Health

Summary

C complained about the care and treatment provided by the board in relation to excision of a right sided neck lesion.

C had been undergoing monitoring for a neck swelling thought to be a benign tumour. After a number of years of monitoring, C reported that they were experiencing pain and asked to have the mass removed. C underwent surgery to have the mass removed. The lesion had grown on the vagus nerve (the main nerve of the parasympathetic nervous system, which controls some body functions including digestion) and encased it, so the vagus nerve was cut in order to remove the lesion. Following surgery, C experienced gastroparesis (paralysis of the stomach, resulting in food and liquid remaining in the stomach for a prolonged period) and vocal cord palsy (where the vocal cords are unable to move properly).

We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that the care and treatment that C received was unreasonable because there was a failure to recognise the lesion involved the vagus nerve and a failure to adequately discuss risks and consequences with C prior to listing them for surgery. We considered that it should have been made clearer to C that the surgery was likely to lead to injury or loss of function of the nerve. We also found that the events should have triggered the Duty of Candour process and that there was a failure to acknowledge the failings had occurred. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment in relation to excision of their right-sided neck lesion. 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:

• Structures involved in benign neck lesions should be carefully considered, and risks and consequences of removal of benign neck lesions should be clearly explained to patients prior to 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

C complained about the nursing care provided to their late parent (A) whilst in hospital. They complained about a lack of adherence to infection control, poor staff attitude and breaches of uniform policy. C also complained that A had been issued a zimmer frame without appropriate assessment and guidance, and that staff inappropriately handled A when transferring them to a hospital trolley. C also raised concerns about the management of A’s medicines. A did not receive their prescribed medications and were able to self-administer after medicine was left in their possession.

Through the board’s own investigation of the complaint, they identified appropriate improvements to areas including staff behaviour, infection control, breaches in uniform policy, and moving and handling. C was unhappy with this response and brought their complaint to this office.

We took independent advice from a senior nurse adviser. We found that the nursing care provided to A had been unreasonable. The board were unable to evidence basic nursing care in A’s case due to poor documentation. We identified significant failures highlighting that appropriate assessments did not appear to have been carried out for A or documented during the admissions. 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/information-leaflet.

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

• Nursing documentation should be completed to the required standard.
• Patients should be issued mobility aids after proper assessment and instruction provided.

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 the board provided to their late spouse (A). A had a history of heart failure and severe left ventricular systolic dysfunction (LVSD, a severely weakened function in heart pumping) as well as other chronic health conditions.

C complained about the cardiac (heart) care and treatment that A received prior to their death from cardiac failure.

We took independent advice from a consultant cardiologist. We found that clinical aspects of A’s care were reasonable; however, the board’s communication was unreasonable in relation to a prescription for A’s heart medication, an echocardiogram (an image of the heart) and a possible referral to a specialist heart failure service. We upheld this part of C’s complaint on the basis of unreasonable communication.

C also complained about how the board handled their complaint.We found that the board’s handling of the complaint was reasonable. We did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified by 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:

• Discussions and outcomes from multi-disciplinary team meetings should be clearly documented in medical records and patient notes.

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 standard of medical care and treatment provided by the practice and about the way that they handled C's complaint. C attended the practice with symptoms of rectal bleeding, a change in bowel habit and abdominal pain. The practice made a routine referral to hospital but did not carry out a rectal examination. C was later diagnosed with bowel cancer. C felt that there was an unreasonable delay in diagnosing and treating their cancer.

We took independent advice from a GP. We found that C's referral to hospital should have been marked as urgent given their symptoms and a rectal examination undertaken. We also found that information about C’s family history was not recorded correctly. Therefore, we upheld this part of C's complaint. However, we noted that it was unlikely that these failings would have had any impact on the treatment options or outcome for C.

C also complained that the practice failed to handle their complaint reasonably. We found that the practice failed to reflect on the failings in their response to C. 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 investigation in relation to the standard of medical care and complaint handling. 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:

• Clinical staff should be aware of the relevant guidelines for urgent suspicion of cancer and standard practice to ensure all patients with similar symptoms are provided with a reasonable standard of medical care.

In relation to complaints handling, we recommended:

• Relevant staff should ensure that failings are reflected on and that the complaint investigation and response are focused on the complainant.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the Scottish Ambulance Service (SAS) unreasonably delayed in dispatching an ambulance for their late parent (A) and, as a result, this had an adverse impact on A’s care and treatment. C questioned why an SAS call handler initially advised them that an ambulance was not needed, when a locum GP subsequently arranged for one as soon as they learned of A’s condition. Shortly after arriving at A&E, A died following a cardiac arrest.

We took independent advice from a paramedic adviser. We found that the actions of the SAS in relation to the allocation and dispatch of an ambulance for A were reasonable, based on the information, resources, and systems in place at the time. We also found that the project improvement initiatives the SAS are undertaking to mitigate the challenges with the triaging of abdominal pain are reasonable. Therefore, we did not uphold the complaint. We did, however, provide feedback to the SAS that when responding to a complaint, where possible, it would be helpful if they provided the complainant with information and explanation of any improvement initiatives that they are taking to address issues raised within the complaint.

Summary

C complained about the treatment provided to their partner (A) when they were admitted to hospital. A presented to the A&E after they woke up feeling generally unwell. A experienced weakness, lost vision, and pins and needles in their hands and feet. When assessed in the A&E, A gave a history of a three-day headache.

