Health

Summary

Mr and Mrs C's son is a young adult with severe learning difficulties and various complex medical issues. Mr and Mrs C complained to the board, through an advocacy worker, about the staff member responsible for the co-ordination of nursing care at home for their son. The board responded saying that many of the issues raised had happened outwith the time limit specified in the NHS complaints procedure, and so could not be investigated. Mr and Mrs C said that they were aware of the time limit, but explained that they thought there were exceptional circumstances in their case. They asked the board to give consideration to these, and to disregard the time limit.

Our investigation found that although the board was entitled to decide not to consider complaints outwith the time limit, there was no evidence that they had in fact considered the specific grounds raised by Mr and Mrs C, or explained why they did not consider the grounds to be relevant. Mr and Mrs C also said that they were misinformed about a communications book that was removed from their home, and that their complaint had been investigated by inappropriate staff members. However, we found the staff who had investigated were suitably impartial. We also found that the board made reasonable efforts to contact Mr and Mrs C's advocacy worker to discuss and clarify the outstanding issues. On balance, we did not uphold Mr and Mrs C's complaint, as we found that the board's complaints handling was generally reasonable overall, and that they proportionately responded to a number of complex and sensitive matters. However, as we did identify aspects that were not satisfactory, we made recommendations in relation to these.

Recommendations

We recommended that the board:

• provide Mr and Mrs C with confirmation that the grounds they had put forward as exceptional circumstances were considered by the board, and provide an explanation for the decision reached;
• apologise to Mr and Mrs C for the initial statement that a communications book belonged to the board, and for not informing them of or involving them in the investigation regarding the book, nor the subsequent outcome; and
• consider alternative options for Mr and Mrs C's family's contact with the Complex Care Service.

Summary

Mr C has complex needs and requires long-term care and specialist input. He has severe dementia, with limited capacity to judge distance or to understand and participate in therapies, and his wife (Mrs C) has welfare power of attorney for him. Mr C can move about, but is at particular risk of falling. In November 2007 Mr C was admitted to a continuing care ward, where he remains a patient. Mrs C made a number of complaints about aspects of the care and treatment that her husband has received. These included the actions the board took to address Mr C's condition in February 2011, medication, observation and monitoring, staffing levels, carer communication, charting and record-keeping, the standard of bathroom facilities and complaints handling.

Our investigation included taking independent advice from two of our medical advisers - one in mental health and one a GP. We took account of this advice as well as evidence from Mrs C and the board. Mrs C said that in February 2011 her husband became very unwell and staff failed to take reasonable measures to bring his temperature down and call a doctor within a reasonable time. Our investigation found that staff took appropriate action when Mr C became unwell and that their interventions overall were reasonable. In relation to the drug regime and administration, however, although we found that the principal contributing factor to Mr C's falls was most likely to have been involuntary muscle twitching, we also found that there were significant failings. These included the discontinuation of an antidepressant for three weeks; the timing of medication; and failure to ensure Mr C received prescribed medication when off the ward. We also found that the board failed to administer flu vaccinations to Mr C, either within a reasonable time or at all, placing his physical health at risk.

Mrs C also said that the board failed to ensure that Mr C was sufficiently hydrated (had enough fluids). We found that throughout the period Mr C was well hydrated and had effective liver and kidney function, but that there were inconsistencies in recording and monitoring his fluid balances. We also found that the board failed to properly assess Mr C's falls risk or properly record or implement a fall prevention care plan.

Mr C was sedated because he wandered at night due to agitation, and Mrs C felt that this could have been managed without resorting to sedation if there were more staff. We did not uphold this complaint as we found that, while it was difficult to reach a definitive conclusion on whether staffing levels were reasonable, staff used sedating medication as a last resort and then only rarely. In relation to Mrs C's complaint about bathroom facilities, the evidence available suggested that the ward is cleaned to an acceptable standard and that any problems are addressed within a reasonable time.

Mrs C said that staff communication about assessment of her husband's capacity and administration of sedative drugs was inadequate and she was also concerned that a 'do not attempt to resuscitate' certificate (DNAR - showing that a doctor is not required to resuscitate the patient if their heart stops) was signed by medical staff without her input. We upheld this complaint as we found that communication with Mrs C was not of a reasonable standard and did not comply with the Adults with Incapacity legislation. The board's record-keeping was also of concern and we found that at times it fell below a reasonable standard and did not, amongst other things, record a reasonable standard of communication with Mrs C. We also found instances of statements in the board's complaints responses that were either inaccurate or misleading, indicating that Mrs C's complaint was not investigated as thoroughly as it should have been.

