Health

Summary

C complained about the nursing care and treatment they received during their admission to Ninewells Hospital. This related to the treatment of a pressure ulcer which C complained was left to deteriorate to the extent that on discharge it was worse than on admission. They said that as a consequence, their treatment had to be continued intensively at home.

The board apologised that C's wound had been worse on discharge and accepted that the simple dressings used by nursing staff would not have encouraged wound healing. They also accepted that there was a requirement to support all staff members to attend an update training session on wound care and that encouragement needed to be given to all team members to have the confidence to ask their peers or others working within the multidisciplinary team for advice and assistance.

We took independent advice from a nursing adviser. We found that there had been a failure to assess, measure and treat C's wound in accordance with the Scottish adapted pressure ulcer grading tool and Healthcare Improvement Scotland (HIS) Pressure Ulcer Standards (2018). We also found that the review carried out by the board had not been thorough enough, a number of failings had not been identified and that the action already taken by the board was not enough to demonstrate that there had been improvement with regard to pressure ulcer assessment and grading. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to assess, measure and treat their pressure ulcer in accordance with the Scottish adapted pressure ulcer grading tool and HIS Pressure Ulcer Standards (2018). 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:

• All pressure ulcers should be assessed, measured and treated in accordance with the Scottish adapted pressure ulcer grading tool and HIS Pressure Ulcer Standards (2018).

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 the actions taken by the board. A took a number of medications and over the years C became concerned about A's capacity to administer their own medication safely. There was an accidental overdose when A took too much Warfarin (a blood thinning medication). C complained about the care and treatment that A received following the overdose and that the board failed to ensure A could safely administer their medication.

We took independent advice from a specialist district nurse. We found that, as A was not bleeding, it was suitable for them to be treated in the community. Appropriate monitoring was carried out and no untoward events occurred for A while they were managed in the community.

We noted that district nurses had a role to play in keeping A safe. However, it was not normally their role to administer regular medication and not their sole responsibility to ensure that A was supported in their home to carry out everyday tasks safely. We found that the district nurses had acted reasonably and appropriately, and responded promptly when problems had arisen. We also noted that the record-keeping was of a very high standard.

We did not uphold C's complaints.

Summary

C complained on behalf of their late parent (A) about the care and treatment provided by their GP at the practice. A had been attending the practice with shortness of breath and a persistent cough. An urgent referral for suspected cancer was made, however C considered that the practice should have made the referral sooner.

We reviewed the relevant medical records and sought independent advice from a GP. We found that as A was high-risk patient who was failing to respond to antibiotics, an urgent referral to the chest clinic should have been made eleven months earlier and as such, we concluded that the practice failed to correctly follow the Scottish Suspected Cancer Referral guidelines. We upheld the 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:

• Clinical staff should be familiar with the Scottish Suspected Cancer Referral Guidelines and refer patients for specialist assessment in accordance with the guidelines.

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 failure of emergency mental health services to treat them during crisis admissions. C stated that they had been brought to the hospital on multiple occasions by police but that an assessment was not always carried out. C also complained that they had not been allocated a psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness) or a community psychiatric nurse.

The board responded by advising that services treated C appropriately when they attended and completed assessments when required. They also stated that C previously was supported by a psychiatrist but disengaged from this service and did not re-engage with services in the intervening period. C was unhappy with this response and brought their complaint to us.

We took independent advice from a psychiatric adviser and a mental health nurse. We found that the medical records showed that the board had acted reasonably and occasions where full assessments were not completed were appropriate and in keeping with strategies put in place to treat C. We considered that the plan to manage C's crisis contacts was in their best interests and we found no evidence of mental health assessment's being unreasonably withheld. Therefore, we did not uphold this aspect of C's complaint.

In relation to the allocation of a psychiatrist, we found that C had disengaged with services. However, proposed actions suggested by a psychiatrist to re-engage and support C did not appear to be actioned and records showed an unexplained gap in contact between C and services of around 18 months. Therefore, we upheld this aspect of C's complaint.

