Health

Summary
Ms C was injured when there was an accident involving the stair lift on which she was being transported by a member of the Scottish Ambulance Service (the Service) to a hospital appointment. She complained that, following the accident, she reported the matter to the receptionist at the clinic and was told that someone (apparently the lead nurse of the clinic) would come to see her. This did not happen before Ms C was collected again by the Service for transport home.

Ms C also complained that despite being in pain from her injuries no hospital staff came to check her over. She also said that when the board responded to her complaints the letters contained inaccurate information, including referring to her injuries being caused when she was 'putting her aunt onto the stair lift' and that she had been 'walking with the consultant' within the clinic. Ms C was in fact in a wheelchair the whole time she was in the clinic on this day.

We upheld all of Ms C's complaints and made relevant recommendations. The board acknowledged that the incident had occurred (while Ms C was in the care of the Service) and that Ms C had made hospital staff aware that it had happened. Although a member of staff checked with the Service that they knew about the matter, no action was taken to report it within the hospital's own policy on accidents. The board had not referred in their response to the failure of the lead nurse to come to speak to Ms C while she was in the clinic.

On the matter of Ms C not being checked over, the board said that the consultant that Ms C was there to see recalled Ms C mentioning that she had had an accident but not that she had been injured and/or was in pain. They also said that none of the other staff had any recollection either of Ms C saying she was in pain or that she seemed to be in pain. Although there was no conclusive evidence to support either version of events, we found that although aware that there had been an accident, there was little evidence to suggest that staff had taken steps to find out how Ms C was after it happened. On balance, therefore, we took the view that little or no effort had been made by staff to establish the extent of Ms C's injuries and/or pain.

On the issue of their complaint response, the board acknowledged that there were errors in two letters. In particular, the chief executive said that the comment about Ms C walking within the clinic was based on the recollections of staff from a previous visit to the clinic by Ms C. The chief executive accepted that on the day in question Ms C was in a wheelchair the whole time she was in the clinic.

Recommendations
We recommended that the board:
• apologise to Ms C for the failures identified; and
• review the policy and procedures for reporting accidents and ensure that all staff are aware of the policy and their responsibilities within it.

Summary
Mr C complained on behalf of his mother about a cancer diagnosis that was delayed due to 'human error' by a radiologist (a medical specialist that uses imaging to diagnose and treat disease) in interpreting a scan.

He also complained about the board's complaints handling and what he regarded as confusing and/or contradictory information.

We upheld Mr C's complaint about the misinterpreted scan. We found that the board had already acknowledged this and apologised to him.

When looking at the complaint, we took account of the action already taken by the board. We also looked at the remedial action they took to minimise the likelihood of a recurrence and took advice from our medical adviser, who compared the board's action to national standards set by the Royal College of Radiographers. We found that the remedial action either matched or exceeded the national standards and we were satisfied that appropriate and timely action had been taken to address the failings identified. We, therefore, did not make any recommendations.

On the issue of the complaints handling, we found that the information provided to Mr C was clear and was not contradictory.
 

Summary
Mrs C complained to the board about aspects of the care and treatment provided to her late husband (Mr C) both in hospital and by the Out of Hours Service (OOHS). Mr C had been suffering from cancer. When he became unwell with abdominal pain and diarrhoea, Mrs C contacted the OOHS and Mr C was taken to hospital.

Mrs C complained that Mr C should have been taken to a different hospital, and that he was given inadequate clinical treatment and pain relief. She also complained about delays in diagnosis and treatment; poor communication and unhelpful attitudes from staff; the time taken for an OOHS doctor to arrive at the house and that the doctor was uncaring.

We did not uphold the majority of Mrs C's complaints. We established that, as an emergency ambulance was called, it was appropriate for Mr C to be taken to the hospital where he was treated. After taking advice from one of our medical advisers, we also found that while Mr C was in hospital he received appropriate clinical treatment, staff carried out appropriate investigations, and the general level of communication was adequate.

We upheld two of Mrs C's complaints as we found that for a period Mr C's pain was not managed appropriately; and that there had been a fifteen minute delay by the OOHS doctor in arriving for the home visit.

We did not make recommendations on this complaint as the board have already taken action to remedy what went wrong. The board have apologised for a breakdown in communication by the nurses in regards to pain relief and staff at the OOHS have apologised for the delay in their doctor making a house call.

Summary
Mr C attended his GP, complaining of blurred vision. Two days later, he attended again with the same symptoms. The GP telephoned the hospital to ask for an appointment to be provided more quickly and was told Mr C would be seen as soon as possible.

