Health

Summary

C complained about the failure of emergency mental health services to treat them during crisis admissions. C stated that they had been brought to the hospital on multiple occasions by police but that an assessment was not always carried out. C also complained that they had not been allocated a psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness) or a community psychiatric nurse.

The board responded by advising that services treated C appropriately when they attended and completed assessments when required. They also stated that C previously was supported by a psychiatrist but disengaged from this service and did not re-engage with services in the intervening period. C was unhappy with this response and brought their complaint to us.

We took independent advice from a psychiatric adviser and a mental health nurse. We found that the medical records showed that the board had acted reasonably and occasions where full assessments were not completed were appropriate and in keeping with strategies put in place to treat C. We considered that the plan to manage C's crisis contacts was in their best interests and we found no evidence of mental health assessment's being unreasonably withheld. Therefore, we did not uphold this aspect of C's complaint.

In relation to the allocation of a psychiatrist, we found that C had disengaged with services. However, proposed actions suggested by a psychiatrist to re-engage and support C did not appear to be actioned and records showed an unexplained gap in contact between C and services of around 18 months. Therefore, we upheld this aspect of C's complaint.

C requested a review of our decision and the case was reopened for further consideration. Details of this are explained below.

C was admitted to A&E at the Royal Infirmary of Edinburgh (RIE). After being transferred to an acute medical unit (AMU) from A&E, they left the ward and returned to their home. The police were contacted and they visited C at their home. C was detained under the Mental Health (Care and Treatment) (Scotland) Act 2003 (the Act) and returned to the RIE the following morning. C complained that the assessment carried out following C being detained and taken to hospital was unreasonable.

We took independent clinical advice from a consultant psychiatrist. We found that, while the board met the minimum requirement of the Act in terms of undertaking a medical assessment, there was no clear documentation detailing the mental state examination. We considered, given the complexity of the case, the lack of recent review and the presentation of C at the time, a formal assessment undertaken by an appropriately trained clinician from psychiatric services would have been reasonable and this did not take place. As such, we upheld this aspect of C's complaint.

C also complained that the assessment that was undertaken into their capacity was unreasonable. We found that there was no evidence to suggest that C did not have capacity to make their own decisions at the time. We noted that informal assessments are undertaken in every clinical interaction and we would not expect a formal capacity assessment to have been undertaken when clinicians considered C retained capacity. The psychiatric team had advised that in terms of C's mental health they considered C had capacity to make decisions on their care. The focus was then on whether C's physical injuries required care but C had consented to treatment for the same. Therefore, it was determined that there was no reason to detain C or undertake a formal capacity assessment. As such, we did not consider the lack of a capacity assessment to be unreasonable in these circumstances. We did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to undertake a formal assessment of them by an appropriately trained clinician from psychiatric services. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that the agreed actions and proposed strategies were not pursued. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Individual clinicians will reflect on the outcome of this investigation as required within their annual appraisal process.
• The board should take steps to ensure that treatment plans devised are effectively followed through, in order to try and foster trusting relationships, minimise a sense of rejection, demonstrate service consistency and reliability and show a willingness to work in an open, engaging and non-judgemental manner.

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 practice had failed to provide the correct prescription for their child (A). A had been diagnosed with type 1 diabetes and had been self-administering their medication with no issue. C said that this had changed and A found injections very painful. This had caused both A and the family significant distress. C said that the practice had prescribed the wrong type of needle and that this was not the type of needle specified by the hospital.

We took independent medical advice. We found that the practice had reasonably relied on their prescribing software. This was in line with both hospital and pharmacy requirements. The software had substituted a different product, and it was reasonable for this to have been prescribed. Additionally, the practice had responded timeously to C when they reported the problems A was having. Therefore, we did not uphold this aspect of C's complaint.

C also complained that the practice had failed to provide an adequate supply of needles.

The practice had accepted that A was not provided with the correct number of needles. They did not accept that they had not responded to C's requests for assistance timeously. We found that it was clear that C had not been prescribed the correct amount of needles and that it would be appropriate for the practice to reflect on this error, to improve future practice. Therefore, we upheld this aspect of C's complaint.

We noted that the practice had already committed to reviewing A and C's case through a Significant Event Analysis (SEA) and we asked them to provide us with a copy of their findings, as well as feeding them back to the board. We did not make any further recommendations.

