Health

Summary

C complained about a failure to diagnose their late partner (A)'s spinal cord cancer when they attended Wishaw General Hospital. They attended the Accident & Emergency Department and were referred on to the medical team for an urgent MRI scan for a suspected malignant spinal cord compression (MSSC, MSCC can happen when cancer grows in the bones of the spine or in the tissues around the spinal cord). However, this was subsequently changed to a CT scan, the result of which was normal, and A was discharged. A attended a private neurology (the science of the nerves and the nervoussystem, especially of the diseases affecting them) appointment the following week, where arrangements were made for an urgent hospital admission and a tumour in the spinal cord was diagnosed. A was left confined to a wheelchair following surgery and died around ten months later. C complained that, in not carrying out an MRI scan, the board failed to adhere to national guidance on MSCC management.

We took independent medical advice from a consultant radiologist (a specialist in the analysis of images of the body), who advised that it is normal practice to initially investigate any patient with a history of prior malignancy and suspected MSCC with an MRI of the whole spine. We, therefore, considered that it was unreasonable in A's case for the board to have carried out a CT rather than an MRI scan. It was noted that there was limited MRI scanner availability the day A presented, however, guidance allows for an MRI scan to take place within 24 hours. We found that an MRI scan should have been undertaken the following day and this omission was unreasonable. Had the MRI scan taken place, the spinal tumour would have been detected earlier. We were unable to say whether this would have had an impact on A's overall prognosis. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to conduct an MRI scan prior to discharging A. 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:

• NHS Lanarkshire's guidance on the management of MSCC should be reviewed to ensure that it is in line with NICE guidance. The findings of this investigation should be shared to ensure relevant learning for staff.

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 to us about the care and treatment that they and their two children had received from a dentist. They said that they were told by the dentist that they and the children did not have any cavities, but when they attended another dentist, they were told that they had cavities and needed fillings. One of the children also needed crowns and experienced an abscess.

We took independent advice from a dentist. We found that the dentist complained about had failed to take bitewing X-rays (detect decay between teeth and changes in the thickness of bone caused by gum disease) for C and their children, which was unreasonable. There were also failings in relation to documentation. Whilst it was reasonable that one of the children was told that they had no cavities, we found that based on the evidence available, C and the other child had cavities that needed treatment when they attended the dentist.

We also found that the abscess experienced by one of the children was not avoidable, however, the dentist did not follow the relevant guidance on treating the abscess and gave the child antibiotics with no justification for their prescription. There was also no evidence available to demonstrate that the dentist discussed and explained treatment plans to C on all occasions. Given these failings, we found that the dentist's practice fell below the expected standard and upheld complaints about the care and treatment provided to all three patients.

C also complained to us about the way in which their complaint had been handled. We found that the dentist had not responded to C's concerns regarding their own care and treatment, or that of one of the children. Consequently, we found that the dentist had not handled C's complaint in line with the NHS Complaint Handing Procedure and we also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. 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:

• Bitewing x-rays should be taken in line with the relevant guidance. (Selection Criteria for Dental Radiography, FGDP).
• Clinical notes should be recorded in line with the relevant standards (4.1, Standards for the Dental Team, GDC & Clniical and Examination & Record Keeping Standards (FGDP)).
• Communication with patients and/or their guardians, and conversations regarding consent, should be carried out and documented in line with the relevant standards (Principles 2 and 3, Standards for the Dental Team, GDC).
• Diagnosing and treating abscesses should be in line with the relevant guidance (Management of Acute Dental Problems Guidance, SDCEP).
• Radiography reporting should comply with the relevant regulations.

In relation to complaints handling, we recommended:

• Complaints should be responded to in line with the NHS Complaints Handling Procedure.

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 on behalf of their parent (A) who had stage one oesophageal cancer at the time of the complaint. A was admitted to hospital via the A&E and later diagnosed with pulmonary embolism (PE, a blockage of an artery in the lungs).

C complained that the board delayed in diagnosing the PE and that the care and treatment they provided to A was subject to delays and unreasonable. C was concerned that A had been incorrectly treated as a palliative patient when their cancer was not advanced and that should not have impacted the care A received.