Just over a month later, Mr C saw a consultant ophthalmologist who could not find anything wrong. Mr C questioned this and was told that the consultant could send him for a scan. Mr C attended for a scan three weeks later. The following week, the consultant telephoned and said that the results of the scan showed Mr C had suffered a stroke and urgently needed to attend the stroke clinic. Mr C was dissatisfied with the consultant's attitude and was unhappy that it took over nine weeks to diagnose that he had suffered a stroke.

After taking advice from one of our medical advisers, we found that Mr C's symptoms were not typical of a stroke and that the consultant had carried out an appropriate assessment. We did, however, uphold his complaint that there was a delay in the board providing him with an ophthalmology appointment after the GP asked for Mr C to be seen more urgently.
 

Recommendation
We recommended that the board:
• apologise to Mr C for the failure to act on the second GP referral.
 

Summary
Mr C was on holiday when he sought treatment for a dental infection. He complained about the care and treatment provided by the board when he attended the emergency department at a hospital. Mr C explained to a member of staff that he was in a lot of pain, his face had become swollen, and that he was seeking antibiotics and painkillers. They told Mr C to contact NHS 24 as there was no dentist available to treat him.

Mr C spoke to a healthcare professional at NHS 24 who took some information and told him to return to the emergency department where he would be helped. However, on his return to the emergency department, Mr C said that he was told to leave and that NHS 24 would call him. However, they did not. Mr C received treatment from his own dentist when he returned home several days later.

Mr C complained that the board's failure to treat him was unacceptable given the dangers of an untreated infection, and that the board should have treated him with antibiotics and painkillers in the absence of a dentist. Mr C also complained that the board's response to his complaint was inadequate.

We took advice from our medical adviser, and found that communication failures led Mr C to leave the hospital, but that a consultation should have been arranged when he returned to the emergency department after his telephone call with NHS 24. The provision of simple pain relief and prescription of antibiotics, if required, would have been reasonable medical care. We told the board this, and upheld this complaint. However, as Mr C had already received an apology from the board and they had taken measures to try to prevent this happening again, we did not make any recommendations. We found that the board had considered and dealt with Mr C's complaint in line with NHS complaints procedures.

Summary
Mr C complained about the treatment that his late mother (Mrs A) received in hospital.

Mrs A was admitted with shortness of breath, and was in hospital for five days. She was discharged back to her care home but when she arrived there, staff were concerned about her condition. They contacted a GP who authorised that Mrs A be redirected to the community hospital. She was admitted to the community hospital, where she died of pneumonia some five hours after admission.

We upheld most of Mr C's complaints. We noted that before we began our investigation, the board had already accepted there were failings and communication problems, and had set out an action plan to prevent a repeat occurrence. We also established that there were communication failings between staff about the facility to which Mrs A should have been discharged. Initially the consultant had deemed that Mrs A should be discharged directly to the community hospital for palliative care but they refused as Mrs A did not require rehabilitation. This information was not passed back to the consultant, and a junior doctor decided that Mrs A could then be discharged back to the care home.

We took advice from one of our medical advisers who said that the board failed in the overall management of the care of and discharge planning for Mrs A. It appeared that arrangements for her discharge were managed by junior medical and nursing staff without any involvement of more senior staff. The inadequate arrangements that resulted from this meant that Mrs A and her family were badly let down during the final hours of her life.

Recommendations
We recommended that the board:
• take into account the adviser's comments on the action plan and provide a more detailed consideration of the failings which have been identified and demonstrate how effective the suggested measures have been; and
• apologise to Mr C for the overall manner in which Mrs A's discharge from hospital was handled.

Summary
Mr C complained that his GP failed to refer him to a specialist for carpal tunnel syndrome. He also complained that his GP failed to diagnose him with cubital tunnel syndrome. He said that his GP did not examine him and dismissed his concerns about pins and needles in his little finger because this was an unusual symptom of carpal tunnel syndrome.

In response to Mr C's complaint, the practice said that the GP had carried out an examination and referred him to a specialist. The practice also said that there was no mention of tingling or numbness in his little fingers in either his medical records or the correspondence from the hospital orthopaedic consultant.

We took advice from our medical adviser. The adviser said that although the entry in Mr C's medical records was inadequate in terms of the examination carried out by the GP, a referral had been made to the appropriate specialist. We also confirmed that there was no evidence in Mr C's medical records or letters from the specialist to reflect that Mr C had specifically complained about pins and needles in his little finger. The GP records referred to pins and needles across Mr C's fingers and a hospital letter in particular referred to numbness in Mr C's left middle finger.