Summary

C complained on behalf of their relative (A) about the treatment A had received from the board. A had emergency surgery to repair a dissected aorta (a tear in the heart) and was discharged following treatment. A developed an infection in their surgical wound and was readmitted to hospital for further treatment. C complained that in treating A's infection, the board incorrectly administered A with penicillin (an antibiotic) to which they are allergic. Following intravenous Co-Amoxiclav (antibiotic used for bacterial infections), A developed a skin rash. C also complained that A was administered ibuprofen which should not have been prescribed to A due to the heart medication they were taking.

We took independent advice from a clinical adviser. We found that there was no evidence in A's medical records of a penicillin allergy prior to the development of their skin rash following intravenous Co-Amoxiclav. We also found that the board's use of a penicillin derivative was reasonable and an appropriate choice of antibiotic for A's wound infection. We noted that the potential adverse effects of taking ibuprofen did not mean that it could never be used in patients taking A's heart medication. In A's case, the use of ibuprofen postoperatively had not been sufficiently documented, therefore we were not able to determine whether its use was appropriate. On balance, we found that the board had provided a reasonable standard of treatment to A and did not uphold this aspect of C's complaint.

C further complained that the board had not provided A with clear information regarding their cardiology (area of medicine concerning diseases and defects of the heart and blood vessels) rehabilitation and aftercare, resulting in a delay in A receiving appropriate follow-up appointments.

We took independent advice from a cardiologist. We found that the board had not correctly processed A's referrals for cardiology follow-up and cardiac rehabilitation or done so in a timely manner. The board had not correctly identified a discrepancy in A's nutritional assessment scoring or followed this up at the time. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and A's family for not correctly processing the referrals for their cardiology follow-up and cardiac rehabilitation, and for providing A with aftercare that fell below a reasonable standard. 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:

• Ensure a process or system is implemented so that discrepancies with patient malnutrition universal screening tool (MUST) scores/nutritional assessments are easily identifiable so that follow-up dietetics reviews can be requested.
• Ensure appropriate referral pathways are in place to ensure patients receive timely cardiology and cardiac rehabilitation follow-up as noted in a patient's post-surgical discharge summary.

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's decision to discharge their late parent (A) from University Hospital Monklands. A had metastatic cancer (cancer that has spread from the part of the body where it started) and had been admitted to hospital with blood in their urine. A was treated with antibiotics and antifungals, however, their infection markers remained elevated. As A showed no other signs of infection, their elevated infection markers were attributed to their cancer and they were discharged home. A was readmitted to hospital the following day with a deep vein thrombosis (DVT, blood clot in a vein). Their condition deteriorated and they died eight days later.

C complained that A had been discharged from the hospital before they were fit to return home. C also raised concerns about the hospital staff's communication regarding A's condition and discharge. C considered that failings by the board meant that A endured unnecessary suffering which distressed family members.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We were satisfied that the hospital staff communicated clearly and regularly with C throughout A's admission to the extent that C was kept informed as to how A was fairing on the ward. We were also satisfied that nursing and clinical staff appropriately monitored and recorded changes in A's mobility and attempted to provide physiotherapy when A was willing and able to participate.

We found that, in the days before A's discharge, C had raised concerns with the nursing staff regarding A's foot being swollen. We noted that this should have raised the suspicion of a DVT specifically and that investigations should have been carried out prior to A being discharged. Whilst the nursing staff advised C that their concerns would be passed on to the medical team, we found no evidence of this happening and concluded that an opportunity was missed to investigate and diagnose A's DVT prior to their discharge. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards setout in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 underwent surgery for removal of a complex cyst on their right ovary. C complained that during the surgical procedure the board unreasonably removed their left ovary despite their express wishes it should be retained. They said that in the absence of a fully informed pre-surgical consultation, the board had not understood their surgical choices and had unreasonably prepared them for surgery. They said that following surgery, the board had failed to provide them with adequate pain relief and had withheld their medication. C also complained that the board's handling of their complaint was inadequate and that there were delays and inaccuracies in their response.

We took independent advice from an appropriately qualified adviser with experience in obstetrics and gynaecology (pregnancy, childbirth and the female reproductive system). We found that the surgical procedure performed was in line with the recommendations of a multidisciplinary team (MDT) and that the board had acted on what they believed were C's express instructions and for which written consent had been obtained. As such, we did not uphold this part of the complaint.

