Health

Summary

After Mr C'’s daughter (Mrs A) experienced several episodes of breathlessness, she was seen by her GP, who concluded she had a virus. Over the following days, Mrs A remained breathless. She collapsed at home and her GP was called out. He found that her blood pressure was low, but rising. He concluded that she had had a vasovagal episode (a temporary loss of blood to the brain) but was improving. Mrs A had further collapses over the following days and was eventually taken by ambulance to hospital. Shortly after arriving there, Mrs A collapsed again and, despite attempts to revive her, she died. Mrs A was found to have had a pulmonary embolism (a blockage in the artery that transports blood to the lungs). Mr C felt that Mrs A’'s GP could, and should, have diagnosed Mrs A'’s pulmonary embolism or could have arranged for more urgent investigations to establish the cause of her symptoms.

We took independent advice on this case from one of our medical advisers. We found that, with the benefit of hindsight, it was likely that Mrs A’'s collapses at home were caused by initial smaller thromboembolic (blocking of a blood vessel by a blood clot) events. However, there was evidence to suggest that Mrs A was also suffering from a viral infection, which may have contributed to her symptoms. We accepted the adviser's view that Mrs A’'s symptoms were consistent with a viral infection rather than a pulmonary embolism. There was clear evidence that the GP had considered a number of possible diagnoses but had ruled out pulmonary embolism. Based on the information available to him at the time, we were satisfied that his examinations of Mrs A were thorough and his conclusions reasonable.

Summary

After Mr C’'s daughter (Mrs A) experienced several episodes of breathlessness, she was seen by her GP, who concluded she had a virus. Over the following days, Mrs A remained breathless. She collapsed at home and her GP was called out. He found that her blood pressure was low, but rising. He concluded that she had had a vasovagal episode (a temporary loss of blood to the brain) but was improving. Mrs A had further collapses over the following days and was eventually taken by ambulance to hospital. Shortly after arriving there, Mrs A collapsed again and, despite attempts to revive her, she died. Mrs A was found to have had a pulmonary embolism (a blockage in the artery that transports blood to the lungs). Mr C complained that there was a lack of urgency from accident and emergency (A&E) staff in diagnosing the cause of his daughter's symptoms. He also complained that Mrs A was left alone in a cubicle and that he and his wife were not allowed to sit with her.

After taking independent advice on this complaint from one of our medical advisers, we upheld Mr C's complaints. We found that Mrs A was seen by a nurse immediately on arrival at the hospital. However, she asked to use the toilet and was allowed to do so, which delayed triage (the process of deciding which patients should be treated first based on how sick or seriously injured they are) by around 30 minutes. Mrs A was triaged by a nurse and was prioritised as 'urgent', meaning she would be seen by a doctor within one hour. Our adviser said that Mrs A's symptoms were sufficiently abnormal to merit being prioritised as 'very urgent', which should have resulted in a doctor seeing her within ten minutes. Mrs A collapsed around twenty minutes after triage. We were satisfied that Mrs A was treated appropriately following her collapse, but we criticised the board for failing to identify the seriousness of her condition. Although we found it appropriate for Mrs A to be given privacy to use the toilet, we were also critical that Mrs A’s parents were not allowed to sit with her in the cubicle, or that staff did not ask Mrs A whether she wished to be visited.

Recommendations

We recommended that the board:

• apologise to Mrs A's family for the issues highlighted in our investigation;
• share this decision with staff carrying out triage in A&E with a view to ensuring an appropriate combination of tool-based prioritisation and professional judgement;
• take steps to ensure that the Fife Early Warning system (a system based on observation, and used to monitor changes in the patient’s condition) is being properly implemented and understood by staff in A&E;
• take steps to ensure that the triage process and decisions reached regarding treatment priority are properly documented; and
• remind nursing staff of the Nursing and Midwifery Council guidance on standard of conduct, performance and ethics 2008.

Summary

Mr C was referred for hospital physiotherapy treatment but, as he had not received an appointment after two months, he complained to the board. In their response, the board acknowledged that their waiting list for routine physiotherapy appointments was much longer than they would like it to be. They apologised to Mr C and explained the steps they were taking to try to reduce the waiting list. They also confirmed that they had sent him a separate letter offering him an appointment. However, as Mr C did not receive this, he was unable to respond to the offer, and because of this he was removed from the waiting list and discharged. When he contacted the board to ask why he had not heard anything, he found out he had been discharged and brought his complaint to us.

Our investigation found that although the board do not keep copies of appointment letters, they had recorded on their system that a letter had been sent to Mr C and the date it was sent. They also provided us with evidence that they had notified Mr C’s GP of his discharge. We obtained independent advice from our medical adviser, who is a GP. The adviser confirmed that this was reasonable and that the onus was then on Mr C to get in touch. We noted that, despite having been told by the board that an appointment letter had been sent, he waited over six months to get in touch with them to tell them he had not received it. When he did get in touch, the physiotherapy service phoned him to explore the possibility of reinstating his referral but Mr C indicated that he no longer wished an appointment.

As we considered the board’s response to the initial complaint to have been reasonable, and as Mr C himself appeared to have delayed in querying why he had not received the appointment letter, we did not uphold the complaint.

Summary

Mrs C attended the medical practice as she had a swollen, discoloured and painful varicose vein in her right leg. She was initially seen by the practice nurse, who prescribed antibiotics (drugs to treat bacterial infection) and anti-inflammatory medication after consulting one of the practice doctors. The following day, as Mrs C’s leg continued to be very painful, she again phoned the practice and was advised by one of the doctors that she had not allowed enough time for the medication to work. Over the next 12 days, Mrs C was visited at home twice, as she felt she was not improving. On the afternoon of the second home visit, the doctor who visited Mrs C arranged for her to be seen by a vascular specialist at hospital. Mrs C requested an ambulance to take her there. She was offered a non-emergency ambulance but due to the possibility she might wait a number of hours for it and miss the appointment, the practice told her that she might wish to make her own travel arrangements, which she did. At the hospital, an ultrasound scan of Mrs C's right leg revealed a blood clot from the ankle to the groin, and she required emergency surgery. Mrs C was admitted to hospital the same day and discharged several days later.

Mrs C complained that the practice failed to appropriately assess and treat her symptoms, and that she should not have had to make her own way to the hospital. She was dissatisfied with the explanations provided by the practice and the way in which they dealt with her concerns and complained to us, saying that she had no faith in them.

We took independent advice on this case from one of our medical advisers. The advice, which we accepted, was that the practice had not failed in their care of Mrs C. Indeed, the adviser considered the prompt referral of Mrs C to a vascular surgeon was evidence of excellent practice. The adviser also said that Mrs C did not need an emergency ambulance to take her to hospital and the reason that she was given as to why she might wish to make her own way there was reasonable. However, we also accepted that the practice may not have given Mrs C clear explanations and reassurance about her diagnosis and treatment. In addition, while there were clearly conflicting views about the reasons for the breakdown in Mrs C‘s relationship with the practice, we took the view that they should reflect on whether they had fully considered the reasons for Mrs C’s dissatisfaction and loss of faith, and how these could be resolved, particularly as she remains a patient there.

Recommendations

We recommended that the practice:

• review the way they communicate with their patients; and
• invite Mrs C to a meeting to discuss her concerns.

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.