Health

Summary

C complained about the care and treatment provided to their parent (A) during an admission to hospital. C complained that the board had failed to manage placement of a nasogastric tube (NG) correctly and did not act timeously on signs of a complication. C said that the board failed to carry out an adverse event review of this event.

C complained that the board dismissed A’s known diagnosis of myasthenia gravis (a rare long-term condition that causes muscle weakness) too quickly and failed to arrange a neurology (speicalism concerned with the diagnosis and treatment of disorders of the nervous system) review. Finally, C said that the board did not maintain A's privacy or dignity when providing end of life care and communication with the family was poor.

The board apologised for failures in A’s care in respect of the NG tube insertion and for aspects of their communication. The complication which occurred with the NG tube was a rare but known complication of the procedure. The board said that A’s case had been reviewed at a Mortality and Morbidity (M&M) meeting and points of learning had been identified.

We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system), a consultant gastroenterologist (specialist in the diagnosis and treatment of disorders of the stomach and intestines) and a consultant respiratory physician (specialist in conditions affecting the lungs).

We found that there were aspects of A’s care which were reasonably managed including the review by neurology, the decision to site the NG tube, the end of life care provided to A and the review of the admission undertaken by the M&M meeting.

However, we found that the chest x-ray undertaken after insertion of the NG tube was unreasonably delayed. Therefore, we upheld this part of C’s complaint. However, we noted that the board had recognised this failure as part of their own review of C’s complaint.

C complained that the board failed to handle their complaint reasonably. We found that the board took a significantly long time to respond to C’s complaint and failed to provide C with any updates or a revised date of response. Therefore, we upheld this part of 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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaint Handling Procedure. They should be managed within timescales or updates should be provided to account for delays and to provide a revised timescale for completion. Complaints should be properly investigated and the complaint response should be accurate.

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 parent (A) during two admissions to hospital. Both admissions were due to concerns about A's lungs. A was admitted to hospital for a third time and was diagnosed with empyema (pockets of pus) in their left lung. C complained that this was missed during A's first two admissions and that A was unreasonably discharged from hospital on both occasions.

We took independent advice from a consultant who specialises in both respiratory and general medicine. We found that there was no evidence that empyema was present during the two admissions. However, there were missed signs that indicated the potential for empyema to develop. In particular, the presence of high C-reactive protein (CRP, an indicator of inflammation in the body) during the first admission and the recent history of pulmonary and pleural infection at the time of the second admission. We considered that it would have been reasonable for the board to carry out further investigation during A's admissions to hospital. We concluded that the board did not take reasonable steps to establish whether there was an evolving infection or potential for empyema to develop. Therefore, we upheld this part of C's complaint.

In respect of A's first admission, we found that A was clinically well enough to be discharged. However, there was a failure to recognise the significance of the raised CRP in the context of A's presentation, and to consider further assessment on this basis. Therefore, we upheld this part of C's complaint.

In respect of A's second admission, we found that A was clinically well enough to be discharged. In contrast to the first discharge, A's CRP was not as significantly high and was shown to be declining. As such, there was less indication that A would benefit from remaining in hospital. Therefore, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failure to recognise the signs of potentially developing empyema and the unreasonable discharge. C has highlighted the importance to them that the apology acknowledges the impact on A and on A's spouse, who has had to provide care. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• Rising CRP blood test in the context of pleural infection should prompt further assessment and consideration of the potential for empyema to develop.

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 parent (A). A was assessed by a junior doctor in A&E who ordered various tests and investigations. A was later moved to the acute assessment unit and diagnosed with a perforated bowel. A underwent emergency surgery and developed sepsis. C complained that there was a delay in identifying A’s condition. They said that the board focussed on potential cardiac issues rather than an abdominal cause. C considered that this delay resulted in a worse outcome for A.

The board acknowledged that a more senior doctor may have identified the cause of A’s symptoms quicker. However, they said that the care provided was reasonable. They also noted that this this complaint had resulted in learning and ongoing development.

