Health

Summary

C complained about the dental care and treatment that they received. C underwent root canal treatment (RCT) on their lower right tooth. C said that this was not performed appropriately and that they should have been referred earlier to an endodontist (a dentist with special training to treat problems affecting the inside of the tooth). C was also concerned that the dentist had caused injury to the inferior alveolar nerve (a nerve that runs through the lower jaw, providing sensation to the lower teeth, gum, lip and chin), left a gap in their tooth and caused a dent to another tooth.

We took independent advice from a dentist. We did not find conclusive evidence that the dentist caused injury to the inferior alveolar nerve or a dent to C's tooth. We noted that the dentist did refer C to the endodontist but we did not find conclusive evidence that this should have happened sooner. However, we concluded that the dentist did not follow current guidance on endodontic practice. There was no evidence of the use of special tests or periapical radiographs (an x-ray that shows the entire tooth, from the crown to the root tip and surrounding bone) taken before the RCT was performed. As such, it was not possible to determine the case complexity. The dentist also used incorrect solution to irrigate the tooth canal and used an old method for assessing the quality of the radiograph imaging taken. Therefore, we upheld 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/meaningful-apologies.

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

• The dentist should take the following actions. Read through the Professional duty of candour from the General Dental Council and make reflective notes. Read through A Guide to Good Endodontic Practice and make some reflective notes. Read through Section 5.4.1 of Guidance Notes for Dental Practitioners on the Safe Use of X-ray equipment (Second Edition, 2020) and make some reflective notes. Read the following article (https://www.dentalprotection.org/uk/articles/tempted-to-change-the-records) from Dental Protection and make some reflective notes. Undertake a CPD course on Endodontics (e.g. Turas online courses from British Endodontic Society) https://learn.nes.nhs.scot/59573

In relation to complaints handling, we recommended:

• The dental practice’s complaints procedure should be revised to ensure it aligns with SPSO’s Model Complaints Handling Procedure: www.spso.org.uk/the-model-complaints-handling-procedures. If further assistance is required with this, the dentist / practice can contact the SPSO’s Improvement, Standards and Engagement Team: https://www.spso.org.uk/training or NHS Lothian.

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 communicate appropriately with their partner (A) regarding charges for treatment. A is a non-UK resident and was charged for non-urgent treatment at hospital following an accident. C complained that A was not informed of the financial liabilities they would incur prior to their treatment, despite having confirmed that they were a non-UK resident and having repeatedly tried to ascertain this information. According to the relevant guidance, any liability to charging should be explained from the outset and patients should be asked to sign an undertaking that they agree to this, ideally before treatment commences.

In their response to the complaint, the board said that the correct process had been followed, and that the variation to the standard processing of A’s case was due to the local address information that was initially recorded. The board confirmed that further training and advice would be provided for clinical teams to ensure that they are fully aware of the guidance and how to advise potentially liable patients appropriately.

We found no evidence that the guidance was followed in A’s case. We considered it a failing on the board’s part that A’s overseas address was not recorded at their initial presentation, noting that their overseas status was documented in the records at that time. We also found that there was a missed opportunity to follow up on matters when A’s relative contacted the Private and Overseas Financial Team with an enquiry a few days after A’s initial presentation at the hospital. Therefore, we upheld C's complaint.

We acknowledged that the board had taken significant steps to improve their service following C’s complaint. A's insurer had also settled the outstanding sum. Therefore, we made no financial recommendation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings we have identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies. We note that the board do not intend to pursue A for any outstanding treatment charges not covered by A’s insurer. For A's records, and for the avoidance of any doubt, we request that the board’s apology letter includes a statement confirming that no outstanding sums are owed to the board.

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

• All relevant staff are familiar with how to input patient details on the MPI screen. All staff are aware of the Private and Overseas Finance Team contact details.

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 nursing care provided to their late parent (A) during their admission to hospital. A arrived at the emergency department before being admitted to a ward. While in hospital, A lost weight and had difficulty eating. Due to delirium, A’s mobility was poor and they experienced a number of falls whilst in hospital. This resulted in a broken hip requiring surgery.

In response to the complaint, the board agreed that there had been multiple failings in relation to the management of A’s diet and reduction in weight. When mobilising A, it was explained that staff did so in accordance with physiotherapy assessments and a number of measures were put in place to prevent A from falls. However, the board acknowledged that due to staffing levels, A did not receive the level of care that they should have.