Recommendations

We recommended that the board:

• implement measures to avoid patients being given medication at the end of one medication round and the beginning of the next, thereby ensuring an appropriate period of time has elapsed between doses;
• implement checking mechanisms to ensure the prescription sheets are transcribed accurately;
• ensure patients authorised to be off-the-ward receive medication consistently as prescribed by medical staff;
• review the processes for managing, prescribing, administering and recording in relation to the flu vaccination;
• ensure that falls prevention procedures, including developing and evaluating falls prevention plans, are consistent with the board's policy;
• ensure effective systems are in place to keep staffing levels under review;
• take measures to ensure appropriate compliance with the Adults with Incapacity Act, with particular regard to DNAR decision making and communication with relative or carers;
• ensure that relatives' communication documentation is used consistently to record the nature and content of discussion with relatives or carers;
• build flexibility into the charge nurse's appointment system so that there are opportunities for communication outwith scheduled times to deal with issues as they arise;
• ensure that record-keeping reflects the care and medication given and a reasonable standard of communication;
• consider implementing unplanned visits to ensure a reasonable standard of hygiene;
• ensure complaints are investigated thoroughly and that responses are accurate; and
• apologise to Mrs C for all the failings identified in our investigation.

Summary

Mrs C's daughter (Ms A) has a history of anorexia nervosa and depression. Ms A was assessed by an on-call psychiatrist after her mother expressed a concern about a deterioration in her mental health. Ms A was allowed to go home and was to be followed up by the crisis care team. The next day, following an incident that concerned Mrs C, police brought Ms A to hospital for assessment. Mrs C attended with her. Ms A was seen by a mental health assessment nurse and a doctor in the early hours of the morning. They offered to admit her to hospital, but she refused and she and her mother returned home. However, later that day, after what Mrs C described as a violent outburst in the presence of the family doctor, police officers brought Ms A back to hospital for a further assessment. The assessing nurse decided not to detain Ms A or to offer to admit her to hospital. The next day, Ms A was detained under a short-term certificate. She was admitted to another hospital and remained there for six weeks. Mrs C was unhappy about the standard of psychiatric assessments Ms A received at the first hospital, particularly the second assessment.

Our investigation found that the first assessment was reasonable and that it was unlikely that Ms A met short-term detention criteria under the relevant legislation. We also found that the follow-up arrangements after her discharge were reasonable. However, in relation to the second assessment, we found that while the critical factors relating to her risk of suicide were assessed and the diagnosis reached was reasonable, there were instances of poor practice. In reaching their decision, the assessing nurse did not make use of all the available information which would have significantly strengthened the assessment and decision making.

Recommendations

We recommended that the board:

• put quality assurance measures in place to ensure that evidence based assessment templates are completed by relevant staff in full and as intended;
• ensure that staff involved in conducting out-of-hours and urgent assessments have (and utilise) access to previous clinical records whenever practicable, especially when considerations of risk are involved; and
• apologise to Mrs C for the failings identified in relation to the second assessment.

Summary

Mrs C, who is an advocacy worker, complained to the board on behalf of her client (Mr A), that he had been abused by a member of staff. The police had been contacted but no charges were made due to a lack of witnesses. The member of staff had also contacted the police about being assaulted by Mr A. Mr A was dissatisfied with the board's investigation into his complaint.

Our investigation found that the board had taken Mr A's allegations seriously. They had conducted a thorough investigation and interviewed appropriate staff in order to reach conclusions. We, therefore, did not uphold the complaint that the board failed to adequately investigate Mr A's complaint about being abused by a member of staff.

Summary

Mr C complained that he was unreasonably charged for a temporary lower denture that he was unable to wear because it did not fit. He was unhappy about the appearance of his new upper denture and that his dentist refused to make a new denture without charge. Mr C said that he had told his dentist that he liked the appearance of his old denture, and wanted his new upper denture to look the same.

The dental clinic told us that Mr C needed to have five teeth extracted, and they had advised him that his best clinical option was to have new temporary dentures made. Mr C instead opted to have his existing dentures adapted. We found that, as the dentist had warned that this could result in the denture being a poor fit, Mr C had not been charged unreasonably.

In relation to the appearance of Mr C's new denture we found that dentures are provided by the NHS on the basis of clinical rather than cosmetic need. Mr C told us that he had not taken his glasses to these appointments and had simply assumed that the denture would be similar in appearance to his old one. There was no evidence that Mr C had told his dentist clearly at the relevant appointments that he was totally dissatisfied with the appearance or shape of the upper denture. As there was also no evidence that he had clearly told his dentist that he wanted his new denture to look the same as the old one, we did not uphold this complaint. Nor did we find it unreasonable that Mr C's dentist refused to make a new upper denture without charge. We noted that Mr C has the option of seeing a new dentist for a second opinion.