We found that despite reasonable attempts to include C in the pre-surgical decision-making and consent process, the board had failed to clarify with C their understanding of the proposed surgical plan and the circumstances in which C's left ovary was to be removed. We also found that the board had not telephoned C following the MDT team meeting as had been agreed, and some of the pre-surgical discussions that had taken place between the parties were brief or had not been documented in the clinical records. Therefore, on balance, we upheld this part of the complaint.

Following C's surgical procedure we found that there were two occasions where analgesia (pain medication) had been delayed after being requested, and on one of those occasions where it appeared to have been an inadequate dose. However, we found that C's usual pain regime medications had been administered regularly and their acute pain medications administered when requested. As such, we found that C had been provided with appropriate pain relief and did not uphold this part of the complaint.

We found that the board's complaint handling in this case was poor. There was a failure by the board to update C on the progress of the investigation and there were delays in a number of their responses. The board's final response contained a number of factual inaccuracies and it had not adequately addressed all of C's concerns. As such, we upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to clarify their understanding of the proposed surgical plan, the circumstances in which their left ovary was to be removed and for failing to handle their complaint reasonably. Also apologise for not sufficiently documenting the discussions that took place between the parties at the initial consultation, for failing to contact C by telephone following the MDT meeting, and for failing to document the pre-operative discussions which took place between the parties on the morning of C's surgery. 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:

• Ensure all discussions between patients and clinicians are clearly documented as part of the consent process.
• All relevant clinical staff should be reminded of the need to ensure all reasonably practical steps are taken to clarify a patient's understanding of a proposed surgical plan prior to consent being obtained and that patients are fully counselled on the nature of borderline ovarian cancer results.

In relation to complaints handling, we recommended:

• The board should ensure all complaints are handled in line with the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. Where a response to a complaint cannot be provided within an agreed timescale, complainants should be provided within an updated timescale as to when they can expect to receive a response. The board should ensure all responses are accurate, reflect the available evidence and information, and address all points raised. Where there has been a delay in providing a response beyond the normal timescale, the board's stage 2 response should include an apology.

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 their child (A) with orthognathic treatment (orthognathics is a specialist subset of dentistry which involves surgical correction of growth issues with the jaw and lower face) within a reasonable timescale.

A's teeth were overcrowded to the extent that they caused pain in their head and jaw and difficulties with eating and speech. Following referral to an orthodontist, A was placed on the waiting list for orthognathic treatment. However, despite it being identified that A would require surgery, their treatment was not progressed. The board explained to C that this was due to a shortage of orthognathic specialists in their area and that an agreement with neighbouring health boards for them to provide treatment had come to an end. C complained that the board had failed A by not providing the required treatment within their area, or making arrangements for the treatment to be provided in another area, or privately.

The board were open and honest about the fact that they struggled to provide specialist orthodontic and orthognathic appointments over a number of years due to staff recruitment issues and the loss of arrangements with neighbouring health boards. They acknowledged and apologised for the fact that this led to substantial delays for A. We commended the board for their transparency in this respect and acknowledged that there were a number of factors beyond their control that limited the provision of these services and contributed to a long waiting list for all patients in the area.

We took independent advice from an orthodontic specialist. We found that, whilst it was recognised at an early stage that A would benefit from orthognathic surgery, this treatment would not have been available to A for a number of years. Surgery was first discussed when they were 11 years of age. We noted that, prior to surgery, there would be 12 to 36 months of preparatory orthodontic treatment and this would not normally start until the patient was 15 or 16 due to their bones needing to develop. Once this preparatory treatment had been completed, a multidisciplinary discussion would be undertaken to assess the nature of the surgery that would be required. The available evidence showed that the board followed this approach for A.

Whilst we were satisfied with the overall treatment plan for A, we found that there was an unreasonable delay of around 18 months to A being seen by a consultant following their referral to the orthognathic service. Although this did not delay A's treatment, we recognised that the long wait for a consultation and details as to what treatment options were available would have added to C and A's distress. Therefore, we upheld this complaint. We did not make any recommendations due to the appropriate action already taken by the board.

Summary

C complained about the care and treatment they received from the board for their hearing problems, and for their problems of dizziness/loss of balance.

We took independent advice from an ear nose and throat (ENT) specialist. We found that C's hearing problems were investigated appropriately and they were given multiple repeated investigations. We also found that appropriate steps were taken to investigate C's problems of dizziness/loss of balance. Therefore, we did not uphold C's complaints.