We concluded that it was made clear that Mr C was experiencing symptoms of cubital tunnel syndrome only after surgery for carpal tunnel syndrome had left symptoms of numbness in his little finger. We did not uphold the complaint.

Summary
Mr and Ms C complained about the care and treatment provided to Ms C's mother (Mrs A) by her medical practice.

They complained that the practice failed to adequately investigate the decline in Mrs A's mental health; properly monitor her repeat prescription medication; fully investigate her incontinence problems; or arrange for Mrs A to have an influenza vaccination without being prompted by the family. They also complained that the practice failed to provide treatment in line with the Adults with Incapacity legislation and that there were unreasonable delays in responding to their complaints.

Turning first to the complaint that the practice failed to provide treatment in line with the Adults with Incapacity legislation, we found that they acted within their procedures, but that there were communication failures. These were contrary to the principles underpinning the legislation and also contributed to the delay in arranging the influenza vaccination. We found that there were shortcomings by the practice in the way they handled the complaint in that there were delays and that the practice failed to tell Mr and Ms C of their right to approach the SPSO at the beginning of the complaints process. We also found that the practice did not closely monitor Mrs A's repeat prescription. We made recommendations to address the failings that we found. However, we did not find any failures by the practice in the provision of care and treatment in relation to Mrs A's mental health and incontinence problems.
 

Recommendations
We recommended that the practice:
• review their systems to monitor repeat prescriptions;
• ensure effective communication takes place between practitioners and all the key people involved in a patient's care;
• review their complaints handling to ensure it complies with the NHS complaints procedure, with particular reference to timescales; and
• apologise for the failures identified.

Summary
Ms C attended a dental practice for the first time. She said she was still waiting fifteen minutes after the appointment time, and that no one had told her that there would be a delay or explained it to her. She said that there were staff around the reception area who could have done so, including the practice manager. Ms C said that after approaching and speaking to some staff members she decided to leave without seeing the dentist and without registering as a patient. She also had some complaints about the practice's handling of her subsequent written complaint about her experience.

The practice's account of events on the day was that, without waiting for Ms C to approach them, they had told her of the delay and apologised. They said that the various members of staff who had been involved all considered her behaviour to have been difficult, and the records had been noted to the effect that she would not be accepted as a patient if she decided to come back.

Regarding their complaints handling, they said they had tried to reply to the complaint by telephone but that Ms C had not wanted to speak to them.

Although we considered the note in the records to be quite strong evidence, we could not establish sufficient facts to decide between the two contradictory accounts of what happened on the day. In the absence of firm evidence one way or the other, we could not uphold the complaint about those events. The practice, however, told us they now displayed a sign on the wall, saying that if a patient was waiting more than ten minutes after their appointment time, they should tell reception staff. We considered this to be a constructive approach to the complaint.

Our investigation found that the specific issues in Ms C's complaint had been reasonably handled. It is acceptable practice to try to reply to complaints by telephone, although when this did not work out, the practice should have sent a written reply. However, at that point Ms C had telephoned us for advice, we had contacted the practice to request that they reply, and a reply was then promptly sent. We did not consider that further action by us was needed. We did note that the complaint reply contained very little information about the investigation that had been carried out and very little explanation of the practice's conclusions. We did not consider that this gave us sufficient grounds to uphold the complaint, but we did make a recommendation to the practice about this.

Recommendation
We recommended that the practice:
• ensure that written complaint replies contain a reasonable amount of information about how the complaint investigation was done and how the conclusion was reached.

Summary
Mrs C, who was the manager of a care home, complained to the board about the way one of her residents (Mrs A) was discharged from hospital back to the care home. Mrs C felt that it was inappropriate to have discharged Mrs A as she was in an unkempt state, was agitated; had struggled with ambulance staff; and that Mrs A's safety, along with that of care home staff, was at risk.

When Mrs C tried to have the hospital re-admit Mrs A, she was told the bed was no longer available. Mrs C also complained that the board's investigation of her complaint had not included seeking comments from clinical staff who had attended Mrs A following her discharge.

We established that Mrs A had been admitted to the hospital for an assessment and that when this had been completed then there was no clinical reason for her to remain in hospital. We did establish that there had been a communication issue between hospital staff in that initially Mrs A's hospital bed was to have been kept available for a time should she not settle back into the care home. However, from a clinical perspective it had been appropriate to discharge Mrs A from hospital.

We also found that the board's investigation of the complaint was reasonable and it was for them to decide who should be contacted to provide comments as part of their investigation.