Health

Summary

C complained about the care and treatment their late parent (A) received from board. A was admitted to A&E at Victoria Hospital following a fall at home. A was found to have fractured their femur and was subsequently transferred to a ward. A died shortly after transferring to the ward. No post-mortem was required by the Procurator Fiscal and a heart attack was recorded as the likely cause of death.

C said that they were told by the board's staff that tests carried out in the A&E did not indicate any problems with A's heart. As such, no additional monitoring was required when A transferred to the ward.

C complained that the board's staff failed to note and act upon a number of “red flag” symptoms that should have highlighted that A was at increased risk of a heart attack. C noted that A had been given a high dose of morphine by the ambulance crew. C complained that the board's staff failed to adequately monitor A's general condition or their reaction to the morphine.

We found that A's general condition was reasonably assessed in the A&E. An echocardiogram (a heart scan that uses sound waves to create images) was carried out and did not raise any concerns about A's heart. Whilst A displayed a number of symptoms that could have been linked to a heart problem, the tests carried out by hospital staff were thorough and gave no indication that there was a need for any specific additional heart monitoring when A transferred to the ward.

A was given a high dosage of morphine by the ambulance crew. We accepted medical advice that the hospital staff should have been aware of this and that they should have monitored A's response to this medication. We found no record of the morphine dosage having been recorded upon A's admission to hospital, or of specific monitoring taking place to check for any adverse reactions to the medication. A displayed symptoms that could have been caused by morphine. It was not possible to determine whether A's death was caused by a problem with their heart, or a reaction to the morphine. However, we were critical of the board's failure to record the morphine dosage and monitor A's reaction to it throughout their admission. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• That the board confirms to this office whether they assess patient care against the Scottish Standards for the Care of Hip Fracture patients and provides details of any learning and improvements resulting from C's complaint.
• That the board share a copy of this decision with the departments involved in A's care with a view to preventing similar issues in the future.

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 investigate, diagnose and treat gastrointestinal (relating to the stomach and intestines) problems and swallowing difficulties that they had experienced over a number of years. As a result of previous abuse, C required invasive procedures to be carried out under general anaesthetic. C complained that the board placed unreasonable emphasis on their trauma when making decisions about their treatment.

We took independent clinical advice from a consultant in gastroenterology (medicine of the digestive system and its disorders) and hepatology (liver disease). We considered C's initial treatment plan to be reasonable: a CT scan of C's colon followed by an upper GI endoscopy (a medical procedure where a tube-like instrumentis put into the body to look inside) as recommended by the private clinic that they attended, and a colonoscopy (examination of the bowel with a camera on aflexible tube) if indicated by the results of the CT scan. We found that the decision not to carry out a colonoscopy at this stage was reasonable, given the risks of performing this under general anaesthetic and the previous normal investigations.

We were critical of the board's failure to offer C a flexible sigmoidoscopy (an imaging test done to monitor the colon and rectum for the presence of ulcers, polyps or other abnormalities) after they developed rectal bleeding, but noted that this did not impact on C's overall treatment plan. C had gone on to have a colonoscopy under a different NHS board, which did not identify any significant pathology.

We did not consider the emphasis placed on C's childhood trauma to be excessive and we noted that reasonable investigations were carried out into C's swallowing difficulties.

Therefore, we did not uphold this complaint.

With regard to C's complaint that the board's complaint response contained inaccurate information, we found that generally their response was thorough and detailed. With the exception of an incorrect reference to C having anaemia, we found that the board's response to be factually accurate with clear explanations as to what investigations had been carried out and why. We did not uphold the complaint.

Summary

C complained about the care and treatment of their late parent (A) in the weeks prior to their death in Queen Margaret Hospital. C raised concerns that staff failed to notice and act upon A's deteriorating condition, and particularly a dramatic deterioration on the day that A died. C noted that the post mortem identified evidence of a chest infection, and they complained that A died of an easily treatable condition. C raised concerns about the stoppage of A's diuretic medication (drugs that enable the body to get rid of excess fluids), which they considered contributed to a fluid build-up in A's lungs.

We obtained independent medical advice from a consultant geriatrician (a doctor specialising in medical care for the elderly), who noted from the records that the expected level of observations took place. We found that sufficient attention was paid to A's fluid build-up, and that the decision to stop their diuretic medication was reasonable in the circumstances. However, we noted that A's vomiting and unstable observations in the days prior to their death were not acted upon. We noted that this should have prompted further clinical review. While we could not be certain that this would have identified a chest infection or how unwell A was, we considered that this should have received more attention from medical staff. We found no evidence to support that any dramatic deterioration in A's condition was overlooked on the day A died. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to act on A's vomiting and abnormal observations in the last few days of their life. 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:

• Abnormal clinical observations (such as low blood pressure and high heart rate) and vomiting should prompt timely clinical review / further assessment of the patient.

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 late child (A) who died of cancer. A received treatment from the dermatology department for a mole on their back. The mole was removed and, following testing, it was found to be cancerous.

A had further treatment from the plastic surgery department to excise (remove by cutting) more tissue from the area, which was tested and confirmed no cancer cells were present. After, A presented with abnormal lymph nodes, tests confirmed that they were cancerous. A underwent a procedure to remove the lymph nodes and some painful lumps on their body. After this procedure, A refused any further treatment.

C complained that the board did not do enough in the early stages to treat A's cancer. C felt that the procedure to remove the initial mole should have been more thorough, that A should have been monitored more closely for any spread of cancer, and that other treatments should have been considered at an earlier date. C said that they were unhappy with the board's communication with A and their family and that they were unhappy with the way in which the board handled their complaint, as they felt it was not consistent with their recollection of events.

We sought independent advice from clinical advisers with relevant experience. Both advisers reached the view that the care and treatment provided to A by the dermatology and plastic surgery departments were reasonable both in the early stages, and when the cancer later returned. It was also their view that the board's communication with A and their family members was reasonable.

In light of the evidence and the advice received, we found that the care and treatment provided to A and the communication from the board to A and their family was reasonable. We also found that the board's response to C's complaint was in line with what was recorded in the medical records. Our investigation did not identify any evidence that would cause us to doubt the board's position as detailed in their response. Therefore, we considered that the board handled and responded to C's complaint reasonably.

For the reasons set out above, we did not uphold C's complaints.

Summary

C complained on behalf of their parent (A). A had dementia, lived in their own home and took a number of medications. C raised concerns that A was not able to take their medication safely without supervision.

We took independent advice from a GP. We found that the primary responsibility of the practice was to prescribe appropriate medication for A's condition. They also had a role in assessing A's mental state and making appropriate referrals to other specialists. In terms of those responsibilities, we found that there was no evidence of failure on the practice's part.

There was a problem with one of A's prescriptions when they changed pharmacy. The practice addressed this problem quickly and an appropriate apology was given. As such, we did not uphold the complaint.

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.