Health

Summary

Mrs C complained about the care and treatment that the board provided to her late mother (Mrs A) before she committed suicide. Mrs A had been admitted to hospital with low mood and worsening anxiety. She had a diagnosis of recurrent depressive disorder and a history of drug overdoses dating back a number of years. When it was initially proposed that Mrs A would be discharged from hospital, both she and Mrs C had concerns that she was being discharged too early. After taking independent advice from one of our medical advisers, we found that that staff had taken these concerns on board and had postponed the discharge by five days, which we found showed evidence of reasonable patient and carer involvement. We found that Mrs A's subsequent discharge was appropriately planned and phased. Risk assessments had been carried out and she had three successful overnight passes before her discharge. In view of all of this, we considered that it had been reasonable for the board to discharge Mrs A.

Mrs C also complained that staff had failed to ensure that there was an adequate support package in place when Mrs A was discharged. It had been agreed that she would be followed up by a community psychiatric nurse (CPN) and would attend an out-patient psychiatric clinic. We found that the planned follow-up care at the time of Mrs A's discharge was reasonable, in that it was adequate to meet her needs and her level of assessed risk. However, Mrs A's consultant in hospital had recorded that she would receive CPN input for as long as was indicated after she was discharged, and in the weeks after her first appointment with a CPN, Mrs A's anxiety levels had increased. Mrs C, Mrs A and her GP had all contacted the board to say that she was struggling with increased anxiety. Despite this, after a second CPN visit, it was decided that the visits would stop. Although it was decided that she would be referred to a mental health day service, Mrs A had concerns about this. The CPN also told Mrs A that she was moving to another job. We found that, on balance, in view of Mrs A's increased anxiety it was unreasonable to discontinue the CPN follow-up after only two visits and so we upheld this complaint. We did, however, consider that it was appropriate for the CPN to tell Mrs A that she was moving to another job. Mrs A took her own life just two days after the second appointment. Had the CPN input been continued, the next visit would probably not have been for another few weeks. We took the view that it would, therefore, be unreasonable to say that the withdrawal of CPN support was a significant factor in Mrs A's decision to take her own life.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the premature decision that Mrs A no longer needed to see a CPN; and
• make the relevant staff aware of our finding on this complaint.

Summary

Mr C complained on behalf of his partner (Ms B) that the care and treatment provided to her late mother (Mrs A) was inappropriate. Mrs A, who lived in a care home, was admitted to hospital where she was diagnosed with pneumonia and treated with intravenous antibiotics (drugs to fight a bacterial infection, delivered straight to the patient's vein). Mrs A was discharged to her care home three days later with antibiotic tablets, but died suddenly in the early hours of the following morning.

Our investigation included taking independent advice from two of our advisers, a medical adviser and a nursing adviser. The medical adviser said that Mrs A's condition had improved while she was in hospital. Because she was returning to a care home, it was reasonable for the hospital to consider discharging her. However, there was clearly a lack of discussion with the family and the care home about Mrs A's ongoing care. Ms B was not aware that her mother had been in hospital until the care home phoned to tell her that Mrs A had died. The medical adviser was also concerned that there was a lack of communication with Mrs A about her treatment, including a medical decision not to attempt resuscitation if her heart or breathing stopped (DNACPR). There was also no evidence that Mrs A's mental capacity had been appropriately assessed. The nursing adviser said that there was a lack of communication between nursing staff and Mrs A's family and her carers in planning for her discharge, and a general lack of detail in the nursing notes.

Recommendations

We recommended that the board:

• ensure that relevant staff reflect on the medical adviser's comments in relation to the assessment of patients who lack mental capacity to make complex decisions about their care and treatment;
• issue a reminder to relevant staff of the requirement to keep clear, accurate and legible records;
• ensure that relevant staff reflect on the medical adviser's comments in relation to the completion of the DNACPR form;
• provide evidence that relevant staff have reflected on the specific reasons why there was a failure to communicate with the patient and her family; and
• apologise to Mr C and his partner for the failures identified during this investigation.

Summary

Mrs C, who lives on one of the Scottish islands, complained that the board failed to repay her full transport and accommodation costs when she escorted her mother to a mainland hospital for in-patient treatment. Mrs C had intended to stay for four nights, then take her mother home but, as her mother was not well enough to leave hospital on the expected date, Mrs C had to return home alone. She was unhappy that, in these circumstances, the board had not paid her full costs.

The board's patient transport policy says that they can only reimburse costs associated with escorting a patient to and from hospital. Mrs C had chosen to stay over, and the board explained that as her mother was not discharged when expected, there was only one approved journey for which an escort was required. They also explained that they can only reimburse accommodation costs when the escort stays and escorts the patient home (provided that the total cost of the stay does not exceed the cost of a second return fare to collect the patient). If the patient is not discharged when expected, accommodation costs cannot be reimbursed, but the board will pay for a second return journey to escort the patient home. We also found that the guidance says that authorised escorts are expected to return home at the earliest opportunity or to stay at their own expense. We noted that the patient travel team had advised Mrs C of the available options before the outward journey. On her return they had said that they would be happy to book a second flight for her to collect her mother, or alternatively if she organised her own flight for this, they would pay her overnight accommodation claim.