C requested a review of our decision and the case was reopened for further consideration. Details of this are explained below.

C was admitted to A&E at the Royal Infirmary of Edinburgh (RIE). After being transferred to an acute medical unit (AMU) from A&E, they left the ward and returned to their home. The police were contacted and they visited C at their home. C was detained under the Mental Health (Care and Treatment) (Scotland) Act 2003 (the Act) and returned to the RIE the following morning. C complained that the assessment carried out following C being detained and taken to hospital was unreasonable.

We took independent clinical advice from a consultant psychiatrist. We found that, while the board met the minimum requirement of the Act in terms of undertaking a medical assessment, there was no clear documentation detailing the mental state examination. We considered, given the complexity of the case, the lack of recent review and the presentation of C at the time, a formal assessment undertaken by an appropriately trained clinician from psychiatric services would have been reasonable and this did not take place. As such, we upheld this aspect of C's complaint.

C also complained that the assessment that was undertaken into their capacity was unreasonable. We found that there was no evidence to suggest that C did not have capacity to make their own decisions at the time. We noted that informal assessments are undertaken in every clinical interaction and we would not expect a formal capacity assessment to have been undertaken when clinicians considered C retained capacity. The psychiatric team had advised that in terms of C's mental health they considered C had capacity to make decisions on their care. The focus was then on whether C's physical injuries required care but C had consented to treatment for the same. Therefore, it was determined that there was no reason to detain C or undertake a formal capacity assessment. As such, we did not consider the lack of a capacity assessment to be unreasonable in these circumstances. 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 failing to undertake a formal assessment of them by an appropriately trained clinician from psychiatric services. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that the agreed actions and proposed strategies were not pursued. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Individual clinicians will reflect on the outcome of this investigation as required within their annual appraisal process.
• The board should take steps to ensure that treatment plans devised are effectively followed through, in order to try and foster trusting relationships, minimise a sense of rejection, demonstrate service consistency and reliability and show a willingness to work in an open, engaging and non-judgemental manner.

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 practice had failed to provide the correct prescription for their child (A). A had been diagnosed with type 1 diabetes and had been self-administering their medication with no issue. C said that this had changed and A found injections very painful. This had caused both A and the family significant distress. C said that the practice had prescribed the wrong type of needle and that this was not the type of needle specified by the hospital.

We took independent medical advice. We found that the practice had reasonably relied on their prescribing software. This was in line with both hospital and pharmacy requirements. The software had substituted a different product, and it was reasonable for this to have been prescribed. Additionally, the practice had responded timeously to C when they reported the problems A was having. Therefore, we did not uphold this aspect of C's complaint.

C also complained that the practice had failed to provide an adequate supply of needles.

The practice had accepted that A was not provided with the correct number of needles. They did not accept that they had not responded to C's requests for assistance timeously. We found that it was clear that C had not been prescribed the correct amount of needles and that it would be appropriate for the practice to reflect on this error, to improve future practice. Therefore, we upheld this aspect of C's complaint.

We noted that the practice had already committed to reviewing A and C's case through a Significant Event Analysis (SEA) and we asked them to provide us with a copy of their findings, as well as feeding them back to the board. We did not make any further recommendations.

Summary

C complained on behalf of their relative (A) about the treatment A had received from the board. A had emergency surgery to repair a dissected aorta (a tear in the heart) and was discharged following treatment. A developed an infection in their surgical wound and was readmitted to hospital for further treatment. C complained that in treating A's infection, the board incorrectly administered A with penicillin (an antibiotic) to which they are allergic. Following intravenous Co-Amoxiclav (antibiotic used for bacterial infections), A developed a skin rash. C also complained that A was administered ibuprofen which should not have been prescribed to A due to the heart medication they were taking.