Summary

Mr C was admitted to hospital as an emergency case in October 2009 with a perforated colon (hole in the bowel). The surgeon treated it conservatively (with medical treatment avoiding radical therapeutic measures or operative procedures) and explained to Mr C that further investigation was needed once this had settled down. Mr C was discharged several weeks later, then had a further episode of pain and inflammation which was also managed conservatively. Mr C had a scheduled colonoscopy (examination of the bowel with a camera on a flexible tube) in December 2009 and was diagnosed with complex diverticular disease (disease of the colon). Shortly after the colonoscopy, Mr C was admitted to hospital with abdominal pain and inflammation, again managed conservatively. He was admitted again in February 2010 with a diverticular bleed (a bleed in the colon). In March 2010, he agreed to a surgical resection (partial removal of the colon) and to lose weight as he had a high body mass index (a measure for estimating human body fat).

The surgeon reviewed Mr C in September 2010 and agreed to proceed with surgery when a consultant urologist (a clinician who treats disorders of the urinary tract) became available. Surgery was planned for October 2010 but this had to be cancelled. However, Mr C in fact underwent surgery a few days earlier than originally planned. The surgeon said that the procedure was extremely complex and that participation from other specialists was needed. Mr C believed that the procedure was complicated because the hospital failed to perform it within a reasonable time.

Mr C had further procedures including repeat dilatation (enlargement) of the anastomosis (the site of the bowel after resection). One of these procedures was performed on a date in February 2012, after another cancellation. Mr C said nobody contacted him from the hospital to tell him of that cancellation, and he only found out when he phoned the surgeon's secretary the day before. A reversal ileostomy (a surgical procedure carried out on the small intestine) was then planned, but in March 2012 surgeons told Mr C that a stent (mesh tube) should be inserted first. The reversal was performed in May 2012.

Mr C said that the board failed to notify him of cancelled appointments and contact him to rearrange them. Mr C also said that the board failed to give reasonable or consistent explanations about why the appointments had been cancelled. As a result of these failures, and the failure to provide appropriate treatment within a reasonable time, Mr C said that his life had been on hold and he had been unable to work.

Our investigation found that the board provided Mr C with appropriate treatment for his perforated colon and post-operative complications, within a reasonable time, so we did not uphold this complaint. We did, however, uphold his complaints about cancellations. It was not clear that he was told about the cancellations within a reasonable time, and the board acknowledged that there were shortcomings in communication. They apologised and addressed this with administration staff. We also found that, while the board's explanation when responding to Mr C's complaint was reasonable, that did not appear to be the case when he initially brought this to the attention of staff. The board accepted that there were further shortcomings when Mr C was seeking explanations from staff, and regretted his poor experience at the time of the cancellations.

Summary

Mr C complained to us about the treatment he received from his medical practice for problems with his neck. GPs at the practice saw Mr C five times during a five month period. He had reported a number of symptoms, including neck pain. Mr C reported that at one appointment he specifically raised concerns about cancer, but there was no record of this conversation in his medical file. He also reported being able to feel a lump, but none of the GPs who examined him during this period were able to find this until his final appointment. He was then referred for an urgent ultrasound scan (a special scanning technique that uses sound waves to produce internal images of the body), which found a lump that turned out to be cancerous. Mr C had a history of unexplained deep vein thrombosis (blood clots) dating back two to three years. He was concerned that this put him at increased risk of developing cancer, but that his GPs had not taken this into account.

In our investigation we examined Mr C's medical records and evidence from Mr C. We also took independent advice from one of our medical advisers. Our investigation found that, while there was conflicting information about one consultation, no evidence of a neck lump was found before the final consultation. While the GPs should have taken Mr C's history of unexplained deep vein thrombosis into consideration in making a diagnosis, without any evidence of a lump there was no evidence to act on. We also found that the practice had clearly set out the issues that were discussed at each consultation over the five month period, and had passed on an apology from one of the GPs involved.

Summary

Mr C's wife (Mrs C) was admitted to hospital for an operation to repair a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall).

After her operation Mrs C complained of pain. The surgeon examined her and found evidence of swelling. A CT scan (a special scan using a computer to produce an image of the body) was requested and the results suggested that Mrs C's bowel had been pierced. Mrs C was operated on and had the section of pierced bowel removed. She suffered pain and discomfort from this procedure and it took her eight weeks to recover from it. Mr C told us that he considered that the staff at the hospital had failed to provide appropriate treatment during the operation. He felt that this resulted in Mrs C's bowel being pierced.

