Health

Summary

C complained on behalf of their late spouse (A) who was admitted to Ninewells Hospital. A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR, a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place some time after their admission and they died a week later.

C complained that clinicians failed to discuss the DNACPR with family prior to this being put in place and, when they were consulted, the family were clear that they were not in agreement with it. The family also complained that the DNACPR form was only signed by one clinician, rather than the two required for the form. C considered this was further evidence that the DNACPR decision was taken incorrectly.

In response, the board said that the decision to put a DNACPR in place was made following discussion at the multi-disciplinary team meeting, the records did not show any disagreement by the family at the time and the form was completed by one of the junior medical staff, on the lead consultant’s instruction.

We took independent advice from an appropriately qualified adviser. We found that the board failed to follow appropriate processes and procedures in relation to the implementation of the DNACPR, in as far as they failed to both adequately document conversations with family members, and to complete the required paperwork correctly. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow appropriate processes and procedures in relation to the implementation of the DNACPR, more specifically for failing to adequately document conversations with family members, and also in failing to complete the required paperwork correctly. 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:

• Clinicians involved should reflect on the complaint and identified failures with respect to the implementation of the DNACPR, specifically documenting communications with family and completing the relevant paperwork and forms.
• Medical professionals and clinicians are aware of, and adhere to, relevant professional standards and guidance with respect to maintaining clinical records and recording decision-making.

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 had been treated for chlamydia and gonorrhoea (two types of sexually transmitted infection) by the board. C continued to feel unwell and attended an appointment at the board. C was concerned that they were not physically examined or tested for pelvic inflammatory disease (an infection of the female upper genital tract, including the womb, fallopian tubes and ovaries) and that they were advised to isolate with a possible COVID-19 infection.

We took independent advice from a consultant in sexual and reproductive health with a background in hospital gynaecology (female reproductive system). We found that C reported symptoms which were consistent with pelvic inflammatory disease. In the circumstances, it was unreasonable that a physical assessment was not performed, or as an alternative, empirical antibiotic therapy commenced for possible pelvic inflammatory disease. It was unreasonable that further steps were not taken to assess for and exclude pelvic inflammatory disease as a possible diagnosis in this case, prior to providing the advice regarding self-isolation for possible COVID-19 infection.

In light of the above, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not performing a physical assessment for pelvic inflammatory disease or as an alternative commencing empirical antibiotic therapy. 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:

• Patients who present with abdominal pain and fever, in the context of a recent sexually transmitted infection, should be physically examined and/or commenced on empirical antibiotic therapy.

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 partner (A) about the care and treatment they received at the Royal Infirmary of Edinburgh for heart disease. A’s condition deteriorated and they were transferred to the intensive care unit and then ultimately referred to another health board for a heart transplant. A died five days later.

C said that the board did not treat the left side of A’s heart which resulted in a grave outcome for A. C also said that the board did not notice that A was deteriorating and that A should have been transferred to the other health board earlier.

The board said that when A was admitted they had a blocked right coronary artery and treatment was given for this. They explained that there was no viability in the left side of A’s heart (due to damage caused by a previous heart attack) and therefore, to treat that side would have subjected A to additional risk. The board said that A was very unwell, but reasonably stable until their sudden deterioration. They said that there was no indication that an earlier referral outwith the health board was warranted or would have altered the outcome.

We took independent clinical advice from a consultant cardiologist (a doctor that that deals with diseases and abnormalities of the heart). We found that it was reasonable for the board not to have a treatment plan for the left side of A’s heart as it would have exposed A to increased risk and there would have been no benefit to A (due to irreversible damage caused by a previous heart attack). The board reasonably monitored A’s condition and provided appropriate care and treatment in response to their deteriorating condition. We also found that the board’s decision to refer A to another heath board was reasonable and that there was no indication this should have been done earlier.

As such, we did not uphold this complaint. We did, however, provide feedback to the board regarding their communication with A.