We took independent advice from a nursing adviser. We found that basic nursing care could not be evidenced in A’s case due to a lack of individualised care planning and delivery. We found that the care provided to A was inadequate and inconsistent and was not provided to the standard required. Therefore, 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 report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Nursing documentation should be completed to standard required.
• Patients should receive appropriate nursing care.

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 them with reasonable care and treatment. C had a cancer diagnosis and was concerned about the length of time taken to arrange their surgery.

We took independent advice from a consultant clinical oncologist (specialist in the diagnosis and treatment of cancer). We found that it was reasonable for C's treatment plan to change and the delays in arranging a date for surgery were unavoidable due to capacity issues. Therefore, we did not uphold this part of C's complaint.

C also complained that the board's communication was unreasonable. We found that the board’s complaint response contained inaccurate information. In particular, it indicated that a provisional date for surgery was offered to C when this was not the case. Therefore, we upheld this part of C's complaint. However, we made no recommendations based on appropriate action already taken by the board.

Summary

C complained that the board failed to reasonably investigate and/or diagnose the cause of their symptoms of significant weight loss, intense abdominal pain, vomiting, altered bowel habit and nausea. C also complained that they were discharged from the board’s gastroenterology service (specialists in the diagnosis and treatment of disorders of the stomach and intestines) despite these ongoing symptoms. C said that they were left with no option but to obtain private care and treatment in England where they were diagnosed as suffering from mesenteric ischaemia (restricted blood flow to the intestines). C underwent surgery to correct this privately. While this resulted in significant improvements in C’s health, C complained that this course of action should not have been necessary and that there were cost implications.

In their complaints response, the board acknowledged and apologised for issues with delays in providing investigations, and failings with respect to communication. However, they considered the clinical decisions made in relation to the investigation and management of C’s case were appropriate.

We took independent advice from a consultant gastroenterologist and a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the board should have considered a diagnosis of mesenteric ischaemia as a strong possibility based on C’s presenting symptoms. Furthermore, when a CT scan was undertaken there was a failure to report the narrowing of the blood vessels supplying the gut. We found that the decision to discharge C from the gastroenterology service was unreasonable given their ongoing persistent symptoms and, of particular concern, their ongoing weight loss. Therefore, we upheld C’s complaints.

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 set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Calculate and reimburse C in relation to their private treatment (including the cost of travel to and from London for C after their discharge from the gastroenterology service) on production of appropriate receipts. The calculation should be based on what the treatment / surgery would have cost the NHS (rather than the full cost of the treatment) and what proportion of that C had to pay. The payment should be made by the date indicated; if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from the initial date to the date of payment.

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

• Care should be taken when discharging patients with ongoing and persistent symptoms and, in particular, who have ongoing weight loss when there is no clear explanation or diagnosis established.
• Where a patient presents with post-prandial abdominal pain and weight loss with no apparent cause despite extensive investigation there should be a high index of suspicion of mesenteric ischaemia as a strong possibility being the diagnosis, there should be interdisciplinary working between a multi-disciplinary team (the investigating team and radiology) so as to reduce the risk of missing mesenteric ischaemia as a diagnosis and there should be a specific review for evidence of any mesenteric blood vessel atherome on CT scans carried out.

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 that the board provided to their elderly parent (A). A was an active and independent adult who tripped in the community and was admitted to hospital. In hospital, A developed a grade 4 (most severe) sacral (lower back) pressure sore. The board treated A’s pressure sore using Negative Pressure Wound Therapy (NPWT). A deteriorated while in hospital and died approximately twenty weeks after they were admitted.

C raised concerns about the medical and nursing care that the board provided to A. In particular, C was concerned about how the board handled A’s deterioration in hospital, that there were missed opportunities to discharge A from hospital and A’s end of life care.

The board said that A’s mobility was limited due to pain after admission and that there were no missed opportunities to discharge A. The board apologised for delays in obtaining pressure-relieving equipment for A and that discussions with A regarding the commencement of NPWT were not fully recorded. The board shared an improvement plan regarding the care of pressure sores.