The board apologised for the delay in diagnosing PE and for the delays to A's care that happened whilst they were an in-patient e.g. delay to x-ray being carried out. The board considered various aspects of A's care, such as, when they decided to use a nasogastric (reaching or supplying the stomach via the nose) feeding tube and the action they took to manage A's sepsis, to be appropriate at the time.

We took independent clinical advice from advisers with relevant experience. We concluded that the board failed to diagnose the PE when they should have, that they failed to carry out the x-ray when it should have been done, and that they delayed starting antibiotics to treat suspected pneumonia. We considered that if these delays did not happen, it is likely that A would not have needed to be admitted to a high dependency unit for care. We noted that the decision to use a nasogastric feeding tube was taken reasonably and in line with relevant guidelines.

In light of this, we found that there was an unreasonable delay in diagnosing PE and that there was a delay in starting antibiotics for suspected pneumonia. These delays likely led to A's condition worsening and contributed towards the requirement for A to be admitted to a high dependency unit. There were also communication failings that led to a delay in an x-ray being carried out.

We identified failings in the way in which the board handled the complaint. We found that the board's response to C's complaint did not address the matters raised in a structured format, which made it difficult to follow.

As such, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. 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 suitable handover tool should be used consistently to ensure instructions have been carried out as prescribed, e.g (SBAR) Handover Tool.
• Patients presenting with symptoms of pulmonary embolism should be diagnosed and treated in line with the relevant guidelines. Clinicians should be aware of confirmation/cognitive bias in differential diagnosis of patients with pre-existing conditions.
• Patients should be treated appropriately for their presenting symptoms and where appropriate antibiotic treatment commenced.

In relation to complaints handling, we recommended:

• Complaint responses should be clear and understandable, in line with the NHS Complaints Handling Procedure.

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's spouse (A) had advanced kidney cancer which had spread to their brain. A was admitted to hospital after they developed breathing problems. They were diagnosed with a pulmonary embolus (blood clot in the lung). A agreed for the pulmonary embolus to be treated in hospital, in the hope that they could be discharged once stable, but their condition deteriorated and they died in hospital.

There was a period during A's admission when their medication was stopped while clarification was sought as to their treatment plan. C complained about the clinical decision-making regarding A's care and treatment. C considered that failings in A's care and treatment led to their death in hospital, denying them of the right to be cared for at home. C also complained about the board's communication.

We took independent advice from a consultant physician. We noted how difficult this case was, in particular from the perspective of the family. Although we noted certain areas of care that could have been better, we considered that overall the standard of care and treatment was reasonable and that A was nearing the end of their life by the time of their admission. We did not consider that the outcome would have been different had there not been a period of time during which medication was withdrawn pending clarification of A's treatment plan. Therefore, we did not uphold this complaint.

We noted that a number of physicians were involved in A's care and treatment and that there had been a degree of uncertainty about A's treatment plan. Although some aspects of communication could have been better, we considered that the clinicians did their best to communicate to A's family how ill A was and to have appropriate discussions with them around resuscitation and escalation. Therefore, we did not uphold the complaint about communication.

Summary

C complained about the treatment that they received from the practice during a three year period. C had repeatedly reported symptoms of a cough and breathlessness and was prescribed an inhaler but it took a number of years until they were diagnosed with Sjogren's syndrome (a condition which affects parts of the body that produce fluids like tears and spit (saliva)). C believed that action should have been taken by the GP at the practice to arrive at the diagnosis sooner.

We took independent advice from a clinician and found that the GP had provided C with appropriate medical treatment in view of the reported clinical symptoms and that they made a timely referral to hospital specialists. Although C was subsequently diagnosed with Sjogren's syndrome, this was not as a result of a failing in the treatment provided by the practice. We did not uphold the complaint.

Summary

C complained to the board about the care and treatment which their late parent (A) received at the A&E at Glasgow Royal Infirmary. A had presented as an emergency following them taking too much medication. A was not admitted to hospital but was discharged home and advised to take Codeine (a sleep-inducing and analgesic drug derived from morphine). A died shortly after their discharge from hospital.

