Health

Summary

C complained about the care and treatment provided by the board to their parent (A), who was admitted to hospital with severe back pain after suffering a suspected fall and later diagnosed with osteoporosis (a condition that affects the bones, causing become fragile and more likely to break). C complained about the physiotherapy and occupational therapy assessments carried out during A's admission, the communication by staff and a lack of recognition of A's cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). C also complained about the lack of written information about osteoporosis/fragility fractures and how they should be managed after A's discharge, and A's follow up care, in particular, the failure to carry out a DEXA scan (a special type of x-ray that measures the density of bones).

In order to investigate C's complaint, we took independent advice from a trauma and orthopaedics (conditions involving the musculoskeletal system) adviser. We found that it was reasonable, in light of cognitive assessments undertaken by A, for staff to have taken the information A provided at face value. It was also reasonable in light of current practice and guidance for the board not to have provided A with written information about the management of osteoporosis upon discharge. We also found that the decision not to offer a DEXA scan was appropriate given the diagnosis, and that the appropriate treatment for this type of injury (osteoporosis/fragility fractures) was conservative management and therefore follow up care was not a requirement.

However, we identified a number of failings including that the board unreasonably delayed in starting A's osteoporosis treatment and that there were also failings in communication. In view of these specific failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the delay in starting A's osteoporosis treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• There should be a clear treatment pathway in place for patients starting osteoporosis treatment which is based on the relevant national guidance so as to avoid unreasonable delay in the start of their treatment.

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 provided to their spouse (A) when they became unwell with severe lower abdominal pain and vomiting. A was visited and examined by an out-of-hours (OOH) GP, who administered an injection for vomiting and left some medication for A. A's condition worsened and a different OOH GP attended the same evening. A was taken to hospital by ambulance and was found to have a perforated bowel (hole in the large intestine) and kidney failure. Medical intervention was not considered appropriate and A's care was redirected to palliative care. A died in hospital two days later.

C complained that the first OOH GP missed important aspects of A's condition during their home visit. C further complained that when A was admitted to hospital, A was left in pain and discomfort for many hours and it was only when C raised concerns that A was given stronger pain relief.

We took independent advice from a GP adviser, as well as a registered nurse and a general physician in acute medicine.

We found that overall, the assessment and examination carried out by the first OOH GP was reasonable and appropriate. It was determined that there was nothing suggestive of an acute abdomen (sudden, severe abdominal pain) which would have necessitated admission to hospital. We did not uphold this aspect of C's complaint.

C also complained that A was given unreasonable care and treatment in the hospital, in relation to managing A's pain. We considered that overall, the approach to A's pain management by nursing staff was reasonable. Nursing staff identified A's level of pain from first admission and throughout and took appropriate action to try and address this.

However, we found that given the very high doses of morphine administered, medical staff should have checked the medication prescribed to see if it was working, and review or prescribe something else. Furthermore, given that the medical team would have been aware that A was on the ward round for comfort care, a palliative care referral could have been made earlier. We considered that an earlier referral may have supported better comfort care for A in the final stages of life. As such, 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. 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:

• Pain medication prescribed for patients should be appropriately checked by medical staff to see if it is adequately working. Referrals to palliative care should be made in a timely way without delay.

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 late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, the patient in the bay beside A was confirmed positive for COVID-19. A received a test for COVID-19 and was discharged home. A was then made aware that they had COVID-19. A's condition deteriorated and they died.

C complained about the placement of A within an amber zone, rather than a green zone at the hospital. C was also concerned that A was placed in a bay beside the other patient, who subsequently tested positive for COVID-19.

We sought independent advice from a consultant oncologist (a specialist in the diagnosis and treatment of cancer). We noted that the COVID-19 guidance in place at the time required NHS Boards to have COVID/Non-COVID areas and provided examples of pathways for how NHS Boards might separate patients. The guidance was not prescriptive and each NHS Board had to decide how to apply the guidance to the different hospital environments within their area. We found that the board’s internal pathways were consistent with the pathways set out in the guidance. Given that A did not meet the criteria for a low risk/green zone within the hospital, we found it was reasonable to place A in an amber zone based on the information known at the time. We therefore did not uphold this aspect of the complaint.