We took independent advice from a consultant geriatrician (medicine of the elderly) and a registered nurse. We found that the medical care provided to A was reasonable. We did not uphold this point of C’s complaint. We found that A’s pressure sore was avoidable. We also found that the board failed to provide reasonable nursing care and treatment to A, failed to reasonably assess and treat A’s wounds, failed to reasonably use NPWT in A’s case and failed to complete a significant adverse event review and follow duty of candour procedures in response to A’s avoidable pressure sore. Therefore, we upheld this point of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failures in nursing care identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Negative Pressure Wound Therapy should only be applied where appropriate and in accordance with manufacturers guidance, board policy and Health Improvement Scotland Guidance.
• Where failings occur, they should be acknowledged and appropriate action should be taken in line with relevant legislation, policies and procedures (particularly duty of candour and adverse event policy).
• Nursing staff should make sure patient’s physical needs are assessed and responded to.
• Patients should receive appropriate and timely wound care in line with the patient’s presentation. In particular:
• Assessments should be completed holistically and on a timely basis, including any required referrals, and should appropriately document the progression/deterioration of a wound;
• Treatment of the would should be appropriate using the correct products for the type of wound; and
• Patients should receive appropriate treatment for pressure damage in line with relevant guidance.

In relation to complaints handling, we recommended:

• Cases involving a death, the circumstances of which are the subject of concern to, or complaint by, the nearest relatives of the deceased about the medical treatment given to the deceased with a suggestion that the medical treatment may have contributed to the death of the patient should be referred to the Procurator Fiscal, in accordance with relevant guidance.

Summary

C complained on behalf of their client (B) about the care provided to B's late parent (A) during their admissions to hospital. A was admitted and discharged from the hospital. A was readmitted a few days later following a fall at their home. A suffered significant injury including spinal and sacral fractures. A remained in hospital for treatment but died a few weeks later. C's concerns related to the clinical and nursing care provided to A during their admissions, particularly in relation to the assessment of A’s cognitive function and capacity, their falls risk, and overall assessments carried out with respect to their condition and deterioration.

In response to the complaint, the board acknowledged that protocols on completion of falls and bed rail risk assessments were not followed and that in the day prior to A’s death, guidance on the timeliness and extent of observations which should have been carried out were not followed, and that the care fell below the expected standard. The board confirmed that appropriate documentation with respect to the assessment of A’s capacity was completed during their admission. C was dissatisfied with the board’s response.

We took independent advice from a consultant geriatrician and a registered nurse. With respect to A’s clinical care, we found that documentation used to assess A’s capacity was not completed to a reasonable standard and we upheld this complaint. We found that the clinical treatment of A during the two days immediately prior to their death was reasonable and we did not uphold this aspect of the complaint.

We considered the nursing care provided to A during the two admissions. We found that the care regarding falls management was unreasonable as appropriate documentation and assessments were not completed correctly or in a timely manner. We also found that there was a lack of evidence of the monitoring of A’s condition which would have made clinical assessment of A’s condition and deterioration more difficult. We found that the level of care and record keeping was unreasonable and upheld the complaint for each admission.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failures identified the decision. 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:

• Relevant staff are aware of National Standards with respect to falls prevention; the requirements to complete and update Falls Risks Assessments and that these are carried out accurately and in a timely manner. Assessments, evaluations, and intervention should be completed in line with guidance.
• Relevant staff are familiar with the adult with incapacity process and the importance of delirium screening tools with patients where delirium is observed and evident.

Summary

C had concerns about the care and treatment that their late parent (A) received from the practice. At the time the care and treatment took place, the practice was being managed as a GP partnership arrangement. By the time C had submitted their complaint to the practice, the previous partnership arrangement had ended and a medical group took over the running of the practice. The named GP Partner who C had raised concerns about had also left the practice. C was concerned that the practice, under its new management, refused to respond to their complaint and did not follow the complaint handling procedure.

GPs are independent contractors who deliver general medical services to patients on behalf of the health board. If a complaint is received about care given by a practice and the practice still has an active contract, then the practice will deal with the complaint accordingly. However, if the complaint relates to a closed practice or a partnership arrangement that no longer exists, as is the case here, this means that the contract with the health board would no longer be active. The practice’s position is that they had no involvement in the care and treatment provided to A because this took place under the dissolved partnership arrangement.

We found that the practice should have advised C to contact the NHS board at the earliest opportunity, in line with the complaints handling procedure.

