Health

Summary

Miss B and Miss C complained that the nursing and physiotherapy care and treatment given to their mother (Mrs A) in hospital was inadequate. They said that although their mother had advanced dementia she had been living an active life. Although not independent, she had been fully mobile unaided, eating by herself, interested in her surroundings and reading and talking. However, after she was discharged from hospital she had a urine infection and pressure ulcers on her heels. She was immobile, and no longer able to swallow tablets or eat solid food. She also took little notice of her surroundings and did not talk. Her daughters believed that this was a result of what happened in hospital.

Our investigation considered all the relevant documentation, including the complaints correspondence and Mrs A's medical records. We also obtained independent advice from two of our advisers (a nursing adviser and a physiotherapist). We upheld the complaint, as our investigation found that there were aspects of Mrs A's care and treatment that were unsatisfactory. A care plan should have been put in place when Mrs A's heels became discoloured. Although we found no evidence that Mrs A developed a urine infection while in hospital, we found that her medical records lacked detail. The content of the physiotherapy treatment provided was appropriate, but the frequency of treatment was not. It was not in accordance with Scottish Intercollegiate Guidelines Network (SIGN) guidelines and was inadequate, although our adviser noted that the outcome was unlikely to have been different even with more sessions. We also found that Mrs A's overall management and treatment lacked documented evidence of planning and what was done. There was also no documented evidence of discharge planning or contact with community physiotherapy about follow-up treatment.

Recommendations

We recommended that the board:

• provide the Ombudsman with a copy of the board's own implementation plan relating to the national standards for dementia care implemented in 2011;
• undertake an audit of current practice of skin care in the hospital and report back to the Ombudsman;
• provide the Ombudsman with a copy of an action plan to illustrate learning from this complaint in relation to the prevention and management of pressure ulcers;
• provide the Ombudsman with a copy of an action plan to address the failings identified in relation to medical records;
• apologise to Miss B and Miss C for the failings identified;
• review their processes to ensure that they meet relevant standards;
• remind physiotherapy staff of the need to maintain full and accurate records in line with the Chartered Society of Physiotherapy guidance; and
• bring the issues raised in this complaint to the attention of the physiotherapy staff involved to see if lessons can be learned, and report back to the Ombudsman.

Summary

Mr C complained that he had raised concerns with the board about the service provided by his local community pharmacy, and that he was dissatisfied with their response. We did not, however, uphold his complaint as we found that the board treated Mr C's concerns seriously. They spent a considerable amount of time trying to resolve them and sent him comprehensive responses, after seeking advice from appropriate sources both internally and externally.

Summary

After an accident, Mr C was admitted to the emergency department at University Hospital Ayr with a suspected broken collarbone. He was in severe pain and had been given pain relief by ambulance paramedics. The medical records showed that he was placed in an 'urgent' triage category, with a target time of having a medical assessment within one hour of admission. (Triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are.) However, Mr C was not assessed by an orthopaedic doctor (dealing with conditions involving the musculoskeletal system) until several hours later. The doctor ordered an x-ray and while at the radiology department, a healthcare professional adjusted Mr C's position and he felt a shooting pain. After the x-ray was taken, Mr C said the doctor told him that he had no broken bones, and that the arm might have been dislocated, but popped back into place. Mr C was told to take pain relief and soak in a hot bath, and was discharged with pain relief medicine an hour later. Nine days later, he returned to work. The next day, while involved in manual labour, he suffered a further injury and went back to the emergency department. Tests showed that he had a fracture of the neck of the shoulder blade.

Mr C complained about the time it took before he saw a doctor on his first visit, and said that the doctor did not make him aware of the severity of his injury. Mr C also said that although the board said in their response to his complaint that the use of a sling had been discussed with him and that he had a full range of movement when he left hospital, he did not agree with this. He said that he had felt relief when he returned from x-ray, but this was due to the medication. Mr C also complained about the board's complaints handling.

After taking independent advice from one of our medical advisers, we found that Mr C's wait was well within the national target timescale (four hours from admission to completion of management), particularly as dislocation of the shoulder was not initially suspected and there was no evidence to support that it had been dislocated. We also noted that, while Mr C was waiting, the emergency department had to deal with three emergencies that required more immediate medical attention than he did. Our adviser said that the care and treatment and discharge advice Mr C received was reasonable. An x-ray was performed (the results of which the adviser said were normal), and an assessment of the range of movement in the shoulder was carried out and noted. The advice Mr C received when he was discharged was, therefore, reasonable in light of the evidence of his injury, as was the doctor's decision not to provide a sling. In view of all of this, we did not uphold Mr C's complaints about his care and treatment.

We did, however, uphold the complaint about the board's complaints handling. We found that there were delays and that they did not respond all the elements of Mr C's complaint. We were also concerned that Mr C was not told that he could approach us (as he should have been) when the board contacted him about the delay in responding to his complaint.