We recognised how distressing it must have been for C to learn that their parent had contracted COVID-19 while in hospital. To assess this aspect of C's complaint we obtained the relevant clinical records for the other patient and shared these with the independent adviser. We found that the symptoms the other patient was exhibiting were not thought to be due to COVID-19 and we did not identify any failure regarding the placement of A beside this patient. We therefore did not uphold this aspect of the complaint.

Summary

C, an advocate for A, complained about the way A was treated by the board for their chronic psychotic illness. A experienced a relapse when administration of their medication was changed from a depot injection (a slow release method) to an oral route. A subsequently required two in-patient admissions. C complained the second admission only occurred due to a failure by the board to manage A's medication properly, and to being discharged from their first admission when they were still experiencing psychotic symptoms.

We took independent clinical advice from a consultant psychiatrist on the board’s management of A's medication and the circumstances of their discharge from hospital during their first in-patient admission. In reference to the board managing A's transition back onto their medication by depot injection, we found that this had been managed appropriately, and in agreement with A. However, we noted that the documentation of this could have been better. While we did not uphold this aspect of the complaint, we gave feedback to the board in respect of record-keeping.

Regarding the timing of A's discharge from hospital, we found that this had been reasonable and person-centred in approach, noting there was no reference in the medical records to A experiencing psychotic symptoms at the time of their discharge. As such, we did not uphold this aspect of the complaint.

Summary

C, an advocate for A, complained about the actions of the board's paediatrics department in relation to child protection concerns raised about A's child (B). C complained that the board did not reasonably communicate with A about the concerns raised and that they took an unreasonable length of time to arrange a child protection conference. C also complained that the board failed to fully involve the family GP in the child protection process and to explain the rationale for proposing to reassess B's autism spectrum disorder (ASD) diagnosis.

To investigate C's concerns, we reviewed the relevant clinical records and sought independent advice from a consultant community paediatrician. Our investigation found that the steps taken to invite A to a meeting to discuss the concerns about B and to share a summary of the professionals meeting held were reasonable. We also concluded that from the time the concerns were noted to holding a child protection conference, it was reasonable to consult with other professionals, gather information and attempt to speak with A. As such, we did not consider there was an unreasonable delay in holding the child protection case conference.

We also found evidence that the family GP was invited to a professionals meeting by email, however, due to administrative errors outwith the board’s control, the email was not received by the GP. With regards to the reassessment of B's ASD diagnosis, we concluded this was explained both in writing and at a meeting. We therefore did not uphold C's complaints.

Summary

C complained about the treatment they received at the Queen Elizabeth University Hospital. C said that they had been admitted with problems concerning a foot ulcer and that on both occasions they were discharged home after one night in hospital. C felt that they should have been admitted for a longer period to ensure that their condition improved and that they were able to take any medication which was required. The board felt that C was fit for discharge on both occasions and that there was no clinical requirement that C should remain in hospital and it was appropriate to discharge C home with support from the district nurses.

We took independent advice from an adviser and found that staff at the hospital had carried out appropriate investigations and that it was appropriate to discharge C home with support from the district nurses to change the foot dressings. We did not uphold the complaint.

Summary

C attended Queen Elizabeth University Hospital (QEUH) on a number of occasions prior to being diagnosed with cauda equina syndrome (CES, a narrowing of the spinal column where all of the nerves in the lower back suddenly become severely compressed). C required two emergency surgical procedures and has been significantly impacted by the condition. C complained that there were missed opportunities to diagnose CES, and about the clinical assessments carried out at QEUH.

C's complaint concerned assessments in A&E and in gynaecology (specialists in the female reproductive system). We took independent advice from a consultant in emergency medicine and a consultant gynaecologist. We found that C was assessed appropriately during each admission to A&E. We found that C was displaying no red flag symptoms and that appropriate follow-ups were arranged. We also found that C was not exhibiting symptoms which would indicate CES, nor was C displaying symptoms which would have triggered immediate imaging. We were satisfied that C was assessed appropriately and that it was reasonable to arrange follow-up gynaecology assessment later that day. We did not uphold these aspects of the complaint.