We took independent advice from a clinical adviser. We found that there was no evidence in A's medical records of a penicillin allergy prior to the development of their skin rash following intravenous Co-Amoxiclav. We also found that the board's use of a penicillin derivative was reasonable and an appropriate choice of antibiotic for A's wound infection. We noted that the potential adverse effects of taking ibuprofen did not mean that it could never be used in patients taking A's heart medication. In A's case, the use of ibuprofen postoperatively had not been sufficiently documented, therefore we were not able to determine whether its use was appropriate. On balance, we found that the board had provided a reasonable standard of treatment to A and did not uphold this aspect of C's complaint.

C further complained that the board had not provided A with clear information regarding their cardiology (area of medicine concerning diseases and defects of the heart and blood vessels) rehabilitation and aftercare, resulting in a delay in A receiving appropriate follow-up appointments.

We took independent advice from a cardiologist. We found that the board had not correctly processed A's referrals for cardiology follow-up and cardiac rehabilitation or done so in a timely manner. The board had not correctly identified a discrepancy in A's nutritional assessment scoring or followed this up at the time. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and A's family for not correctly processing the referrals for their cardiology follow-up and cardiac rehabilitation, and for providing A with aftercare that fell below a reasonable standard. 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:

• Ensure a process or system is implemented so that discrepancies with patient malnutrition universal screening tool (MUST) scores/nutritional assessments are easily identifiable so that follow-up dietetics reviews can be requested.
• Ensure appropriate referral pathways are in place to ensure patients receive timely cardiology and cardiac rehabilitation follow-up as noted in a patient's post-surgical discharge summary.

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 board's decision to discharge their late parent (A) from University Hospital Monklands. A had metastatic cancer (cancer that has spread from the part of the body where it started) and had been admitted to hospital with blood in their urine. A was treated with antibiotics and antifungals, however, their infection markers remained elevated. As A showed no other signs of infection, their elevated infection markers were attributed to their cancer and they were discharged home. A was readmitted to hospital the following day with a deep vein thrombosis (DVT, blood clot in a vein). Their condition deteriorated and they died eight days later.

C complained that A had been discharged from the hospital before they were fit to return home. C also raised concerns about the hospital staff's communication regarding A's condition and discharge. C considered that failings by the board meant that A endured unnecessary suffering which distressed family members.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We were satisfied that the hospital staff communicated clearly and regularly with C throughout A's admission to the extent that C was kept informed as to how A was fairing on the ward. We were also satisfied that nursing and clinical staff appropriately monitored and recorded changes in A's mobility and attempted to provide physiotherapy when A was willing and able to participate.

We found that, in the days before A's discharge, C had raised concerns with the nursing staff regarding A's foot being swollen. We noted that this should have raised the suspicion of a DVT specifically and that investigations should have been carried out prior to A being discharged. Whilst the nursing staff advised C that their concerns would be passed on to the medical team, we found no evidence of this happening and concluded that an opportunity was missed to investigate and diagnose A's DVT prior to their discharge. 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 decision. The apology should meet the standards setout in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 underwent surgery for removal of a complex cyst on their right ovary. C complained that during the surgical procedure the board unreasonably removed their left ovary despite their express wishes it should be retained. They said that in the absence of a fully informed pre-surgical consultation, the board had not understood their surgical choices and had unreasonably prepared them for surgery. They said that following surgery, the board had failed to provide them with adequate pain relief and had withheld their medication. C also complained that the board's handling of their complaint was inadequate and that there were delays and inaccuracies in their response.

We took independent advice from an appropriately qualified adviser with experience in obstetrics and gynaecology (pregnancy, childbirth and the female reproductive system). We found that the surgical procedure performed was in line with the recommendations of a multidisciplinary team (MDT) and that the board had acted on what they believed were C's express instructions and for which written consent had been obtained. As such, we did not uphold this part of the complaint.

We found that despite reasonable attempts to include C in the pre-surgical decision-making and consent process, the board had failed to clarify with C their understanding of the proposed surgical plan and the circumstances in which C's left ovary was to be removed. We also found that the board had not telephoned C following the MDT team meeting as had been agreed, and some of the pre-surgical discussions that had taken place between the parties were brief or had not been documented in the clinical records. Therefore, on balance, we upheld this part of the complaint.