Recommendations

We recommended that the board:

• review their complaints handling process in the light of our findings, and raise the shortcomings identified with relevant staff; and
• apologise to Mr C for their failure to fully address the complaint he raised.

Summary

Mrs C complained about the care and treatment she received for her back condition at a clinic at Ayrshire Central Hospital. She said that their treatment of her painful condition was unreasonable, and was unhappy that she was referred to a specialist hip orthopaedic consultant whom she thought did not specialise in the right area for her condition.

We obtained independent advice on this case from two of our medical advisers - a physiotherapist with a specialist interest in spinal conditions and an orthopaedic surgeon with specialist interest in lumbar spine problems. Our physiotherapy adviser explained that the main source of Mrs C's pain was not clear, and that the treatment offered and the clinical pathway followed was reasonable in these circumstances. He said that the guidelines the clinic used were in line with clinical practice and national guidelines. Mrs C was clearly in considerable pain for many months and we fully acknowledged that any delay in receiving treatment would have been very distressing and debilitating for her. However, based on the advice received, we were satisfied that the clinic's care and treatment was reasonable and in line with national standards.

Our orthopaedic adviser explained that Mrs C's pain symptoms were not typical of the type of nerve root problems that were identified on an MRI scan she had (a scan used to diagnose health conditions that affect organs, tissue and bone) but were more typical of hip pain. He, therefore, thought that the initial referral to the hip consultant was appropriate. He said that Mrs C did not have any red flag symptoms (symptoms that would have suggested a very serious underlying cause) and so an MRI referral was, correctly, not considered appropriate. He concluded that the nerve damage identified on the scan was not of a type that should have led to a change in her referral pathway and that it was appropriate for her to continue to see the hip consultant in the first instance. Based on the advice received, we concluded that the board's actions in making and maintaining Mrs C's initial referral to the consultant were appropriate.

Summary

Mr C complained to the board that he had concerns about the validity of an application to provide a community pharmacy in his local area. The board responded that the applicant had fulfilled the criteria to allow the application to proceed to the next stage of the approval process. Mr C complained to us that the board failed to address his concerns about the competency of the application.

We found that, technically, the board had acted in accordance with the procedures although we did think that they could have provided Mr C with additional information - ie that his concerns would be considered by the committee considering the community pharmacy application in due course.

Summary

Mr C's son (Mr A) had been suffering from headaches and vomiting for several days. When Mr A's condition got worse, Mr C took him to the emergency department at Perth Royal Infirmary. They arrived at 01:17, and at 01:29, a triage nurse assessed Mr A and gave him paracetamol (triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are). She arranged for Mr A to see an out-of-hours GP in the department at 03:15, and, without having taken any observations (temperature, blood pressure, pulse and oxygen levels) sent him home to wait for that appointment. After arriving home, Mr A's condition deteriorated further, and he could not move his neck or lift his knees. Mr C returned with him to the hospital at around 03:00, where Mr A saw a GP and was admitted to a medical ward at 03:36 with suspected meningitis, which was confirmed by tests. He was treated with antibiotics and discharged a week later.

Mr C complained that the board failed to provide Mr A with a reasonable standard of care and treatment, in that the triage nurse failed to take any observations and recognise the seriousness of Mr A's condition. He also said that the delay of two hours between Mr A being seen by the nurse and by the GP was not reasonable in light of the serious and potentially life-threatening disease Mr A was suffering from. He complained that the board failed to respond appropriately to the complaint, including that they failed to adequately explain why the nurse did not undertake observations when she examined Mr A.

We took independent advice on this case from our nursing adviser, who said that the care and treatment Mr A received from the triage nurse fell below a reasonable standard. She did not carry out a set of observations, which meant that her decision to refer Mr A to the out-of-hours service was based on minimal information that might have resulted in his further deterioration. The adviser was also critical that Mr A was not allowed to remain in the emergency department and instead was sent home. These failings made a stressful situation more difficult for the family, given Mr A's serious condition. In relation to complaints handling, we were satisfied that the board provided as full an explanation as they could in the circumstances, but in light of the delays, inaccuracies and use of technical terms in the complaint response, we upheld the complaint.

Recommendations

We recommended that the board:

• review the triage process and provide evidence that appropriate protocols and/or guidance are in place;
• take steps to ensure nursing staff in the emergency department at the hospital carry out observations and document patients' vital signs during triage, and report back to the Ombudsman the actions taken;
• provide evidence that their processes ensure staff involved in triage have the appropriate education, training, skills, competencies and adequate supervision in place to provide a reasonable standard of care;
• consider the failings identified to ensure that future responses are appropriate; and
• apologise to Mr C for the failures identified.

Summary

Mr C, who is a prisoner, complained that the prison health centre stopped his prescribed medication without any warning or gradual reduction. Mr C had been prescribed zopiclone (a drug used to treat sleeping problems) and gabapentin (a drug for pain relief). The board told Mr C that his medication was stopped as he had failed to take it in the manner in which it had been prescribed. In addition, they said that Mr C would have been aware of the consequences of his medication being stopped if any discrepancies were found.