The board could have facilitated, where possible, communications between the former partner(s) and C. If the former partners were not able to provide a response, the Primary Care Service department within the board could then have considered either providing a response, or commissioning an external review and/or signposting to another appropriate body if applicable. We upheld this aspect of C’s complaint.

Additionally, C considered whether the practice should have carried out a Significant Event Analysis (SEA) or similar review in line with the Healthcare Improvement Scotland national framework. Given the particular circumstances, we found that it was reasonable that the practice, under its new management, did not carry out a SEA when the complaint was brought to their attention. As such, I do not uphold this aspect to the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not advising them to contact the NHS Board about their complaint at the earliest opportunity given that it related to the care and treatment provided under a dissolved partnership arrangement. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• If someone complains about the service of another Primary Care service provider, and the practice has no involvement in the issue, the person should be advised to contact the relevant board or service provider directly.

Summary

C complained that they had received substandard care across a series of surgeries to their nose. They said that the board inaccurately stated that C was suffering from a recognised complication and that the board failed to provide C with sufficient information about the possible complications of surgery. The surgery had left C with a deformed nose, significant impairment to their breathing, constant pain and affected their ability to work. C was seen for a second opinion by another Health Board in Scotland and had received surgery in England from a surgeon with expertise in this area. C believed that their medical records had been deliberately falsified or altered to conceal mistakes in their care.

The board had responded to a series of complaints from C, but their position was that C was suffering from recognised complications, which treatment had been unable to resolve. They did not accept C had been misled about their treatment, or that C’s records had been altered or falsified.

We took advice from a consultant surgeon, with expertise in the type of surgery C underwent. We found that C's complications were ones associated with the type of surgery that they had undergone. Therefore,we did not uphold this aspect of the complaint. Parts of C's records were not well maintained, although there was no evidence of falsification or alteration. Consequently, it could not be demonstrated that C had given informed consent to some of the procedures, and board staff failed to have full and frank discussions with C about their surgeries and the condition of their nose. We upheld this aspect of the complaint around providing sufficient information on the complications of surgery.

We found that C was suffering from a recognised complication of surgery, but that the consent process had fallen below a reasonable standard. There were errors in C's medical records, particularly around the first surgery C underwent, but overall, we found that C's care and treatment was reasonably documented. Therefore, we did not uphold this aspect of C's complaint.

There was not, however a clear enough treatment plan for C, and some aspects of the complications C was experiencing were not being addressed. We also found that the board's own complaint investigations should have identified the errors in C's records. Therefore, we upheld this aspect of the complaint around ongoing treatment plans.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should confirm that they have considered whether there are additional referrals required to manage the issues caused to C by their surgeries and that staff have reflected on whether these should have been made earlier as part of C’s treatment plan.

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

• Patients should be given complete and accurate information during the consent process for surgery to enable them to make informed decisions about the planned procedure. Discussions with patients should be fully documented in the medical record and include key areas of discussion in relation to the pros/cons of the procedure, the risks associated with the procedure generally, and with reference to any specific risks for the individual patient.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that concerns raised are appropriately investigated, failings, and good practice, are identified and that learning from complaints is used to drive service development and improvement. There should be a review of complaints by senior staff during the board’s investigative process.

Summary

C complained to us that the board failed to provide them with reasonable care and treatment during an appointment for a cataract procedure. We took independent advice on the complaint from a consultant ophthalmologist. We found that the scratch on the lens was not caused by the doctor but rather by the folding process of the lens in the lens introducer. However, it was unreasonable that a large scratch on the lens had not been identified after it had been inserted during the procedure. Had the issue been noticed at the time of the procedure, C would have been put into an informed position regarding the issue, of the symptoms that they would likely experience and the plan to remedy the issue. It could have been resolved much sooner, thereby lessening the pain and discomfort C endured over an extended period of time and the subsequent effect this had on their life.

C also complained that the board failed to provide reasonable follow up care and treatment following the appointment. We found that early follow up and intervention by the board would have allowed for a relatively straightforward lens exchange. Better information and communication throughout this process would have allowed for smoother patient care. Therefore, we upheld both of C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaints considered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients should receive appropriate follow up care and treatment and a review appointment should be promptly arranged at the hospital when this is appropriate.
• Surgical staff should routinely inspect the intraocular lens post insertion.