We did not uphold the complaint as we found that the board had acted in accordance with their procedures. We noted that although they were of the view that they had provided accurate information before Mrs C travelled, the board had also asked the patient travel team to review the guidance issued to patients and GPs, to ensure that it is as clear as possible for the future.

Summary

Mrs C is 88 years old and has a number of health issues, including osteoarthritis (the most common form of arthritis that affects the joints). After she attended hospital for investigation of a breathing problem, she complained that service staff treated her unreasonably when assisting her to and from their patient transport vehicle. Mrs C also complained that there was an delay in the vehicle arriving to take her home from hospital, and that the service’s handling of her complaint was unreasonable.

As there was no independent evidence of what occurred when Mrs C arrived at the hospital, or when she was returned home, we could not say for certain what happened. However, we noted that the service upheld her complaint about patient transport crew walking her to and from their vehicle when they should have used a wheelchair, and that the methods they used to assist her caused her pain. They also acknowledged that Mrs C was left waiting for a considerable time for transport home from the hospital, and we found that the records in fact showed that she had to wait for almost two and a half hours from when the service logged her as ready for transport. In relation to complaints handling, we saw evidence that the service had taken Mrs C’s complaint seriously, but had accepted that there were delays in their investigation. We upheld all Mrs C's complaints, but as the service had already taken action by apologising, speaking to the staff involved, and amending their records to show the correct type of transport she needs in future, we made only one recommendation.

Recommendations

We recommended that the service:

• ensure there is no unnecessary delay in crews providing statements in response to complaints.

Summary

Mrs C complained about the care and treatment that a hospital provided to her brother (Mr A) after he was admitted with increasing confusion and suspected pneumonia. Mrs C, who was her brother's welfare guardian, was concerned that he was not given enough fluids and food; he was discharged prematurely and was readmitted a few hours later; there was a failure to diagnose his fractured leg; changes were made to his medication; and about poor communication.

After taking independent advice from three of our medical advisers (a nurse, a consultant physician and a consultant psychiatrist), we found that nursing staff did not fully take into account Mr A's specific needs. He had a long standing mental illness and, despite knowing that there was a problem with him eating and drinking, there was no specific information on how to manage this. We found that Mr A's fluid intake was not properly monitored and there was a lack of consideration given to blood test results that indicated possible signs of dehydration.

We did not consider that Mr A's discharge was unreasonable, because dehydration is difficult to diagnose. Hospital staff had taken steps to speak with Mr A's community psychiatric nurse (CPN) to establish his usual behaviour, and it was agreed that the CPN would visit him at home later that day to see if he needed psychiatric review. In addition, when it was known that his blood test results were abnormal, he was readmitted to hospital. Although we could not be certain when Mr A fractured his leg, he was promptly reviewed and diagnosed after bruising and swelling were identified.

We were also of the view that it was appropriate to stop some of Mr A's medication (which had a sedating effect) because this could make his pneumonia worse. However, we considered that medical staff could have explained this to the family when Mr A was first admitted to hospital. In addition, although we found that the hospital obtained appropriate information from Mr A's GP, we thought that nursing staff could have sought advice sooner from the CPN about Mr A's eating and drinking.

Recommendations

We recommended that the board:

• review fluid intake and output monitoring for patients with communication difficulties who have suspected or actual dehydration, and audit their documentation of patients from the ward Mr A was in;
• ensure that the educational and training needs of nursing staff in the ward have been met in terms of holistically managing patients with mental illness;
• draw to the attention of relevant staff involved in Mr A's care the importance of ensuring that relatives, particularly those with welfare guardianship, are fully informed of the reasons for any changes in treatment in a timely manner and that the content of discussions are sufficiently documented; and
• apologise to Mrs C and Mr A for the failings we identified.

Summary

Mrs A lives in a care home and needs 24 hour nursing care as she has numerous medical conditions. Her son (Mr C) considered that her medical and nursing needs met the criteria for continuing care funding (funding provided by the NHS for specialist clinical or nursing treatment) set out in the Scottish Government's guidance document (CEL6). The board assessed Mrs A's needs, but did not consider that she met the criteria for continuing care funding. Mr C appealed this, but funding was again refused. He complained to us about the board's assessment of his mother's eligibility. He did not believe the assessment process had been followed correctly or that he and the professionals who directly care for his mother were sufficiently involved in it.

We found that, in terms of the assessment of Mrs A's clinical and nursing needs, the board took an appropriately multi-disciplinary approach, using a single assessor to gather information and comments from various professionals involved in Mrs A's care. We did not uphold the complaint, as we were satisfied that the board had suitable tools in place to properly assess Mrs A's eligibility for continuing care funding and that the assessor was able to reach a clear, reasoned and evidence-based conclusion. The overall assessment was appropriate and well-documented.