Summary

C complained to the practice about the lack of care provided to their late parent (A). C said that A had reported breathing and sleeping problems in a telephone consultation to the GP but the GP had only provided medication and A died from a suspected heart attack a week later. The practice believed that appropriate treatment had been provided.

We took independent advice from a GP. We found that there was no evidence that A had reported breathing problems to the GP and that there were no recorded symptoms which would have indicated that A required a face-to-face GP consultation, a hospital admission, or that A would suffer a sudden event a week after the telephone consultation. Therefore, we did not uphold the complaint.

Summary

C developed an infection following a wisdom tooth extraction, which was not diagnosed and subsequently spread to their brain. C was reviewed in hospital on several occasions, including out-patient reviews by oral and maxillofacial (OMF) surgeons (specialists in treating diseases and injuries of the mouth and face) and an in-patient admission to Victoria Hospital. C questioned how the infection was missed on so many different occasions by so many different people.

The board indicated in their response that there were no clinical signs which led them to suspect bacterial infection, and jaw joint problems were being considered as the cause of C's symptoms. C was then suspected, during their in-patient admission, to have viral encephalitis (inflammation of the brain). A plan to carry out an MRI wasn't pursued due to noted improvement in C's condition. The responsible consultant reflected that an MRI should have been performed during the admission, and that not doing so may have delayed the identification and treatment of the infection in C's brain.

We took independent medical advice from a consultant OMF surgeon and a consultant physician. While it was noted that C's infection presented atypically and was difficult to diagnose, their C-reactive protein (CRP, inflammation marker) was raised when they initially presented and this wasn't acted upon. A CT scan also showed subtle signs of infection but this wasn't picked up at the time. An urgent out-patient MRI was requested to look for joint problems and not to exclude infection, otherwise it may have been carried out sooner. We also found that the subsequent in-patient assessment didn't give due care and attention to C's recent wisdom tooth extraction and hospital attendances. It was agreed that the failure to pursue an in-patient MRI contributed to the failure to correctly diagnose and appropriately treat C's infection. We considered that the decision to discharge C with a persistent headache was unreasonable. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to diagnose and treat their infection earlier. 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:

• This case should have joint Mortality & Morbidity review. The findings of this investigation should be presented, to ensure relevant learning for staff from the OMF service, radiology and medicine.

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 practice did not take reasonable action in response to their late spouse (A)'s symptoms and condition. A had a long history of degenerative disc disease affecting their spine (when normal changes that take place in the discs of your spine cause pain) and a history of stomach cancer. A visited or contacted the practice several times over three months regarding pain in the neck and shoulder, numbness in the right hand and jerking of the right leg. Tests were undertaken, medication and therapies prescribed and a referral to an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was made. Following a fall at home, A was admitted to hospital where a spread of cancer to A's spine was diagnosed.

A died shortly after C submitted a complaint to the practice about their response to A's symptoms and condition over the previous few months. In response, the practice recounted the actions they had taken in response to A's visits and contacts in their final months, highlighted blood tests whose results did not indicate any significant abnormality or spread of cancer and explained that A's symptoms were relatable to their ongoing diagnosis of degenerative cervical disc and spinal stenosis (a condition where the space around the spinal cord narrows, compressing a section of nerve tissue). The practice advised that a significant case review had been carried out. This had highlighted that A's orthopaedic referral could have been upgraded to urgent when it was clear A's symptoms were not being controlled, but stated that it was doubtful this would have had any impact on the outcome. C was unhappy with this response and brought their complaint to this office.

We took independent advice from a GP. We found that the practice took reasonable action in response to A's symptoms and condition until a point. However, when it was clear that A's symptoms were not being controlled and began to worsen, the practice's actions were unreasonable. We found that the potential significance of test results reported to the practice and the potential link with A's symptoms were not reasonably recognised by the practice until they reviewed A's care and treatment as a result of our investigation of the case. Therefore, we upheld C's complaint. However, while we noted that earlier action by the practice may have led to an earlier admission to hospital, it was extremely unlikely to have prevented A's death.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. The apology should make clear mention of each of the failings identified, whether that was identified by the practice or this office. 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 practice should review how it deals with blood samples that are significantly outwith the normal range. This would include consideration about how they are communicated with the patient, how they are highlighted in the notes and how they are followed up.
• The practice should review their current policy on home visiting patients who are too frail or too unwell to attend the practice to ensure there is a clear criteria for accepting or refusing a home visit and that safeguards are in pace when a home visit request is turned down.

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.