There was a delay in A being assessed in the A&E. Given A’s symptoms, the consultant’s working diagnosis was an atypical migraine. They considered the possibility of a stroke but concluded this was less likely based on A's presentation. A was then transferred to the Acute Medical Unit before quickly being transferred to the care of the Stroke Team. A Computerised Tomography (CT) brain scan was carried out and confirmed a stroke. A further CT scan the next day confirmed that A had suffered a second stroke.

C complained that there was an unreasonable failure by the A&E to diagnose that A had suffered a stroke. In addition to this, C complained that A was not provided appropriate treatment in the form of thrombolysis (medicine to get rid of blood clots in the brain) or thrombectomy (surgery to remove a blood clot or drain fluid from the brain).

We took independent advice from an emergency medicine consultant. We found that an atypical migraine was a reasonable working diagnosis. We found that reasonable consideration was given to the possibility of a stroke and A’s history of diabetes was taken into account.

We considered that there was sufficient reason to arrange a CT scan to assist diagnosis while A was admitted to the A&E. This was due to C’s symptoms and the diagnostic uncertainty. However, earlier imaging was unlikely to have made a material difference to the outcome. In addition to this, we noted that A had suffered a posterior circulation stroke, which is known to be challenging to identify.

We concluded that there was not an unreasonable failure to diagnose A's stroke because of the atypical features of A’s presentation. In addition to this, A was appropriately transferred to the AMU for further investigation, which was promptly carried out. Given the above, we did not uphold this complaint. However, we provided the board with feedback that earlier CT imaging was warranted.

In respect of the treatment provided to A, we found that A would not have been eligible for either thrombolysis or thrombectomy. Overall, we considered the treatment provided to A in the A&E was reasonable. Therefore, we did not uphold this complaint.

Summary

C, a Patient Advice and Support Service (PASS) adviser, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A was under the care of two health boards for treatment of a concurrent bladder and colorectal cancer. While the bladder cancer was timeously treated, A died without having received treatment for the colorectal cancer. C also complained that the board failed to reasonably meet their obligations in accordance with Duty of Candour.

We took independent advice from a colorectal surgeon. We found that there was a failure to provide a reasonable standard of care and treatment to A, particularly in relation to a failure to mark an MRI scan request as urgent, and a failure to report the results of scopes in the normal way. We upheld this complaint. We also found that the board failed to meet their obligations in accordance with Duty of Candour. We upheld this 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:

• Patients should receive reasonable and timeous care.

Summary

C complained about the care and treatment provided to their late parent (A) by a GP Practice. Following a road traffic accident, A was found to be in atrial fibrillation (a type of heart rhythm where the heartbeat is not steady). The hospital asked the GP to review A for anticoagulation (medication to prevent blood clots from forming or growing) once their injuries had resolved. Several weeks later A had an appointment at the practice and was referred for a 24-hour ECG (a medical test that records the heart’s activity over a 24-hour period). Before the results could be assessed by the practice, A suffered a stroke. C complained that the practice unreasonably delayed in initiating anticoagulant therapy.

We took independent advice from a GP. Following our initial enquiries, the practice provided additional explanation regarding the complexity of the decision making as to whether to prescribe anticoagulation to A, and the reasoning behind their decision to wait for the results of the 24-hour ECG. Following this additional explanation, we considered that the practice’s position and treatment plan was reasonable. We therefore did not uphold the complaint. However, we noted that not everything the practice had said in their further explanation was documented in the medical records and we provided feedback to the practice on this point.

Summary

C complained about the care and treatment provided to their late parent (A) by a GP Practice when A was a resident in a care home. Care home staff had reported that A was agitated and unsettled, possibly in pain and with poor sleep at night. The practice requested that care home staff take a set of observations (temperature, oxygen saturation, pulse, blood pressure) and obtain a urine sample. When observations were later taken by care home staff, the practice advised that they were all normal, thereby giving a NEWS Score (a tool used to quickly determine the degree of illness of a patient and identify acute deterioration) of 0. They said that no visit was indicated at that time and queries about medication for agitation would be discussed on the next GP round to the care home. C was of the view that the report of agitation and confusion should have led to GP review.

We took independent advice from a GP. We found that the care and treatment provided to A was unreasonable, as A had delirium until proven otherwise and should have been seen and assessed for this. We also noted that the practice appear to have relied on a NEWS score to decide no visit was needed, but NEWS is not validated for use in primary care. We therefore upheld the complaint.

During the course of our investigation the practice carried out a Significant Event Review. As a result, they had developed a protocol, to be used alongside physiological measurements, for assessing delirium in the care home setting and had shared and discussed this with the care home. We considered these actions to reasonably address the failings in this case, so aside from apologising to C, we made no further learning and improvement recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to assess A for delirium. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .

Summary

C complained about the board’s assessment of their parent (A) and the decision not to admit A to hospital for further assessment and treatment. C felt that the board inappropriately relied on information provided on behalf of A, rather than speaking with A directly, and that decisions were based on unreliable information.

A tested positive for COVID-19 in their care home and the following day, care home staff contacted NHS24 about A’s condition and the call was passed to NHS Lanarkshire Out of Hours service. The call was triaged for a clinician to call back, and an out of hours GP contacted the care home shortly afterwards. During the call with the out of hours GP, the decision was taken not to admit A to hospital, but for care home staff to contact A’s GP the following day. A died later that day. In their response, the board explained that the out of hours GP spoke with A’s carers and concluded that an appropriate assessment was undertaken.

We took independent advice from a specialist in general and geriatric medicine. We found that the assessment of A conducted over the telephone was reasonable. The record of the assessment was of the level and standard expected. We concluded that the assessment of A’s condition and the decision not to admit A to hospital at that time was reasonable. We therefore did not uphold the complaint.