We did not uphold Mr C's complaint. After taking independent advice from our medical adviser, we concluded that a pierced bowel was a recognised complication of this type of surgery. We found that Mrs C's treatment during the operation was reasonable, although we were critical of the board's consent policy. We felt that common and serious risks of surgery should be clearly explained to all patients and that these discussions should be recorded on the patients consent form or clinical records. This did not happen in Mrs C's case.

Recommendations

We recommended that the board:

• considers reviewing their consent policy to ensure that all common and serious risks are fully explained to patients when obtaining consent and that these are clearly recorded on the consent form or clinical records.

Summary

Miss C had been receiving a repeat prescription for tablets. However, on one occasion when she visited the pharmacy the pharmacist said the prescription could only be collected on certain dates, and that the next date had not yet arrived. Miss C had not been advised of this previously. The pharmacist gave Miss C five tablets to last until she could pick up her next prescription, although Miss C did not need that many tablets.

Miss C complained to us that the pharmacy applied rules about collection inconsistently and that although they had said there were dosage concerns, they then inconsistently issued more tablets than required. She was also unhappy with the way in which her complaint was handled.

We did not uphold Miss C's complaint about the inconsistent application of rules and issue of tablets. Our investigation found that the pharmacist was required to follow the advice of the prescribing doctor which in this case, was to provide a fortnight's supply of tablets every 14 days. The pattern of prescribing appears to have become slightly out of sync when the last prescription was written, leading to the change in dates. We did, however, make a recommendation to try to avoid this happening to someone else in future.

We upheld the complaint about complaints handling. Although the pharmacy acknowledged Miss C's complaint within their timescales, they did not respond to her until more than ten working days after receiving it, which was outside the recommended time limit. The pharmacy's head office, where the complaint was handled, is in England, and they failed to give Miss C information about the Scottish NHS complaints system and the Ombudsman.

Recommendations

We recommended that the pharmacy:

• provide staff with guidance that ensures that they clearly explain the prescribing regime to patients with repeat prescriptions, as well as indicating the dates on which patients can collect such prescriptions; and
• apologise to Miss C for failing to provide the correct information when responding to her complaint, and for the delay in responding.

Summary

Mrs C was assaulted, and was taken by ambulance to a hospital accident and emergency department (A&E) with two police officers in attendance. She complained that she was not fully examined and that no tests were done to assess whether or not she had a head injury, which meant that her concussion was undiagnosed. She said that this has caused her ongoing health problems.

Mrs C was discharged into the care of the police officers who took her to the police station to make her statement and then took her home. When she later applied for copies of her notes from the incident she took issue with the lack of detail in them. Mrs C complained to the board but was not satisfied with the response she received. She was unhappy that later statements made by the nurse and doctor who saw her on the night indicated that she had been uncooperative and possibly under the influence of alcohol.

Our investigation included taking independent advice from one of our medical advisers. We found that there was a disparity between the notes made at the time of the events and the later statements made by the staff who attended Mrs C. The A&E unit is a GP-led unit and on the night in question was staffed by a nurse practitioner (a specially qualified senior nurse) and an on-call GP. We found that the notes made at the time by the nurse and the GP did not record all the injuries Mrs C had suffered, as recorded by the Scottish Ambulance Service staff who took her to hospital. Nor did any of the notes taken at the time refer to Mrs C as being uncooperative or under the influence of alcohol. However, after Mrs C complained to the board, the nurse and GP were asked for statements and both then referred to her as being uncooperative, possibly due to alcohol intake. The GP said that it was because Mrs C was not cooperating that he was unable to conduct a full examination and assessment of her condition.

Our adviser found that the lack of information in the notes taken at the time did not give a full picture of Mrs C's condition on the night in question. However, he was of the view that with the information now known - that Mrs C had concussion - the management of her condition would have been the same even had the concussion been diagnosed at the time. Mrs C was discharged with a small amount of medication and with advice to return to A&E if her condition worsened. The adviser said that this would have been appropriate. He was also of the view that Mrs C's ongoing problems would probably have occurred even had the concussion been diagnosed at the time. We did, however, uphold Mrs C's complaint because no valid reason was recorded in the notes for the GP not having conducted a full assessment and examination at the time.

Recommendations

We recommended that the board:

• apologise for the failings identified during our investigation; and
• review a sample of notes to establish the quality of record-keeping of the staff involved.