Health

Summary

C’s late partner (A) tested positive for COVID-19. A week after testing positive, A called 111 as they were still feeling very ill. They explained that they had had a fever for a few days and were having difficulty regulating their temperature. A was advised by a nurse practitioner to remain hydrated, continue taking paracetamol, and to continue to self-isolate until they had no fever for 48 hours. They were also advised to call back if they had any further concerns about their symptoms.

C called 111 again a few days later as they were concerned A’s breathing was becoming laboured. C had to wait around 20 minutes before the call was answered. During the call, the call handler repeatedly asked to speak to A to take information directly from them, even though C kept answering for A as A was confused. The call lasted around 30 minutes. The call handler contacted Scottish Ambulance Service and requested an ambulance on an emergency basis, but by the time paramedics arrived A had stopped breathing and could not be resuscitated. C complained about the clinical assessments of A’s condition on both instances.

We took advice from an advanced nurse practitioner with experience of assessing patients with similar presentations. We found the assessment on the first instance to be reasonable, and we therefore did not uphold this complaint.

We considered it unreasonable for the second call to have lasted 30 minutes before an ambulance was called. We noted that the call handler was following the protocol correctly, but were of the view that if the protocol took 30 minutes to establish that an emergency response was required, it was not fit for purpose. We considered that rigid following of the protocol led to a delay in obtaining medical attention for A. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings we have 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:

• Protocol is reviewed so that in patients with shortness of breath as the primary presentation there is a clear escalation route to a medically trained clinician.

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 removed from their GP practice patient list. The practice were contacted by Practitioner Services (part of NHS National Services Scotland who support primary care providers) after this and suggested the practice refer C to the board's Challenging Behaviour General Practice (CBGP). The practice referred C to the CBGP.

C complained that the practice had unreasonably referred them to CBGP. C said the practice were not required to refer C to CBGP, did not have a good reason to refer them and did not follow the correct procedure.

We found that once the practice’s request to have C removed from their patient list was actioned, they were not obliged to arrange any future care for C. However, Practitioner Services found themselves unable to place C on a patient list of another GP practice in the area. They went back to C’s most recent practice and asked them to refer C to the board’s CBGP. The referral the practice sent meant C might (if the referral was accepted) have access to primary care services. We decided that the decision to refer C to CGBP was reasonable in the circumstances. As such, we did not uphold this complaint.

However, we found that the processes in place were not helpful to guiding the situation C found themselves in. Understandably C was left confused about why the referral was made and had to contact the practice themselves to find this out. We passed on our feedback to the relevant health board.

Summary

C complained about various aspects of the care and treatment their late spouse (A) received from the board.

A had a history of vascular (relating to a vessel or vessels, especially those which carry blood) surgery and was admitted to hospital for the removal of a benign tumour. The procedure took place, however, A’s condition deteriorated and they were moved to an infectious diseases unit with suspected sepsis (blood infection). A’s condition deteriorated further and they were transferred to a vascular and critical care ward in a different hospital on an emergency basis. Later that day, A underwent surgery to remove an infected synthetic artery graft (a piece of living tissue that is transplanted surgically).

A experienced an abdominal bleed and was transferred to a critical care unit. After treatment, A was reviewed by a consultant and returned to the vascular and critical care ward. A experienced a fall on the ward. A later developed a lung infection/sepsis and died.

C complained that the board failed to screen, manage or treat A’s infection. C said that A had been discharged from the critical care unit onto the ward too soon. C also complained that the board had failed to properly assess A’s fall risk or treat A properly after their fall.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a registered nurse. We found that the screening, management and treatment of A’s infection and their discharge from the critical care unit was reasonable. We did not uphold these complaints. However, we found that the board had failed to adequately complete risk assessments, including a falls risk assessment, for A. We upheld this complaint.

We also considered that the board made an error of communication while responding to C’s complaint when they referred to MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) instead of MSSA (a bacterial infection which is not resistant to certain antibiotics). We provided feedback to the board about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for wrongly referring to MRSA rather than MSSA when responding to C’s complaint and for their failure to complete A’s Falls Risk Assessment; bed rails and 4AT delirium assessments in line with organisational policy. 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:

• Falls Risk Assessments and bed rails/4ATdelirium assessments should be carried out in line with the board’s stated policy.

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 to the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord).

We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable.

However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming.

In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that there was no contemporaneous evidence that C was reasonably informed of the potential risks and complications of surgery or of the potential for morphine to become habit-forming. 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:

• There should be complete records of discussions with patients about the potential risks and complications of surgery prior to surgery.
• There should be records of discussions with patients regarding the potential for morphine to become habit-forming.

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 provided to their late brother (A). A’s consultations with the practice took place when COVID-19 restrictions were in place and as such, a number of their appointments were held via phone.

A had been complaining of a persistent sore throat and tongue. A also said that they had been reporting a lump in their neck. A was referred to the Ear, Nose and Throat (ENT) department and was diagnosed with oropharyngeal cancer (a type of cancer that begins in the cells of the tonsils). C complained that there was a delay in referring A to ENT for further investigation.

We took independent advice from a GP. We found that there was a poor standard of record keeping by the practice. The records did not always demonstrate that an adequate medical history was obtained or that adequate safety netting and follow-up advice was provided. We also identified that the wrong antibiotics were prescribed on one occasion and that the wrong test for glandular fever was performed. We were concerned that the practice’s own investigation of the complaint did not identify any of these failings.