We took independent advice from an emergency medicine consultant. We found that there were a number of red flags in A’s presentation that should have raised the possibility of significant abdominal pathology. It did not appear that A was reviewed by a senior clinician.

We also found issues in the documentation. No intimate examination was recorded in the records and there was a lack of documentation around the interpretation of an x-ray. Overall, the initial assessment process led to a delay in the diagnosis of acute bowel perforation which is likely to have had a significant effect of the outcome for A. 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/information-leaflets.

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

• Patients should receive appropriate treatment including assessment, relevant tests and senior review in accordance with their symptoms.
• Case records should include details of any tests / examinations carried out and the rationale for any decision making.

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 advice and treatment provided by the board following their positive COVID-19 test was unreasonable. C was a kidney transplant patient who tested positive for COVID-19 in early 2022. C said that they had contacted the renal unit who referred them on to the Covid Pathway (a central unit offering treatment advice and antiviral medication for high-risk patients). C received antiviral medication from a Covid Pathway nurse but was not referred to a renal clinician or advised to stop the immunosuppressant medication they were taking.

C later contacted the renal unit with concerns about diarrhoea. C was advised to stop the immunosuppressant over the weekend and was given advice on what to do if their condition worsened. C felt that they were given wrong advice about their medication and that their disease progression was more severe because of this.

The board advised that they had no record of C’s contact with the renal unit about COVID-19. Their first record was 11 days later, when they spoke to a renal nurse with concerns about diarrhoea.

We took independent advice from a pharmacist and a consultant nephrologist (specialist in the diagnosis, treatment, and management of kidney conditions). We found that if C had indeed phoned the renal unit initially, C should have been escalated to a clinician for medication advice. We were also critical that the nurse at the Covid Pathway had not sought advice from or referred C to the renal unit.

However, we noted that the immunosuppression medication was new and the situation was fluid at the time. We noted that improvements were made within two weeks, during which, guidance was published to ensure robust advice and treatment for COVID-19 positive, immunosuppressed patients and contact details for specialist clinical units were provided to the Covid Pathway. We also considered that the COVID-19 pandemic had since largely subsided.

We considered that the advice and treatment that C received was reasonable as we could not definitively say that C had initially contacted the renal unit, the situation was new and fluid, and improvements to the process had been appropriately and quickly made. Therefore, we did not uphold C's complaint.

Summary

C suffered with lower back and right hip pain. C complained about the care and treatment provided by the practice in relation to their diagnosis of Hip Osteoarthritis. C said that despite raising concerns with the practice, they failed to take appropriate action to ensure C’s symptoms were further investigated.

We took independent advice from a qualified GP. We found that the management of C’s symptoms was reasonable and appropriate steps were taken to investigate C’s symptoms. We did not uphold this aspect of the complaint.

With respect to the handling of C’s complaints, we found that the practice’s complaints handling procedure was not compliant with current requirements. We also found that, whilst their complaints response demonstrated that they had investigated the complaint, the practice unreasonably failed to provide further response to C’s subsequent communications or the communications from our office. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably failing to provide an appropriate response to C’s concerns and to the communications of our office requesting a further response to C. 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 provide complete responses to complaints raised. Those handling and responding to complaints should be aware of the complaints handling procedure and the importance of providing full responses both to complainants and the SPSO.
• The practice's complaints handling procedure is consistent with and reflects the Model 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 about the care and treatment provided to their late spouse (A). C complained that A had an infected toe which remained unresolved despite undergoing several months of treatment. A was diagnosed with oesophageal cancer but was unable to start chemotherapy treatment because of the ongoing infection. C said that A experienced significant pain during this time and that there was a failure to reasonably coordinate A’s care needs.

We took independent advice from a consultant orthopaedic surgeon (specialist in treatment of diseases and injuries of the musculoskeletal system) and a consultant clinical oncologist (specialist in the diagnosis and treatment of cancer). We found that the board had provided reasonable care and treatment to A over several admissions when each one was considered in isolation.