We also found that C was appropriately assessed when they attended the emergency gynaecology appointment. There was no clinical evidence to suggest C needed emergent care. The doctor noted no symptoms of CES and consulted with the consultant on call before discharging C with appropriate advice. We found this was reasonable. We did not uphold this aspect of C's complaint.

Summary

C complained about their waiting time for hip replacement surgery. C was initially added onto the waiting list for surgery but was later removed after C advised the board of their personal circumstances. A couple of months later, C was added back onto the waiting list for surgery but, after a long wait, C had the hip replacement carried out privately later in the year.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C was correctly removed from the waiting list because their personal circumstances meant that they would be unable to undergo hip replacement surgery. However, this decision was not explained to C at the time. We also found that C was unreasonably added back on to the waiting list, when they remained unfit for surgery. We also concluded that there was no out-patient clinic letter to match the date that C was added back onto the waiting list. For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not informing them of the decision to remove them from the waiting list for surgery, for adding them back onto the waiting list when they were not fit for surgery and for there being no out-patient clinic letter to match the date that C

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

• Out-patient clinic letters should be in place to match the date a patient is added to the waiting list.
• Patients should be informed when a decision is made to remove them from the orthopaedic waiting list for surgery.

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

Ccomplained that their late parent (A) called the practice and was given a prescription without being seen in person. C also complained that an appointment or home visit wasn’t arranged when C called three days later and reported that A's condition had worsened.

We obtained independent advice from a general practitioner adviser. We found that the actions taken by the practice at the time of the initial call were reasonable and considered it reasonable for A not to have been seen in person at that time. We also considered that reasonable action was taken when C called three days later, based on what was documented in the records. However, it was acknowledged that there were differing accounts of what had been discussed, and that the symptoms C said they communicated would reasonably have prompted A to be seen in person. Based on the evidence available and the advice obtained, which we accepted, we concluded that A received reasonable medical care and we did not uphold this complaint.

However, we noted that the level of documentation could have been improved. This includes recording when safety netting advice is given (when patients are advised to return if their symptoms don’t improve, advice which the practice said was given to A during the first call but was not documented); reasons why a patient is not spoken to directly (as was the case when C called); and reasons to see or not to see a patient in person, particularly for a repeat caller. We fed this back to the practice for their reflection and learning, along with feedback on their handling of the complaint.

Summary

C complained about the care and treatment provided to their parent (A) when they were a patient at Glasgow Royal Infirmary. C raised concerns that they had to alert staff to the fact that A had become unresponsive. C complained that A was stepped down from critical care to a medicine for the elderly ward when A was still unwell and suffering from delirium. C also complained about changes made to A's death certificate, which had been amended by a consultant, following the initial certificate prepared by a junior doctor. The death certificate was updated to fully reflect A's underlying condition, including the possibility of an underlying cancer diagnosis. However, it was subsequently amended again to remove the reference to cancer in light of C's upset over this.

We obtained independent medical advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A's condition was monitored appropriately and reasonable action was taken in a timely manner when it was noted they had deteriorated. We were satisfied that the board had already acknowledged and apologised for not keeping C updated while they dealt with A's care. Therefore, we did not uphold this complaint.

In relation to the second complaint, we considered action was appropriate as A was no longer in need of critical care, and confirmed delirium would not have been a reason to delay the transfer. We, therefore, did not uphold this complaint.

With regard to the complaint about changes to A's death certificate, we were satisfied that the board had provided an appropriate explanation and apology, and had demonstrated learning. We had no concerns about the accuracy of the death certificate. However, we noted that it would have been good practice to offer a post-mortem examination in light of the clinical uncertainty, and C's concerns, surrounding a possible underlying cancer. While we fed this back to the board, on balance, we did not uphold this complaint.