We considered that there was likely a delay of 15 days in referring A for further investigation. While this was not significant, in light of the other failings identified, 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:

• The medical centre should ensure that staff are confident and knowledgeable in carrying out physical examinations.
• The medical centre should ensure that the Significant Event Analysis addresses both clinical care and treatment and internal processes.
• The medical centre should ensure the standard of record-keeping meets General Medical Council Good Medical Practice standards.
• The medical centre should have a policy to review their cases or seek medical advice, especially when several consultations occur and the case is non-responsive or atypical.

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's community mental health team recorded their transgender status in their medical records, without C's knowledge or consent. In their complaint response, the board said that they considered C's gender transition was relevant to their mental health treatment and medical staff would require access to the information when providing C with treatment.

We took independent advice from appropriate clinical specialists. We found from a clinical perspective that, at the time the information was recorded, it had been reasonable for staff to conclude that consent had been given as this information was provided by C, and that the information was relevant to the treatment being provided and, therefore, reasonable to record. We did not uphold this complaint.

However, we did not make a decision on specific points raised about the ongoing and future management of personal data in the records as we considered these were ultimately more appropriate for the Information Commissioner’s Office.

Summary

C underwent re-root canal treatment from the dentist in an attempt to treat an abscess (a painful swelling caused by a build-up of pus) which had formed under one of their teeth. After attempts to resolve the issue were unsuccessful, C was referred to a specialist. C complained that the re-root canal treatment was not carried out by the dentist in a reasonable manner and limited further treatment options for C.

We took independent advice from a specialist in dentistry. We found that the treatment provided was reasonable. While the treatment did not resolve the presence of C’s abscess, it was not unreasonable.

As such, we did not uphold this complaint.

Summary

C was referred urgently to the gynaecology department (medicine of the female genital tract and its disorders). During the vetting procedure the board requested the referral be downgraded to routine and the GP complied with this request. Following a consultation with the first consultant, C was scheduled for an operation. During the pre-operation examination by the second consultant, a cervical tumour was found and the operation cancelled. When informed of this, C made a verbal complaint about their treatment since being referred.

Biopsy results confirmed the tumour as malignant. C lost faith in the clinicians involved and requested a second opinion. A consultant oncologist (cancer specialist) met with C to discuss this and took steps to arrange a second opinion. C also took steps to obtain the second opinion using personal contacts. The second opinions provided concurred with that of the board. C complained to the board in writing regarding their experiences. A significant clinical incident (SCI) investigation was undertaken and following this, the board responded to C’s complaints. C was dissatisfied with the board’s responses and brought their complaint to this office.

We took independent advice from a consultant gynaecological oncologist. The SCI investigation had found that the board failed to give advice, contrary to relevant guidance, to C’s GP regarding the referral submitted as urgent. We upheld C’s complaint about this and accepted advice received that the board’s revised guidance had addressed the identified failings. However, the board had not apologised to C for these.

The board concluded the time taken between C’s referral by their GP and a correct diagnosis being reached was unreasonable and also accepted the time taken to respond to C’s complaint was unreasonable. We upheld C’s complaints about these and found that the board had not reasonably apologised to C for the delay in diagnosis.

We found that C’s verbal complaint had not resulted in reasonable action being taken as there was no evidence of any consideration regarding the complaint until C made a written complaint over two months later.

We accepted the advice we received that the board provided reasonable care and treatment to C following their diagnosis and that there were no concerns about how the SCI investigation had been carried out in relation to the board’s policy. We did not uphold these complaints.

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 as well as include a clear stated apology for the delay in C’s diagnosis. 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 take all reasonably practicable steps in the present circumstances to ensure that they comply with the Treatment Time Guarantee.

In relation to complaints handling, we recommended:

• The second consultant should take action to ensure that all complaints are appropriately recognised, acknowledged and actioned, including verbal 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, an advice worker, complained on behalf of their client (B) about the treatment which B’s late adult child (A) received from their GP practice. The practice is being managed by the board. A had contacted the practice on a number of occasions over a six-month period reporting problems with their mental health. A was a student studying away from home.

A subsequently completed suicide. B felt that the staff from the practice had failed to take fully into account A’s personal circumstances which all pointed to the fact that A was at increased risk of attempting suicide and that they failed to provide them with appropriate treatment.

We took independent clinical advice from a GP. We found that the GPs involved had formed a good relationship with A. They had recorded A’s mental health symptoms and provided a reasonable level of care and treatment by prescribing appropriate medication and monitoring A’s behaviour. There was also the involvement of a counsellor but there was nothing to indicate that A was going to take their own life. We did not uphold the complaint.

Summary

C attended the Grampian Medical Emergency Department (GMED) out-of-hours service with severe pain in their arms and shoulders. They were referred to the Acute Medical Initial Assessment Unit (AMIA) and then transferred to the Stroke Unit, a unit that has capacity to receive patients with non-stroke problems when the hospital is busy.

C received multiple tests, including multiple electrocardiograms (ECG, test to check a patient’s heart rhythm and electrical activity) in order to diagnose the cause of their symptoms. It was determined to be a trapped nerve in C’s neck and C was discharged from hospital with a prescription for medication for nerve pain and sensitivity.

C complained that there were failings in communication and record-keeping during their admission and that this lead to the unnecessary repetition of ECG tests and a delay in administering pain medication. They also raised concerns that they had been told they had a liver infection requiring antibiotics but this was not recorded, meaning that antibiotics were not prescribed.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the treatment C received during their stay in hospital was reasonable and consistent with the symptoms they experienced and that the communications recorded were reasonable. Therefore, we did not uphold these complaints.