However, on one occasion, we found that an MRI scan result was not correctly reported at the time. This resulted in A receiving lesser surgery than they would otherwise have received.

We also found that the board had failed to report the incident in line with Duty of Candour legislation, or undertake an internal review process to learn from the event. We found that a more coordinated approach to A’s care may have provided a proper overview of their care needs (including pain) which were known to be complex given the number of specialties involved in A’s care. Therefore, we upheld this part of C’s complaint.

C complained that the board’s handling of their complaint was unreasonable. We found that the board kept C reasonably informed of delays.However, they did not accurately describe the failing with the MRI scan or acknowledge the impact this had on A’s surgery and treatment plan. There was also a failure during the complaint process to initiate relevant reporting and investigation processes in relation to the MRI scan reporting when this became known. Therefore, we upheld this part 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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• When an incident or harm occurs, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.
• The board should reflect on whether A’s care could have been managed differently.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with  HYPERLINK "https://www.spso.org.uk/the-model-complaints-handling-procedures" The Model Complaints Handling Procedures | SPSO .

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 their experience of labour and post-birth care. C felt that they had been left too long without assessment and without medical review. C also complained about the actions of a specific doctor, who attempted manual removal of their placenta post birth. C said that this had been painful and that their birth plan had not been followed, making the experience distressing and difficult for C and their partner.

The board had already acknowledged failings in C’s care and the investigation assessed whether the actions set out were reasonable and proportionate means of addressing these. We took independent advice from an obstetrics adviser. We found that the board had acted to address the identified failings. Although C’s experience was distressing, there was no evidence that their baby was put at risk at any point. We upheld some of C’s complaints, but made no further recommendations due to the appropriate actions already taken by the board.

Summary

C’s parent (A) was admitted to the hospital's A&E three days after a fall. A had a complex medical history including chronic pain. On admission, A reported lower right-sided chest pain, associated with gradually increasing shortness of breath. A chest X-ray showed no evidence of r ib fractures but a subsequent CT scan showed multiple right-sided rib fractures (from ribs 3-10), a flail segment (when three or more consecutive ribs are fractured in two or more places, causing a segment of the rib cage to become detached from the rest of the chest wall), an intercostal haematoma (solid pooling of blood between the ribs) and a right sided pleural effusion/haemothorax (build-up of fluid/blood between the ribs). A was treated in the Intensive Care Unit (ICU) for one week before being stepped down to the Medical High Dependency Unit (MHDU). A was reviewed by the ICU team as and when required and after becoming acutely unwell they were transferred to ICU again, where they died a few days later.

In relation to A’s admissions to MHDU, C complained about problems with A’s medication, concerns around pain management and the nursing care A received, in particular issues around fluid and nutrition, and not responding to alarms or adhering to observational guidelines. C also complained that staff in the MHDU failed to provide appropriate care and treatment in response to A's deterioration.

We took independent advice from a consultant in critical care and a senior critical care nurse. We noted that management of A’s condition was complex given their history of chronic pain together with a severe acute injury. We found a number of failings in A’s pain management, including doses of sustained release oxycodone being administered outwith the appropriate dose interval, an increase in dose of oxycodone which was not clearly justified, and lack of involvement of the acute pain service for ongoing support after A returned to the MDHU from ICU. Taking all of this into account, we found that the board failed to provide a reasonable standard of pain management and upheld this aspect of C’s complaint.

We found that NEWS (National Early Warning Score, a tool for identifying deterioration of patients in acute settings) observations were irregular and that there was evidence that nursing staff failed to escalate appropriately when NEWS scores were 5 and above. Nursing records were lacking in detail and there was no evidence of A receiving oral care. On balance, we upheld C’s complaint about the standard of nursing care.