We found that the records showed that Mr C had tried to conceal the zopiclone rather than swallow it in front of staff. This led to him being reviewed by the mental health team, and the zopiclone prescription being discontinued. In addition, health centre staff carried out a spot check of his medication around a month later and he was found to have more gabapentin tablets than he should have had. The staff did not know, therefore, how much of the prescribed medication Mr C had been taking and he had admitted to buying non-prescribed drugs in prison.

We took independent advice on this from one of our medical advisers. The adviser said that although some patients can be affected if gabapentin is stopped abruptly, the health centre did not act unreasonably in discontinuing Mr C's medication immediately, given the difficulties in planning a gradual reduction.

Summary

Ms C had welfare power of attorney (a legal document appointing someone to act or make decisions for another person) for her late brother (Mr A) who had profound learning difficulties and significant communication difficulties. Mr A was admitted to Hairmyres Hospital but died three days later from sepsis (blood infection). Ms C had concerns about some of the clinical decisions that were made and said that staff failed to communicate with her as welfare power of attorney. If they had, Ms C said she could have provided additional and important information about her brother's normal condition and that she could have contributed to the treatment plans that were set up. The board apologised to Ms C that staff failed to act on changes in her brother's medical condition but maintained this was not due to his learning disabilities.

Our investigation found that the board have an 'Adults with Incapacity: Best Practice Guide', in line with the principles of the Adults with Incapacity Act (Scotland) Act 2000. The guide says that, along with the patient's wishes, staff should take account of the views of relevant others as far as it is reasonable and practicable to do so. We took independent advice on the board's actions from our nursing adviser. She said that the best practice guide was very good, but that staff failed to implement it in relation to Mr A's care, and the level of communication fell below the level she would have expected. Ms C was not consulted or involved in the decision-making process and, more importantly, her information about her brother's deterioration was not taken seriously. We upheld Ms C's complaint, as we found staff did not communicate adequately with her, when she was best placed to advise on her brother's medical history and usual state of health, and so failed to act in accordance with the principles of the Adults With Incapacity (Scotland) Act 2000.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings in communication; and
• remind staff of the best practice guidance and ensure it is implemented in appropriate circumstances.

Summary

Ms C, who is a solicitor, complained on behalf of her client (Mr A), who is a prisoner, that the board had refused to prescribe him suboxone (a prescription medication used to treat opiate addiction). Mr A had been prescribed methadone, but said that it was causing him constipation and sickness. He had told the board that he wanted to switch to suboxone instead. However, he was told that suboxone was not available for maintenance treatment (the prescribing of a substitute drug to prevent the use of illicit substances) at that time.

In their response to our enquiries, the board said that all patients within the addictions service are regularly assessed using both national and local guidance. They said that some patients may not be offered the drug of their choice and that Mr A was receiving the most appropriate treatment for his clinical needs.

Mr A required maintenance treatment for his opiate addiction and the board's view was that suboxone was not to be used for this. After taking independent advice from one of our medical advisers, we found that the board's decision had been reasonable and we did not uphold the complaint. The board had produced new guidance for prescribing suboxone in the prison after Ms C complained, and we found that the decision was also in line with this.

Summary

Mrs C complained about the nursing care that her late daughter (Ms A) received while in Monklands Hospital, where she had been admitted with severe stomach problems. While in hospital Ms A was transferred to a second ward, and Mrs C's complaint was about the nursing care her daughter received in that ward. Ms A suffered two falls there and Mrs C complained that nurses had referred to her daughter as a 'boarder' and that she had not been treated with dignity or respect. After the second fall, and some two and a half weeks after being admitted, Ms A was transferred to intensive care after she had a seizure. Her condition deteriorated further and she died the next day.

We took independent advice on this complaint from our nursing adviser, who considered Ms A's relevant clinical records and the complaints correspondence.

Our investigation found that, while the key areas of nursing care were reasonable, a falls assessment and care plan was not implemented after Ms A's first fall, although our adviser said that this might not have prevented the second fall. We also found that the level of communication with Mrs C and her family in the ward before Ms A was transferred to intensive care was not of an acceptable standard. We upheld the complaint, and noted the action already taken by the board in response to it. This included explaining the learning that had come from the complaint, and apologising that an SBAR report (a situation-background-assessment-recommendation report, used as a communication tool) was not completed on transfer between wards; that Mrs C had felt that the nursing staff had not provided the standard of care or communication expected; and that there had been a lack of communication.

Recommendations

We recommended that the board:

• remind nursing staff on the ward of the need to complete appropriate falls assessment and care planning in line with their falls assessment procedure; and
• ensure that staff on the ward are reminded about the importance of communication with relatives and carers.