We sought independent clinical advice from a professional adviser. We found that apart from a failure to complete some initial observations, staff in A&E performed appropriate investigations and that it was clinically appropriate to discharge A from hospital. There was no indication from the clinical records that staff had prescribed A Codeine on discharge or that this was said to them. We did not uphold the complaint.

Summary

C complained to us on behalf of their parent (A) who has dementia. A was admitted to Glasgow Royal Infirmary (GRI), after falling at home. A's condition improved and they were discharged home. After a few days, A was readmitted to GRI and treated for pneumonia (inflammation in the tissue of the lungs). Although A responded well to the treatment, their family was concerned about their mobility and pain when moving. A was referred for imaging of their pelvis and hip, which did not find a skeletal injury. Later that month, A was transferred to Stobhill Ambulatory Care Hospital. Around a week later, A was given a lumbar x-ray, which found a vertebral wedge fracture (a fracture of the bones commonly called the lower back). C raised concerns about A's medical care and their nursing care at both hospitals.

We took independent advice from a consultant physician in geriatric medicine (a specialist in medicine of the elderly). We did not consider that there was an unreasonable delay in carrying out A's lumbar x-ray. In particular, we found that it was appropriate that the medical staff had focused on ruling out A having fractures that might be treatable with surgery. We did not uphold this aspect of C's complaint.

We also took independent advice from an acute nursing specialist. We found that A's pain was not assessed appropriately, as nursing staff did not use the correct tool for someone with cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). We also found that A fell at a time that they should have been under enhanced supervision by nursing staff due to their high risk of falls. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care. 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:

• Patients with cognitive impairment should have their pain levels assessed using an appropriate tool so it can be managed appropriately.
• When patients are considered to require enhanced observations in a cohort room, there should be appropriate nursing staff (in terms of both skill mix and staffing levels) to implement this.

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 made a complaint on behalf of their partner (A), who had a cancer diagnosis. C complained that there was a failure to keep A reasonably informed about appointments for treatment. C considered that the board had failed to ensure that they had A's address correctly recorded on the patient database. C also raised concerns about a delay in responding to the complaint, and a failure to provide a consistent explanation about why A was not reasonably informed of appointments for treatment.

We found that the board were able to provide copies of letters with the correct address, and whilst these had not been received by A, it was not possible to say that they had not been sent. In addition, whilst A turned up for an appointment that A did not know had been cancelled, the consultant did see A to carry out a full consultation. We did not uphold this aspect of C's complaint.

We found that the board provided conflicting accounts of what address information was held on the databases for C and for SPSO and whether or not this required to be corrected/had been corrected.

We also found that there was a delay in responding to C's complaint. We noted that the complaints department had moved, but we considered that it was reasonable to expect that the board would have in place a mechanism to forward the mail addressed to the complaints department to the new location within a reasonable period of time. We upheld these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for (i) a failure to ensure they had correctly recorded on their patient databases A's address which he had lived at since August 2015, (ii) a failure to provide a response to C's complaint within a reasonable period of time and (iii) a failure to provide a consistent explanation regarding why there was a failure to ensure A was reasonably informed of appointments for treatment. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Ensure patient addresses are accurate on all databases.

In relation to complaints handling, we recommended:

• Ensure complaint correspondence received is directed to the correct department.
• Ensure a thorough investigation is carried out before a stage 2 response is sent to a complainant.

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 their family member (A) received from the board.

A had a complex medical history and received treatment in hospital on a number of occasions. C became aware that a wound that A had on their leg had deteriorated. C was very concerned about the condition of the wound.

C complained that, although A had been in and out of hospital on a number of occasions, the board had failed to take reasonable steps to treat A's leg wound. They complained that A was discharged from hospital on multiple occasions following treatment for infections, but that follow-up arrangements were inadequate and, as a result, the leg wound was left to deteriorate. C said that A had suffered both physically and mentally and that family members had been extremely distressed seeing A suffer.