We found that overall the response to A’s deterioration was reasonable. A was regularly reviewed by consultants, with escalation as appropriate. We did not uphold this aspect of C’s complaint. However, we were critical of the board’s complaint handling, noting long delays in compiling the complaint response and a failure to keep C updated, and that the board’s own investigation did not identify failings picked up by our own investigation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified as a result of our investigation. 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:

• Observations are undertaken in accordance with the board’s observations policy and National NEWS Scoring and Guidance, with appropriate escalation. Nursing staff have an understanding of Person Centred Care Plans. Documentation is sufficiently detailed.
• Opioids are administered strictly in accordance with relevant dose periods. Decisions to increase medication doses are clinically justified.
• The board should review how patients with severe chest trauma are managed by the acute pain service after regional analgesia has been removed, and the patient has been stepped down from critical care. Their consideration should include triggers for referral and consideration of policies to ensure that access to the acute pain service for this group of patients is not determined by the choice of step-down environment or nominated parent team, but rather by the extent of the patient’s injuries and likely complexity of their ongoing analgesia management.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedure. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Complainants should also be kept updated on their complaints in line with the Model Complaints Handling Procedure. Additionally, learning from complaints should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

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 treatment that their sibling (A) received from the practice. In responding to C, the practice accepted that a diagnosis had been missed. The practice also conducted a Significant Event Analysis (SEA) which resulted in learning around consideration of A’s symptoms and consideration of blood testing.

C was dissatisfied and raised their complaints with SPSO. We found that while there were aspects of the treatment provided to A that were appropriate, a number of aspects were not, including taking a blood sample before all concerns had been explored, poor recording of symptoms and examination findings, and the undertaking of a telephone consultation. Additionally we found that the refusal to undertake further blood tests in the circumstances, lack of recording of reasons for, or makers of, decisions and the failure of the SEA to explore significant decisions were also aspects of treatment that were not appropriate. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and their family 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:

• Any Significant Event Analysis undertaken by the practice fully explores all relevant decisions.
• Doctors should undertake reasonable consultations with patients and fully consider what the appropriate blood tests would be for patients.
• The standard of record keeping at the practice meets General Medical Council “Good Medical Practice” standards.

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 process followed by the board in commissioning and completing a Level 1 Significant Adverse Event Review (SAER) with respect to the care provided to their partner (A), after they had been diagnosed with Barrett’s oesophagus (a condition where some of the cells in the oesophagus grow abnormally). The SAER was commissioned following the death of A.

C complained to the board about their lack of inclusion and involvement in the SAER process. In response to the complaint, the board concluded that whilst the SAER was carried out appropriately and C had been involved in the process, they failed to adhere to their own and published national guidelines in a number of ways. The lack of an appropriate Family Liaison contact had negatively impacted communication with C during the process.

C was dissatisfied with the board’s complaints response and brought their complaint to our office. We took independent advice from a consultant hepatologist (medical doctor who specialises in diagnosing and treating liver disease) and gastroenterologist (a medical doctor who specialises in conditions affecting your digestive system)

We found that in conducting the SAER, the board had acted in the spirt of national policy and guidance with respect to including C in the SAER process. However, the board’s own policy sets more concrete standards about how communication should be managed. We found that overall C’s level of involvement with the SAER process was reasonable, but that there was issues with respect to miscommunication and managing C’s expectations in this regard. Whilst the board responded to C’s requests to meet relevant members of the SAER team, again the communications were not always consistently responded to by the board.

Issues with communication were impacted by the board’s failure to follow process and appoint an appropriate point of contact to assist C and provide them with support. Given the failure to follow process, and issues with respect to communication, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should provide the complainant with confirmation that the apologies highlighted in Recommendations 2 and 3 of the SAER will be provided.

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

• Problems identified in the management of the adverse event review will be collated and used to create a Shared Learning Notice to ensure learning is board wide.
• Work following this complaint will include that family members must be involved at the earliest point to agree the TOR and are provided with ongoing support for any review, in accordance with the board’s procedures. They must support those identified to take on the role of Family Liaison Manager to have adequate time to carry out this role to a high standard. All staff involved in the adverse event review process will be reminded, via a Shared Learning Notice, of the need to be vigilant and accurate in recording communications in relation to adverse event review management.
• A flowchart had been developed to assist staff with the management of Level 1 adverse events.

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.