify that A's blood results showed signs of recognised malignancy and that they had repeatedly failed to record A's clinical history and review the results of investigations performed. As such, we upheld this 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:

• In view of our findings, carry out a reflective Serious Adverse Event Review (SAER) of this case which includes: a review of the failure to refer A for further investigations, including the lack of detail of their presenting symptoms and the lack of relevant clinical history in A's records; a review of the practice's result handling processes and, where issues are identified, how these are monitored and actioned by a responsible clinician; a review of the guidelines for early referral of suspected urological cancers; and a review of the failure to exclude a urine infection in relation to the care and treatment A received for a kidney infection. Information regarding a patient's care and treatment and diagnosis should be accurately recorded in their clinical records.

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's parent (A) had been treated for kidney cancer and then developed cancer of the bladder. They were receiving dialysis three times a week. The GP practice in this case is managed by the board. A developed back pain and called out a GP, who prescribed dihydrocodeine (an opiate painkiller). They remained in pain the following day and called out another GP, who prescribed diazepam (a medicine used to treat anxiety) and told A to double the dose of dihydrocodeine. After increasing the dosage of dihydrocodeine A became drowsy and unresponsive. They were admitted to hospital and transferred to the Intensive Care Unit for dialysis but did not improve and died of multiple organ failure, and presumed ischaemic bowel disease (lack of blood flow to the intestine). Their death certificate also recorded end stage renal failure and a trial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). C complained that A's GPs should not have prescribed these medications because of A's renal failure.

We took independent advice from a GP adviser. We found that each GP had assessed and treated A appropriately, taking into account their presenting symptoms and existing health concerns. We noted that A's treatment options were significantly limited by their renal failure. We found that it was appropriate to prescribe opiates, as pain control was the objective and A was due dialysis which would significantly reduce the risk of toxicity. We found that although the medications had a sedative effect, they did not cause A's subsequent death. We found some shortcomings in documentation but were satisfied that the board had addressed this matter. We found that the GP treatment provided to A was of a reasonable standard and therefore did not uphold this complaint.

Summary

C's late partner (A) tested positive for COVID-19. A's condition worsened over time and C called 111 as they were concerned A's breathing was becoming laboured. C had to wait around 20 minutes before the call was answered. Once connected, the call lasted around 30 minutes. The call handler contacted the Scottish Ambulance Service (SAS) and said that they were 'looking to arrange an immediate response for a patient'. A's condition deteriorated further and C made a 999 call around ten minutes after ending the call to 111, as assistance had not yet arrived. However, by the time paramedics arrived, A had stopped breathing and could not be resuscitated.

C complained about the length of time it took for an ambulance to arrive. They complained that paramedics did not arrive in personal protective equipment (PPE), and considered that they wasted time getting dressed outside when it was an emergency call. C also queried whether a defibrillator (an electronic device that applies an electric shock to restore the rhythm of a fibrillating heart) had been used as they could not hear any shock being administered.

We took independent advice from a paramedic. With regard to the initial call from NHS 24, we found that this had been dealt with appropriately. The call taker had assigned the request for an ambulance the correct level of priority, in terms of the SAS coding system in place at the time. Therefore, we did not uphold this aspect of the complaint. However, we noted weaknesses in the NHS 24-SAS service interaction and suggested that SAS review the process and consider making improvements if necessary.

We found that the response to the 999 call was reasonable, proportionate and timely. We noted that it would not have been appropriate to provide shock to A, given their clinical condition. We also accepted SAS' explanation as to why crew required to put on PPE when they arrived at the scene, which was necessary for infection control. We did not uphold this complaint.