We found that A's complex medical history meant that they had multiple hospital admissions and that they were seen regularly by community based district nurses and tissue viability nurses. A's wounds were quite severe and were complicated by the fact that their condition caused their leg muscles to contract, keeping the two skin surfaces together and difficult to access for pressure-relieving treatment. There was no suggestion that the wound on A's leg was caused, or made worse, by any shortfall in the care and treatment provided by the board.

We were satisfied that staff caring for A were aware of their wounds and made efforts to relieve the discomfort that they caused as well as working towards helping them to heal. Upon each admission to hospital, A's wounds were assessed and a referral was made to the tissue viability service for review. Whilst on some occasions A was discharged home before the review could occur, they continued to receive care at home from the community tissue viability nurses.

Whilst overall we were satisfied that A's wounds were taken seriously and a management plan was in place, we found that some discharge documentation was incomplete and that communication between the hospital and community based teams was lacking at times. As such, the most up-to-date review information from the acute tissue viability service may not have been communicated to the community nurses who provided the regular care that A required. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Consider holding a multi-disciplinary team meeting to discuss how to improve communication between teams and provide a holistic approach to care for individuals with multiple needs.
• Remind all appropriate staff of the importance of completing all discharge documentation and wound care charts.

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 of their late parent (A) who died in Glasgow Royal Infirmary (GRI) from respiratory failure and an undiagnosed progressive neurological condition. Potential Motor Neurone Disease (MND, a rare condition that progressively damages parts of the nervous system) had been noted by a neurology registrar five months earlier but this diagnosis was never confirmed. A was admitted to GRI four times over the following months, and C complained that their rapidly deteriorating condition was not acted upon and that palliative care was not initiated.

We took independent advice from a consultant neurologist (a specialist in nerves and the nervous system, especially of the diseases affecting them), who noted that investigations planned by the neurology registrar were not followed up, and that a referral to a specialist neuropathy clinic was not fulfilled, within national waiting time targets. We found that the medical teams caring for A during their hospital admissions failed to consider a neurological disorder as the cause of their deterioration and failed to seek specialist neurological input. We considered that neurological clinical standards should have been applied regardless of the absence of a confirmed diagnosis, and this would have included a timely assessment of communication, nutritional and respiratory needs. Notwithstanding this, we found that the palliative symptom treatment offered to A in the last months of their life was of a reasonable standard and, despite the absence of a diagnosis, we saw no evidence that A suffered from a lack of care or treatment. On balance, however, we upheld this complaint.

C also complained that the family were not informed that A's condition was terminal. We did not consider that staff were in a position to predict A would die when they did, given the lack of clear neurological diagnosis, and we were satisfied that there was communication with the family when death was appreciated to be imminent. However, the failure to seek specialist neurological input meant that there was a missed opportunity to clarify the diagnosis and enable clearer communication with the family regarding the prognosis. C also complained that the board failed to explain why a post mortem (PM) was not deemed necessary when A's deterioration and death was viewed as sudden. While we did not consider that a PM would have identified the underlying cause of A's neurological deterioration, we noted that it would have been best practice to discuss this with the family and seek their views before reaching a decision regarding a PM. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family that the failure to seek specialist neurological input meant there was a missed opportunity to clarify A's prognosis and enable clearer communication with them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for failing to ensure planned investigation was carried out within National Waiting Time Guidance; for the failure to seek a specialist neurological opinion during A's hospital admissions; and for the failure to apply the Neurological Standards regardless of the absence of a confirmed diagnosis.

What we said should change to put things right in future:

• An effective handover of care should take place, and planned referrals should be followed up, when a clinician moves on to a different role / their role in providing a patient's care has ended.
• The board should consider their processes for ensuring maximum waiting times from diagnosis to treatment are adhered to, where possible, particularly in regard to patients who have progressive neuromuscular disease.
• The board should provide education to respiratory and emergency physicians to ensure they are aware of the potential contribution of neuromuscular weakness to respiratory failure in emergency situations, how to recognise this and how it can be managed effectively.
• The board should reflect on the view that the Neurological Standards would have been appropriate in this case, regardless of the absence of a confirmed MND diagnosis, and feed this back to relevant staff in a supportive manner to ensure that current standards are applied, where appropriate, in future.

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.