Health

Summary

C complained about the standard of medical care and treatment provided to their late parent (A) during an admission to Queen Elizabeth University Hospital (QEUH). A was admitted to QEUH with worsening symptoms of a chest infection and a leg ulcer. When A’s condition deteriorated, medical staff decided to transfuse three units of blood. During the transfusion, A went into cardiac arrest and died. C complained that the decision to transfuse A with blood was unreasonable given their condition and symptoms, and that this led directly to their death.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A should have had a thorough clinical review prior to the transfusion being prescribed. The transfusion monitoring protocol was not followed, and the board acknowledged that this may have led to a delay in recognising A’s deterioration. We also noted that when A’s observations and condition indicated a serious concern, nursing staff should have contacted a senior doctor but instead contacted the most junior doctor on duty. We considered all of this unreasonable. We saw no evidence that the severity of A’s condition, and likely poor prognosis, was actively considered or discussed with them or their family. This would have been good practice.

We noted that after A's death the team appropriately discussed the case with the Procurator Fiscal and the death certificate review team, who stated that they would be content for a death certificate to be issued without the need for a post mortem examination. However, when this was then discussed with A’s family, they remained concerned and said they would like things investigated further. With reference to the relevant guidance, we found that the case should have been referred back to the Procurator Fiscal for further consideration. If the Procurator Fiscal had still considered there was no need to investigate, the medical team should have offered the family the option of a hospital post mortem examination. We upheld this complaint. We were satisfied that the learning already implemented by the board was appropriate and satisfactorily addressed what had gone wrong in A’s care. However, we made further recommendations in relation to the reporting of a death to the Procurator Fiscal.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to advise the Procurator Fiscal of the family’s ongoing concerns regarding A’s death, and for failing to offer a hospital post mortem. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Share this decision notice with the Procurator Fiscal for advice as to whether the board should take any further steps.

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

• Medical staff are clear about the procedures for reporting deaths to the Procurator Fiscal. In particular, in the event that nearest relatives of the deceased are concerned that medical treatment may have contributed to the death of a patient this requires discussion with the Procurator Fiscal, even if initial reporting has already been 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 attended Aberdeen Royal Infirmary after being referred by their GP for left leg pain and swelling behind the knee. Investigations revealed the presence of a Baker’s cyst (fluid-filled swelling at back of knee) and C was discharged home with no further treatment planned. The pain continued to bother C over the weekend and they sought further medical opinion and returned to the hospital six days later. This time a deep vein thrombosis (DVT, blood clot in a vein) was diagnosed and C was discharged home on blood thinning medication. C believed that the DVT must have been present at their initial presentation to hospital and that action should have been taken at that time to address their symptoms and therefore there was a missed diagnosis.

We took independent advice from two clinical advisers: a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant physician. We found that although there was no evidence of a DVT on the original ultrasound scan, staff failed to act in accordance with guidance and arrange a D-dimer test (a blood test that can be used to help rule out the presence of a serious blood clot) and a further ultrasound scan within seven days. Staff gave C advice to seek further medical opinion should their clinical condition deteriorate which C did. There was no delay to the actual diagnosis of DVT and C’s treatment regime would not have altered in the period until the second scan was performed. However, we upheld the complaint on the basis that there was a failure to act in accordance with the guidance.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to follow the guidance when a negative scan result was obtained. 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:

• Staff should ensure that they are aware of and follow the guidance concerning negative ultrasound findings for DVT.

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 their spouse (A) received for their pressure sores from district nurses. When A died, one of the main causes of death was noted to be multiple pressure sores. C said that there was no examination by a GP at any point. They believed the pressure sores had become infected, causing sepsis and leading to A’s death.

The board outlined the steps district nurses had taken when they identified that A’s sacral and heel pressure areas were starting to break down. They told us that over a four-month period, district nursing staff carried out more than 80 visits as well as providing support over the phone. They said the district nursing team involved A’s GP and the tissue viability service, who agreed with the care and advice that was being provided.

We took independent advice from a nursing adviser. We found that A’s clinical records showed risk factors which increased their risk of developing skin damage: weight loss, poor mobility and double incontinence. We noted that the advice to patients with pressure sores is to move and regularly change position and to use a pressure relieving mattress, cushions and boots. District nurses ordered appropriate equipment for A and monitored A’s pressure areas closely. We found that there was evidence in the notes of appropriate advice being given to A and C regarding sitting in a chair for a long period of time and the detrimental effect this could have on the skin, especially the heels and sacrum. The boots provided to A were returned to the equipment store despite documented advice that these should be worn.

