Health

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.

Summary
Mrs C made a number of complaints about the care and treatment provided to her mother (Mrs A) when she was admitted to the Western Isles Hospital for two days. We found that although staff had recorded that Mrs A was allergic to plasters, they continued to apply them to her. We were satisfied with the action taken by the board in response to Mrs C's complaint about this. However, we found that the record-keeping in relation to the assessment of Mrs A was not satisfactory and that there was no evidence of a risk assessment.

We did not uphold a number of Mrs C's complaints. There was no evidence that staff had failed to use a hoist when lifting Mrs A. We also considered that it was reasonable for staff to decide to keep her in bed rather than hoisting her onto a chair, as she was due to be seen by a doctor. We found that after the initial assessment, there was evidence that the board had listened to the family's views in relation to their mother's care needs. There was no evidence that staff had failed to ensure that Mrs A had a means of summoning help.

Mrs C also complained about the board's handling of her complaint. However, we found that it was reasonable to interview her brother about an allegation that a member of staff had been rude to him. There was no evidence that the board had breached confidentiality when they spoke to him. We also found that the board had not blamed the family for the problems that had occurred, but had tried to provide an explanation about how they had arisen.

Recommendation
We recommended that the board:
• remind nursing staff in the hospital of the importance of good record-keeping in relation to the assessment of patients on admission. This should include risk assessment and should involve obtaining information from relatives and/or carers.

Summary
Mrs C's mother (Mrs A) fell at home and was taken to A&E at Ninewells Hospital. X-rays confirmed that Mrs A had broken her femur and she was transferred to a ward a few hours later. The plan was for Mrs A to have surgery the next morning so she was given no food. When Mrs C called the ward the following morning she was told that there had been an emergency and Mrs A had not yet gone to theatre.

Mrs A went to theatre for her operation that evening. Mrs C telephoned the ward the next morning and was told that her mother had had a satisfactory night and was fine apart from being 'a bit chesty'. When Mrs C and her daughter arrived that afternoon they were told that Mrs A's condition had deteriorated and a team were attempting to resuscitate her. The attempt was unsuccessful and Mrs A died.

When her family saw her, they believed that she had been dead for some time given her pallor and temperature. Mrs C also complained that Mrs A was not given something to eat when she was transferred to the ward and that there had been an unreasonable delay in getting her to theatre. Furthermore, Mrs C believed that no appropriate action had been taken to address her mother's condition following surgery and that it was inappropriate that the family were not alerted when her condition deteriorated. Finally, Mrs C complained about the delay by the board in responding to her complaint.

The board accepted that Mrs A should have been given something to eat when she was transferred to the ward and apologised for their failure to do so. They also acknowledged that there was an unreasonable delay in responding to the complaint and apologised.
In regards to the timing of the operation, we found that this was reasonable as Mrs A's operation began just over 24 hours after admission. We also found that Mrs A's deterioration was rapid and that the care and treatment she received following her operation was reasonable and timely and that the board's failure to alert the family was reasonable in the circumstances. Finally, we found that there was no evidence to bring the timing of Mrs A's death as recorded by the board into question.

Summary
Mr C made a number of complaints about the care and treatment he received in Ninewells Hospital. He had been admitted following a hernia operation at another hospital. At Ninewells, he was found to have a haematoma (bruise) and there was also some evidence of infection.

We found that Mr C had been monitored appropriately following his admission to the hospital. The SEWS (the Scottish Early Warning Score) charts had been completed regularly and appropriately throughout his admission. There was no evidence to suggest that the monitoring, assessment and management of his pain was not reasonable.

Although Mr C complained that he was not provided with his regular prescribed medication until the day after he was admitted, the drug administration record showed that he had self-administered some of his medication on the day of his admission. We found that staff clearly failed to provide him with other medication that he needed, but had not taken to the hospital. We upheld Mr C's complaint about this. However, we did not make any recommendations, as the board had already apologised to Mr C and were taking action to reduce the likelihood of similar problems recurring.

Mr C also complained that the board did not provide him with oral antibiotics for 26 hours after he was taken off an intravenous antibiotic drip, despite his repeated requests and complaints. We upheld this complaint, as the records were not clear on the matter. It was not possible for us to say categorically whether there was a delay in providing him with oral antibiotics or whether the original intention was that the antibiotics should be stopped.
We did not consider that Mr C was asked inappropriate questions in A&E or that the questions were unnecessarily duplicated when he was transferred to a ward. Mr C also complained that the records of his stay in the hospital had
been fabricated. We found no evidence of this. In addition, we found that the board's handling of his complaint was satisfactory.

Recommendation
We recommended that the board:
• remind the medical staff involved in Mr C's care and treatment of the need to keep clear, accurate and legible records, which report the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigations or treatment.

Summary
Mr C made a number of complaints about the care and treatment he received in Ninewells Hospital. He had been admitted following a hernia operation at another hospital. At Ninewells, he was found to have a haematoma (bruise) and there was also some evidence of infection.

We found that Mr C had been monitored appropriately following his admission to the hospital. The SEWS (the Scottish Early Warning Score) charts had been completed regularly and appropriately throughout his admission. There was no evidence to suggest that the monitoring, assessment and management of his pain was not reasonable.

Although Mr C complained that he was not provided with his regular prescribed medication until the day after he was admitted, the drug administration record showed that he had self-administered some of his medication on the day of his admission. We found that staff clearly failed to provide him with other medication that he needed, but had not taken to the hospital. We upheld Mr C's complaint about this. However, we did not make any recommendations, as the board had already apologised to Mr C and were taking action to reduce the likelihood of similar problems recurring.

Mr C also complained that the board did not provide him with oral antibiotics for 26 hours after he was taken off an intravenous antibiotic drip, despite his repeated requests and complaints. We upheld this complaint, as the records were not clear on the matter. It was not possible for us to say categorically whether there was a delay in providing him with oral antibiotics or whether the original intention was that the antibiotics should be stopped.
We did not consider that Mr C was asked inappropriate questions in A&E or that the questions were unnecessarily duplicated when he was transferred to a ward. Mr C also complained that the records of his stay in the hospital had been fabricated. We found no evidence of this. In addition, we found that the board's handling of his complaint was satisfactory.

Recommendation
We recommended that the board:
• remind the medical staff involved in Mr C's care and treatment of the need to keep clear, accurate and legible records, which report the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigations or treatment.