Summary

C complained on behalf of their late parent (A) who died following surgery to remove cancerous tissue. C said that the care and treatment that A received in hospital was not reasonable, and that A’s cancer should have been detected earlier. C believed there were failings in the management of A’s care which caused A pain, distress and discomfort and this was worsened by the standard of nursing care.

We took independent advice from two appropriately qualified advisers. We found that the diagnosis concerning the spread of cancer was reasonable and did not uphold this aspect of C's complaint.

In relation to nursing care, we found that there was a lack of accurate and appropriate pressure assessments, and a lack of timely interventions led to the development of severe pressure damage. There was inappropriate wound management causing deterioration to wounds and poor observation of urinary output. We also found that the standard of record-keeping was unreasonable, that national pressure ulcer prevention standards and relevant policy were not followed and there was delay in referring to specialists. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the standard of nursing care provide to A, for failing to carry out appropriate assessments to prevent severe pressure damage, failing to provide appropriate wound management, failing to appropriately monitor urine output, delaying referrals and failing to follow relevant standards and 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:

• A wound chart should be completed for each wound detailing size, tissue type present, treatment and treatment objectives.
• Fluid balance charts should be completed to acceptable standard for early recognition of fluid balance issues.
• Pressure ulcer risk assessments should be calculated properly on admission and reassessments recorded at least weekly and when clinical condition changes.
• Sufficient information should be given to a patient and or their family to allow them to make an informed choice when deciding to decline pressure relieving interventions. This should be recorded in the case notes.
• Tissue viability referrals should be made in line with the relevant national guidance.

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 referred to Raigmore Hospital by their midwife with high blood pressure. C was pregnant and there were concerns they had pre-eclampsia (a condition that causes high blood pressure during pregnancy and after labour). C said that on attending the hospital they did not receive reasonable treatment over a four-day period. C also considered the care provided to their newborn child (A) was unreasonable.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system) and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). We found that the tests carried out when C attended the ward were reasonable and in line with relevant guidelines. We considered it was reasonable that C was initially discharged prior to their later admission and when C’s condition worsened, appropriate action was taken. As such, we did not uphold this complaint.

In relation to C's concerns about A's health, we considered that the actions taken after concerns were raised about A’s condition were reasonable. While we considered that the communication and documentation was below a reasonable standard, the clinical care provided to A was reasonable. As such, we did not uphold this complaint. However, feedback was provided to the board.

C complained that the board failed to reasonably respond to their complaint. We found that while the response to the complaint was accurate in relation to the medical records, it would have been good practice to provide more detail as to the board's position on certain points. A consultant spoke with C after events and arranged for further details to be provided regarding A’s care, which was good practice, particularly considering the board had identified communication issues. While further detail could have been given, and we provided feedback to the board on this point, on balance, we found the response to be reasonable. As such, we did not uphold the complaint.

Summary

C complained about the care and treatment provided to their late parent (A). A attended Raigmore Hospital with symptoms including lethargy, bruising and weight loss. A was found to be severely anaemic (a low level of red blood cells) and had a very low platelet count (small cells that help the blood to clot). A was asked to attend Caithness General Hospital for regular platelet treatment and further investigations into their condition.

Around a month later, A became unwell and they attended A&E at Caithness General Hospital. A was discharged home the same morning. Two days later, C became concerned about A as they looked 'black and blue'. C phoned the consultant haematologist (a specialist in diseases of the blood and bone marrow) for advice. They told C to contact A's GP if they were concerned about A's condition. By the next morning, A had become very unwell and they were taken to Caithness General Hospital by ambulance. A was found to have intracranial bleeding (bleeding within the skull). A was airlifted to Aberdeen Royal Infirmary that evening for platelet treatment. A's condition continued to worsen and they died the next day.