We considered that there was clear evidence of partnership working between the carers, district nurses, and the wider multi-disciplinary team. Noting the complications associated with A’s incontinence, we found that the documented evidence demonstrated the appropriate treatment being delivered.

Therefore, we did not uphold this complaint.

Summary

C complained about the care of their late parent (A) at Falkirk Community Hospital (FCH). A had a cognitive impairment and gained access to washing-up detergent that had been mistakenly left out in the staff kitchen area. A subsequently became unwell and advice was sought from the out-of-hours (OOH) GP service prior to eventual transfer to Forth Valley Royal Hospital (FVRH), where their condition deteriorated and they died the following week. C raised a complaint with the board, seeking answers as to what happened, and the board commissioned a Significant Adverse Event Review (SAER). The board were unable to conclude with any certainty whether detergent was ingested and contributed to A’s death.

C complained to us about inaccuracies and inconsistencies in the SAER and clinical records, and also about timescales surrounding the SAER and complaint processes.

We took independent clinical advice from a nursing adviser and a GP adviser. It was not possible from the evidence available and advice obtained for us to confirm whether A ingested detergent. We found that the SAER was open, transparent and evidence-based. The report acknowledged that there were inconsistencies and inadequacies in the records. However, we considered that the SAER did not adequately probe into the contact with, and actions of, the OOH GP. The initial advice given by the GP was to monitor A, when the observations should have prompted medical review. The GP assumed these observations were incorrect. When the GP later advised transfer to hospital, this was left to nursing staff to arrange and clear advice was not provided surrounding the urgency of the ambulance request. We found that the GP deviated from standard practice and failed to provide appropriate care to A.

While the SAER acknowledged that record-keeping standards were not adhered to, we highlighted a further shortcoming in that the transfer from FCH to FVRH was not formally documented. We found that there was delay in staff completing an incident report following the detergent incident, and a delay in completing the SAER. We also found that there were delays in responding to C’s complaint, and some confusion between the SAER and complaint processes. The board acknowledged these delays and apologised that the complaint process was very protracted at such a distressing time for the family.

We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the unreasonable delay in completing an incident report, the unreasonable delays in concluding the SAER and responding to the complaint, and the confusion between the two processes, the failure of the SAER to probe sufficiently into the contact with, and actions of, the OOH GP, and the OOH GP’s deviation from standard practice and failure to provide appropriate care to A. 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 board should ensure there are clear mechanisms in place for investigating both significant adverse events and complaints, and clarity between the two processes, with adherence to the board’s SAER policy and Complaints Handling Procedure. The board’s SAER policy should align with Healthcare Improvement Scotland guidance.
• Documentation needs to improve to support safe, effective quality and person-centred care delivery. The board should ensure protocols exist for documentation of handovers and clinical contacts.
• The board should ensure that SAER investigations comprehensively examine contributory factors, and that where possible these are reviewed by someone with knowledge of the relevant speciality, as per Healthcare Improvement Scotland guidance.
• The board should ensure the OOH service has clear protocols in place for escalations to hospital for medical review, including roles and responsibilities in this regard. GPs should act with due care when receiving second hand clinical information.

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 was dissatisfied with the treatment received from the board following an urgent referral to the gastroenterology department (specialists in the diagnosis and treatment of disorders of the stomach and intestines) from their GP after experiencing back pain and rectal bleeding. The referral was triaged by the board and a colonoscopy (examination of the bowel with a camera on a flexible tube) was arranged.

Following the colonoscopy, C was advised there was a probable tumour in their lower bowel. C’s treatment was discussed at a multi-disciplinary team meeting (MDT) and C was advised that a referral to a hospital within another board had been made for a Transanal Endoscopic Mucosal Surgery (TEMS, a minimally invasive surgery) procedure.

C was examined by a colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) at the other board and the TEMS procedure was scheduled. Further MDTs took place where the question of an anterior resection (a surgical procedure to remove the diseased portion of the bowel and rectum) being a more appropriate treatment was considered. C had a meeting with a consultant surgeon at Borders General Hospital and their understanding following this meeting was that clinicians would further consider and reach a decision on what the most appropriate treatment for C was. The consultant surgeon’s letter to C’s GP indicated that their understanding of the outcome of the meeting was that C had expressed a preference for TEMS with further steps, such as an anterior resection, afterwards if needs be, and had made arrangements for C to be seen by the TEMS team.