Following C's surgical procedure we found that there were two occasions where analgesia (pain medication) had been delayed after being requested, and on one of those occasions where it appeared to have been an inadequate dose. However, we found that C's usual pain regime medications had been administered regularly and their acute pain medications administered when requested. As such, we found that C had been provided with appropriate pain relief and did not uphold this part of the complaint.

We found that the board's complaint handling in this case was poor. There was a failure by the board to update C on the progress of the investigation and there were delays in a number of their responses. The board's final response contained a number of factual inaccuracies and it had not adequately addressed all of C's concerns. As such, we upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to clarify their understanding of the proposed surgical plan, the circumstances in which their left ovary was to be removed and for failing to handle their complaint reasonably. Also apologise for not sufficiently documenting the discussions that took place between the parties at the initial consultation, for failing to contact C by telephone following the MDT meeting, and for failing to document the pre-operative discussions which took place between the parties on the morning of C's 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:

• Ensure all discussions between patients and clinicians are clearly documented as part of the consent process.
• All relevant clinical staff should be reminded of the need to ensure all reasonably practical steps are taken to clarify a patient's understanding of a proposed surgical plan prior to consent being obtained and that patients are fully counselled on the nature of borderline ovarian cancer results.

In relation to complaints handling, we recommended:

• The board should ensure all complaints are handled in line with the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. Where a response to a complaint cannot be provided within an agreed timescale, complainants should be provided within an updated timescale as to when they can expect to receive a response. The board should ensure all responses are accurate, reflect the available evidence and information, and address all points raised. Where there has been a delay in providing a response beyond the normal timescale, the board's stage 2 response should include an apology.

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 their child (A) with orthognathic treatment (orthognathics is a specialist subset of dentistry which involves surgical correction of growth issues with the jaw and lower face) within a reasonable timescale.

A's teeth were overcrowded to the extent that they caused pain in their head and jaw and difficulties with eating and speech. Following referral to an orthodontist, A was placed on the waiting list for orthognathic treatment. However, despite it being identified that A would require surgery, their treatment was not progressed. The board explained to C that this was due to a shortage of orthognathic specialists in their area and that an agreement with neighbouring health boards for them to provide treatment had come to an end. C complained that the board had failed A by not providing the required treatment within their area, or making arrangements for the treatment to be provided in another area, or privately.

The board were open and honest about the fact that they struggled to provide specialist orthodontic and orthognathic appointments over a number of years due to staff recruitment issues and the loss of arrangements with neighbouring health boards. They acknowledged and apologised for the fact that this led to substantial delays for A. We commended the board for their transparency in this respect and acknowledged that there were a number of factors beyond their control that limited the provision of these services and contributed to a long waiting list for all patients in the area.

We took independent advice from an orthodontic specialist. We found that, whilst it was recognised at an early stage that A would benefit from orthognathic surgery, this treatment would not have been available to A for a number of years. Surgery was first discussed when they were 11 years of age. We noted that, prior to surgery, there would be 12 to 36 months of preparatory orthodontic treatment and this would not normally start until the patient was 15 or 16 due to their bones needing to develop. Once this preparatory treatment had been completed, a multidisciplinary discussion would be undertaken to assess the nature of the surgery that would be required. The available evidence showed that the board followed this approach for A.

Whilst we were satisfied with the overall treatment plan for A, we found that there was an unreasonable delay of around 18 months to A being seen by a consultant following their referral to the orthognathic service. Although this did not delay A's treatment, we recognised that the long wait for a consultation and details as to what treatment options were available would have added to C and A's distress. Therefore, we upheld this complaint. We did not make any recommendations due to the appropriate action already taken by the board.

Summary

C complained about the care and treatment they received from the board for their hearing problems, and for their problems of dizziness/loss of balance.

We took independent advice from an ear nose and throat (ENT) specialist. We found that C's hearing problems were investigated appropriately and they were given multiple repeated investigations. We also found that appropriate steps were taken to investigate C's problems of dizziness/loss of balance. Therefore, we did not uphold C's complaints.