We took independent advice from a consultant haematologist. We found that there was no evidence A was told about the possible complications they could develop from their low platelet count, such as the risk of internal bleeding. We found A was unreasonably discharged home from Caithness General Hospital, as they should have been referred for emergency platelet treatment. In relation to C's phone call to the consultant haematologist, we acknowledged a GP should normally be the first point of contact. However, we considered appropriate action was not taken in response to the phone call, given C had described signs of A having internal bleeding. For these reasons, 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:

• If a patient/family member contacts a clinician with information that indicates they are seriously unwell, this should be recognised and appropriate action should be taken.
• Patients at risk of developing serious complications should be given clear information about that, and it should be appropriately documented in their medical records.
• Patients, who are found to have low platelet levels, should be referred for timely and appropriate platelet treatment.
• The board’s complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement.

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 child (A) who has a background of low mood and anxiety. C complained about the assessments of A by two paediatric consultants. C also complained that the Child Adolescent Mental Health Service (CAMHS) unreasonably rejected referrals from A’s GP due to social work’s involvement with the family.

We reviewed the relevant medical records and took independent advice from a consultant paediatrician and registered mental health nurse. We concluded that the assessments by both paediatricians were reasonable and appropriate tests and follow-up were arranged. We did not uphold this aspect of C's complaint.

However, we considered that it was unreasonable for CAMHS to reject the referrals on the basis that they failed to risk assess A in accordance with the board’s guidance. On that basis, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to accept the initial referrals to CAMHS and for the subsequent delay in treatment and the distress caused. 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 staff have reflected and learned from the findings of this investigation.
• The CAMHS service correctly follows the board’s suicide prevention guidance and pathway.

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 and their spouse (B) complained about events during two periods of hospital treatment for their child (A). A has complex medical needs. They are cared for by C and B at home, however they have required multiple and prolonged spells in hospital. C and B complained about the care and treatment A received, communication by the board, communication within the board and how their complaint was handled.

In response to C and B’s complaints, the board acknowledged a number of failings in A’s care and treatment and the way in which they had communicated with C and B. They also said that consideration should have been given to earlier involvement of social work and the community children’s nurse.

We took independent advice from a consultant paediatrician and a social work adviser. We found that the care and treatment A received on their first admission were unreasonable. We considered that there was inadequate dietetic support, an unreasonable reliance on C and B's assessment as to whether intake was sufficient, and a lack of information and help for the family when A required emergency care after a gastro-jejunal tube (G-J tube, a tube used to vent the stomach and small intestine) procedure. We upheld this aspect of the complaint.

In relation to A's second hospital treatment, we considered the care and treatment to be reasonable. We did not uphold this aspect of the complaint.

We also found a lack of reasonable communication with C and B about A's care and treatment and a lack of reasonable communication between the board’s staff during A's second admission. We upheld these aspects of the complaint.

Finally, we found that the board failed to handle C and B's complaint reasonably. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the lack of information on what to do if they had concerns following the procedure, for wrongly informing them that the child concern form (CCF) would be removed from A’s medical records (and explain the reasons why this cannot be done) and for the failings identified in complaint handling. 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 relevant staff should be aware of the local guidance for the management of fabricated or induced illness (FII) for multi-agency use, of the guidance for the completion of CCFs, of their roles and responsibilities in such cases; and of the GMC guidance: Protecting children and young people 2012 (in particular Sections 56 and 57).
• Children with feeding tubes should have a de-escalation plan individualised for each child advising of the feeding regimen if the tube dislodges. This should be shared with parents, tertiary and local centres. There should be clear documentation of advice regarding fasting for procedures and a checklist to identify those who may be at risk of fasting. Consideration should be given to carrying out such procedures on an in-patient basis if the patient is considered at increased risk.

In relation to complaints handling, we recommended:

• Complaint investigations and responses, including acknowledgement of receipt, should be in accordance with the board’s Complaints Handling Procedure. The board should keep a complainant regularly updated about their complaint including when they should expect to receive a response to their communication and if there is going to be a delay in providing this.