C attended an appointment at the other board where the colorectal surgeon said that C had refused an anterior resection. C denied this. It was also decided that a further biopsy would be undertaken. Whilst awaiting the results of the biopsy, C complained to the board and had further correspondence with them whilst also approaching this office about their concerns.

We took independent advice from an oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that it was reasonable that C was not referred to an oncologist and that investigations of a tumour reported following their colonoscopy were reasonable. However, we found that the board had unreasonably downgraded C’s referral and that the board’s failure to treat C’s condition as cancer was unreasonable. We noted that the board did not meet the treatment time guarantee and that there were significant delays in decisions on C’s treatment that were reached jointly with another board. We considered that the likelihood of delays should have been made clear to C to allow them the opportunity to properly consider all of the options available. We upheld C’s complaint about the treatment they had received.

C also complained about the board’s response to a complaint they submitted. We found that it was unreasonable that the board did not directly address some matters that C raised and upheld this aspect of C’s complaint. However, we considered it was reasonable that the board took a different position to C about what had been said at a particular consultation.

C also complained about a subsequent response the board provided to them. We found that the board’s response was generally reasonable. Therefore, 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 the specific failings identified. The apology should make clear mention of each of the failings identified and 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:

• In similar cases, referrals and test results should be assessed reasonably and patients should receive treatment within 62 days of the referral and within 31 days from the decision to treat, as per Scottish Government treatment time targets. Our findings should be brought to the attention of relevant clinicians in a supportive manner and they should consider identifying these as learning point for their annual appraisals.
• A mechanism should be in place to ensure patients are informed when delays to treatment are likely.
• The pathway for the treatment of patients from Borders NHS board to another board area should be appropriate and efficient; including that clinician availability does not delay treatment decisions and that it is clear where responsibility for ongoing management and treatment lies at all times.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes responding to all aspects of complaints.

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 on behalf of their parent (A) about their care and treatment at University Hospital Ayr. A was admitted to hospital after an episode where they had become unresponsive. C raised concerns that medical staff decided to change A's epilepsy medication without getting specialist input.

We took independent advice from a specialist in geriatric (medicine of the elderly) and general medicine. We found that A had not been properly assessed, that there was no clear reason for changing their epilepsy medication and that there was a lack of communication with their family about the change. We upheld C's complaint. We considered that the board had not appropriately responded to C's complaint, so we also made a complaints handling recommendation to address that.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's care and treatment and for not adequately addressing their complaint. 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:

• In an emergency setting, patients' medications for specialist conditions should normally only be changed if their diagnosis is clear, the change is unequivocally beneficial and the reasons for the change are discussed with them and/or their families/carers.

In relation to complaints handling, we recommended:

• Complaints should be responded to accurately and as comprehensively as possible, particularly when we have requested that a specific matter is addressed.

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 parent (A) had received from the board. A had a terminal cancer diagnosis and severe arthritis. C complained about a series of admissions A had to hospital. C said A had been discharged without C being consulted, even though they were A’s main carer. This meant A was discharged to a potentially unsafe environment, and did not receive the necessary levels of care.

C said A was readmitted to hospital. A was then discharged to a care home, but was not provided with oxygen. C said that A had required oxygen in hospital and the failure to accept that A required long term oxygen support or to provide A with oxygen meant that A required a further hospital admission.

C said that when A was readmitted to hospital, they received substandard care. A was put on a busy ward, that did not specialise in palliative care or geriatric medicine (medicine of the elderly) and that this type of care was only provided once C intervened.

We took independent advice from a consultant geriatrician. We found that A’s discharge planning was carried out to a reasonable standard. A had capacity and the board’s actions took into account their wishes and included a reasonable assessment of A’s home environment.

We found A was very ill during their final admission and that at times A was dehydrated and eating very little and that this would have been very distressing for C and other family members to have witnessed. We noted that dehydration and low food intake were a common feature of this stage of A’s illness and were not evidence of neglect on the part of staff. We found, based on the advice we received, that communication with A was of a reasonable standard and that their pain and condition was monitored and acted on appropriately.

In terms of A’s discharge without oxygen support, we found that staff gave appropriate consideration how best to manage A’s low oxygen saturation levels and that on discharge A’s own preference was a factor in the decision to discharge A without an oxygen supply.

We did not uphold C's complaints.

