Health

Summary

C complained about the care and treatment that they received from the board during an in-patient stay at Forth Valley Royal Hospital. C was admitted to the hospital while in the early stages of labour. C gave birth a few days later and was discharged to their home the following day. After discharge, C's health began to deteriorate and were later admitted to a different hospital, where they received a blood transfusion and treatment for an infection.

C complained that the board had failed to inform them that they had a yeast infection and failed to provide them with any treatment for this. C also complained that a clinician knowingly recorded an inaccurate pulse rate on their records and that the board failed to appropriately treat their post-natal high blood pressure and/or blood loss.

We took independent advice from an obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the board had failed to inform C that they had a yeast infection. Therefore, we upheld this aspect of their complaint.

We found insufficient evidence to establish that an inaccurate pulse rate had been recorded on C's records. We also found that C's blood pressure and/or blood loss were within normal limits when they were discharged from hospital. Therefore, we did not uphold these aspects of C's complaints.

However, we did find that clinicians failed to reasonably respond to C's high pulse rates at one point during their admission. While this issue was not raised by C in their complaint, we considered that it was reasonable to make recommendations to the board in relation to this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately monitor and respond to 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:

• Clinicians should closely monitor Modified Early Warning Scores (MEWS) and appropriate action should be taken in light of them.
• When a candida (yeast) infection is identified, patients on the ward should be informed.

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 the care and treatment provided to their late parent (A). Following a diagnosis of bladder cancer, the board identified that A would require heart surgery before they would be fit enough for bladder surgery. They referred A to another health board to provide that surgery, but this took a number of months to arrange and carry out. C told us that, by the time the heart surgery was completed, A's cancer had progressed to a point where treatment was no longer possible.

We took independent advice from an oncology consultant (a doctor who specialises in the diagnosis and treatment of cancer). We found that the board failed to identify radiotherapy as a possible alternative treatment, despite this advice being given by their oncology team. In addition, we found that the board had mishandled the referral to the other health board for heart surgery, failing to ensure that the other board were made aware of the urgency required. Then, when there were inevitable delays in surgery as a result, the board failed to identify that the window for treatment was closing.

For these reasons, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of cancer treatment. 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:

• A full range of treatment options should be considered when deciding on a treatment plan, and reconsidered if the viability of the original plan changes.
• All referrals made to other boards for treatment should include full details of any time sensitivity around treatment. Where it is unclear if treatment can be provided quickly enough, direct communication should occur between the relevant teams to explore this and alternative treatment options.

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 failed to provide them with reasonable treatment. C was hospitalised with a right sided homonymous hemianopia (a visual field defect involving the two right, or the two left, halves of the visual fields of both eyes). C believed that a previously diagnosed arachnoid cyst (a non-cancerous fluid-filled sac that grows on the brain or spinal cord) could be the underlying cause of their clinical symptoms. C underwent CT and MRI scanning.

The board concluded that C's arachnoid cyst was stable and unchanged from a previous MRI, and was unlikely to be the cause of their vision loss. Following a deterioration in their symptoms, C sought private neurosurgical opinion (specialist in surgery on the nervous system, especially the brain and spinal cord) and underwent a craniotomy (procedure to open skull to gain access to the brain) to drain the cyst resulting in partial and ongoing recovery of their vision.

C complained to the board that they should have been referred for neurosurgical review and received treatment through the NHS pathway sooner. They said that clinicians leading their care had repeatedly dismissed their concerns that the cyst could be the underlying cause of their symptoms and had excluded several sources of significant information from the clinical decision-making process, including a discrepancy in the scan measurements which had in fact shown the cyst had increased in size.

We took independent advice from a neurosurgical adviser. We found that, despite a marginal increase in the cyst identified through retrospective radiology analysis, C's progressively worsening symptoms could not have been explained purely on the basis of imaging, and there was no evidence to support an argument that an earlier opinion from a neurosurgeon should have been requested. Our investigations found that although multi-disciplinary opinion may have been helpful in this particular case given C's continuing and unexplained neurological symptoms, the board had carried out appropriate investigations and specialist opinions had been sought on multiple occasions to inform decision-making regarding C's care pathway. Therefore, we did not uphold the complaint.

In investigating C's complaint, the board identified that there had been a break in their communications with C. We considered the action taken by the board to address this had been reasonable; however reminded them that in line with the published Model Complaints Handling Procedure, steps should be taken to ensure complainants are kept up to date and given revised timescales for response.

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.