That said, we considered the board failed to properly involve Mr C and the care home in the initial assessment and made recommendations relating to this. We were also critical of their communication and explanations of the assessment process and the purpose of a meeting that Mr C attended. However, we noted that these issues were largely resolved at the appeal stage.

Recommendations

We recommended that the board:

• apologise to Mr C and Mrs A for failing to properly include them in the initial assessment; and
• consider adding a section to their decision-making tool, which records the views of relatives, carers and other stakeholders, such as care home staff.

Summary

Mr C hurt his head when his vehicle overturned. He said that when he arrived at hospital he walked in without a wheelchair or a neck brace. He was examined by a doctor, who instructed a nurse to dress Mr C's head wound and advised him to take painkillers. After this, Mr C attended two GP appointments, but went to hospital again about two weeks later feeling faint and woozy. He said he was left unattended for an hour until seen by a doctor, who did not examine him and advised him to buy painkillers from a shop. A few days later, Mr C saw a consultant who told him that there was nothing wrong and to continue with the painkillers. Mr C complained to us that the board failed to provide a neck collar, and did not properly clean the wound and investigate his injury. Finally, he said that they did not take him seriously when he attended hospital several weeks later.

We took independent advice on this case from one of our medical advisers, who specialises in emergency medicine. The adviser said that there were failings in the care and treatment provided immediately after Mr C's accident. When he was taken to the emergency department, he was not immobilised as he should have been. Given the nature of his injury, it was possible that he might have had a neck fracture, which should have been ruled out through careful examination before he was mobilised. A more thorough investigation might also have highlighted the need for an x-ray. However, there was evidence in the medical records that his wound was treated appropriately. Furthermore, after Mr C's initial attendance at hospital, the adviser said that management of the injury and subsequent symptoms was reasonable. We accepted that advice, but upheld the complaint as we were concerned about the management of his injury immediately after the accident.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised as part of the annual appraisal process of relevant staff; and
• apologise to Mr C for the failures identified during our investigation.

Summary

Mrs C, who has power of attorney for her father (Mr A), complained that she had not been involved in assessments to establish whether he met the criteria for NHS continuing care funding (funding provided by the NHS for specialist clinical or nursing treatment).

We found that, although the assessment is essentially a clinical one, the input of the patient or carers is crucial in the overall process. When Mrs C told the staff about her concerns they assumed this to be an appeal request on their decision, and they instructed an independent clinician to assess Mr A. We found that, from a clinical perspective, the staff acted in an appropriate manner. However, national guidance is quite clear that the views of the patient or their carers are an important part of the process and so we upheld the complaint. We were pleased to note that the board are now involving Mrs C in discussions about Mr A's care and treatment.

Recommendations

We recommended that the board:

• formally apologise to Mrs C for the failings identified in our investigation; and
• remind staff who deal with NHS continuing healthcare applications of the requirement to involve patients and their carers in the process.

Summary

Mr C complained that the board had not provided him with written confirmation of his blood test results. When he attended hospital, he had undergone a test for deep vein thrombosis (DVT), but the copy of his results that he had obtained did not mention this. After he contacted the board to complain, they sent him a further copy of his test results but again there was no indication that the test for DVT had been performed.

During our investigation, we established that there are two methods of reporting test results, one of which contains fuller information than the other. Unfortunately, Mr C had not been provided with the full version. The board asked that we apologise to Mr C on their behalf, and told us that they had reminded staff of their responsibilities in this respect. We also provided Mr C with a full copy of the test results.

Summary

After Mr C fell downstairs, he was admitted to a local hospital, where a scan did not show any fractures. However, the next morning he had no feeling in his legs and he was transferred to a second hospital, where a consultant interpreted a further emergency scan as showing only degenerative changes in his spine. Mr C was later referred elsewhere, where he was finally diagnosed with an undisplaced fracture (a break in the bone, where the two parts of the bone are still aligned) of his spine. He now has to use a wheelchair.

His wife (Mrs C) complained about Mr C's care and treatment at the second hospital. She was concerned that he had not been handled and moved appropriately and that this could have affected the outcome for him. She was unhappy that his undisplaced fracture had not been diagnosed and that he was not kept lying down and in a neck brace.

To investigate the complaint, we considered all the relevant documentation, including the complaints correspondence and Mr C's medical records. We also obtained independent advice from two of our medical advisers, a consultant neurosurgeon and a consultant diagnostic and interventional neuroradiologist. The advice received confirmed that the board missed an undisplaced fracture of a vertebra (a bone of the spine) which should have been detected when interpreting the scan in the second hospital. The adviser commented that, despite this, Mr C had been managed as if he had had a spinal injury. The adviser said, however, that the damage to Mr C's spine had already occurred before he was admitted to the second hospital and that the treatment would not have affected Mr C's outcome. We upheld Mrs C's complaint, but as the board had already admitted that there were failures in the way they cared for and treated Mr C, and had taken action to address this, we did not find it necessary to make any recommendations.