Summary

C complained on behalf of their child (A). A attended their GP practice and A&E at University Hospital Hairmyres on a number of occasions before examination by a physiotherapist led to a referral back to hospital, further x-ray and diagnosis of slipped upper femoral epiphysis of the hip (SUFE, where the growing part of the bone in the hip joint moves). C complained that A was advised to continue walking unaided despite being in severe pain. C believes failings in care contributed to A’s condition worsening to the point where significant surgery was required. C was dissatisfied with the board’s response to their complaint and asked this office to investigate.

In their response to our enquiry, the board confirmed that A’s case had been discussed at a Morbidity and Mortality review, with learning identified. They said that the initial referral letter from the GP to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) prompted no red flags from the orthopaedic team and they suggested musculoskeletal physiotherapy in the first instance. A was given an appointment but they attended A&E in the interim.

We took independent clinical advice from a consultant in emergency medicine and a consultant orthopaedic surgeon. We found that SUFE was a difficult condition to diagnose and we did not consider the delay in diagnosis to be unreasonable. We were, however, critical of the decision to discharge A without further investigation, when they were unable to weight-bear. We noted that the board had identified learning but considered they also ought to develop a multidisciplinary pathway for the limping child. We also found that the referral from the GP was assessed appropriately in view of the information it contained. On balance, we did not uphold this complaint but provided the board with feedback in relation to the issues mentioned above.

Summary

C complained about the standard of medical care and treatment provided to their parent (A). A received a likely diagnosis of metastatic lung and liver cancer. They were placed on palliative care, however, after approximately a year, A remained in good health. C sought a further review, A received subsequent scans, and it was ultimately established that they did not have cancer (approximately two years after the original diagnosis).

C raised concerns about the basis for the initial diagnosis that A had cancer. They also complained about the subsequent management of A. C said there was no appropriate follow-up or subsequent communication after the diagnosis. Ultimately, C requested a review, but said it took significant time for the board to establish there was no cancer.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the diagnosis that A likely had cancer was reasonable. It was based on a reasonable radiological opinion given the findings on A’s CT scan. We did not uphold C’s complaint in that regard.

In relation to A’s subsequent management, we found that there were unreasonable failings. The standard of care and attention the board provided to A following discharge was not reasonable, and we found evidence that follow-up was proposed for A and then not acted on. We also found that there was a failure to respond within a reasonable time to the referral for an oncology review. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified in this investigation and include recognition of the impact the failings have had on them. The apology should meet the standards set out in the SPSO guidelines on apology at www.spso.org.uk/information-leaflets.

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

• Ensure effective systems are in place for review on hospital discharge and communication is effective especially where there is diagnostic uncertainty.

In relation to complaints handling, we recommended:

• Ensure board investigations identify and address incidents covered by the Duty of Candour with the relevant Scottish Government guidance.

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 at Queen Elizabeth University Hospital. A was admitted to hospital with a diagnosis of pancreatitis (inflammation of the pancreas). They were treated with fluids and antibiotics and their fluid balance was measured. They recovered and were discharged later that month. A was readmitted with various symptoms including abdominal pain, vomiting, loose stools and not eating or drinking on two further occasions and was discharged both times. A was later readmitted to the hospital in cardiac arrest and died shortly after arrival at the hospital.

We took independent advice from an appropriately qualified adviser. We found that the board failed to provide A with a reasonable standard of care and treatment. During one admission, there was a lack of comment on A’s hernia, a lack of investigation of low blood pressure and no evidence of a cardiology (specialists in diseases and abnormalities of the heart) input. On another admission, we found that the care and the management plan concerning A’s hernia was below standard and that there appeared to be a delay in the involvement of other specialists. We also found issues relating to the planning of surgery for A. Therefore, we upheld this aspect of C's complaint.

C also complained that A's final discharge from hospital was unreasonable. We found A's discharge to be reasonable and did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not making a timely assessment of risk for surgery, the failure to address A’s low blood pressure, the standard of monitoring and examination of A’s hernia, the delay in the involvement of clinical specialists, the standard of the management plan for A's hernia repair, the standard of planning of A's urgent surgery and for delays in 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:

• The board should have a policy in place on the management of emergency cases and prioritisation to ensure delays and recurrent cancellations of cases are minimised.
• The board should review how deteriorating patients are managed to ensure timely involvement of relevant specialties in care when there are complex patients.
• Ward round documentation needs to reflect concerns and management plans clearly.

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.