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 spouse (A) about the treatment A received in hospital after they fell at home and injured their back. A had previously suffered a stroke and, as a result, a computerised tomography (CT) scan of their brain was carried out. This showed no change from the previous CT scan that was carried out. Following an assessment in A&E, it was concluded that A’s back pain was muscular and that they were also suffering from an infection. A remained in hospital for treatment and observation. Twelve days after being admitted to hospital, MRI scans of A’s brain and lumbar spine were arranged. These scans showed that A had suffered a new stroke and had spinal compression fractures. C felt that A should have had an MRI scan when they were admitted to hospital or soon after. In C’s view, this would have confirmed the issues earlier and resulted in more appropriate care being delivered.

We took independent advice from an appropriately qualified adviser. In respect of whether the board unreasonably delayed in diagnosing and treating A’s stroke, we found that there was not sufficient evidence of a fresh stroke to justify an MRI scan at the time of admission. Based on A’s presentation at the time and the need to prioritise their treatment, there was not an unreasonable delay in the board diagnosing and treating A’s fresh stroke. As such, we did not uphold this complaint.

In respect of whether the board unreasonably delayed in diagnosing and treating A’s spinal compression fractures, we found that, given A’s symptoms, an earlier MRI scan of the spine was not indicated. However, we highlighted one clinician’s entry in the medical records that indicated a need for further investigation of A’s back injury that was identified on the date of admission. This entry also suggested that an x-ray was to be arranged. However, this specific entry in the medical records did not appear to have been followed up or acted on, with no narrative in the records to explain why. For this reason, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for unreasonably delaying in carrying out further investigation into A’s back injury despite a clinician recording this as being indicated. 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 review the circumstances surrounding this with the aim of establishing why the clinician’s findings do not appear to have been followed up and why an x-ray was not carried out when the medical records suggest that it was to be.
• The possibility of osteoporotic fractures should be considered in all older patients presenting with new-onset back pain (particularly where trauma could be involved), unless a clear alternative diagnosis is evident. Under these circumstances, imaging should be undertaken to investigate the possibility further.

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 standard of medical care and treatment provided to their late parent (A) during an admission to Queen Elizabeth University Hospital (QEUH). A was admitted to QEUH with worsening symptoms of a chest infection and a leg ulcer. When A’s condition deteriorated, medical staff decided to transfuse three units of blood. During the transfusion, A went into cardiac arrest and died. C complained that the decision to transfuse A with blood was unreasonable given their condition and symptoms, and that this led directly to their death.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that A should have had a thorough clinical review prior to the transfusion being prescribed. The transfusion monitoring protocol was not followed, and the board acknowledged that this may have led to a delay in recognising A’s deterioration. We also noted that when A’s observations and condition indicated a serious concern, nursing staff should have contacted a senior doctor but instead contacted the most junior doctor on duty. We considered all of this unreasonable. We saw no evidence that the severity of A’s condition, and likely poor prognosis, was actively considered or discussed with them or their family. This would have been good practice.

We noted that after A's death the team appropriately discussed the case with the Procurator Fiscal and the death certificate review team, who stated that they would be content for a death certificate to be issued without the need for a post mortem examination. However, when this was then discussed with A’s family, they remained concerned and said they would like things investigated further. With reference to the relevant guidance, we found that the case should have been referred back to the Procurator Fiscal for further consideration. If the Procurator Fiscal had still considered there was no need to investigate, the medical team should have offered the family the option of a hospital post mortem examination. We upheld this complaint. We were satisfied that the learning already implemented by the board was appropriate and satisfactorily addressed what had gone wrong in A’s care. However, we made further recommendations in relation to the reporting of a death to the Procurator Fiscal.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to advise the Procurator Fiscal of the family’s ongoing concerns regarding A’s death, and for failing to offer a hospital post mortem. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Share this decision notice with the Procurator Fiscal for advice as to whether the board should take any further steps.

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

• Medical staff are clear about the procedures for reporting deaths to the Procurator Fiscal. In particular, in the event that nearest relatives of the deceased are concerned that medical treatment may have contributed to the death of a patient this requires discussion with the Procurator Fiscal, even if initial reporting has already been carried out.

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.