Health

Summary

C complained about the care and treatment provided to their parent (A). A had Alzheimer's disease (the most common cause of dementia) and C had a full power of attorney (POA) in place that was active at the time. This enabled C to make decisions about A's welfare.

A was admitted to Forth Valley Royal Hospital via the acute assessment unit, and was later transferred to a ward. C said that when admitted to hospital A was continent, could walk with a stick, slept through the night, and was eating and drinking. C said that the board made inappropriate changes to A's medication during their admission, and that, when later discharged, A had lost weight, was not eating and drinking, was very frail and could not stand up, and was doubly incontinent. C also had concerns about the way A was treated and spoken to by nursing staff, and that they were discharged with a very large pressure ulcer.

The board apologised for the way in which A was spoken to and treated by nursing staff and that the staff involved have received training and would be monitored going forward. The board also said communication with family members was not documented as it should have been.

The board said it would be expected for A's weight to reduce as they lost excess fluid. They explained that there was a change in A's appetite during their admission, however acknowledged that a referral to a dietician should have been made in light of this change in A's appetite.

The board said that A's mobility was at one point assessed as unsafe, but later it was recorded that A could mobilise with a walking frame. A's continence was recorded as variable during their stay and that A would often get up and mobilise to the bathroom.

In relation to A's pressure ulcer, the board said that A had pressure damage to their sacrum (lower back) on admission to the ward and that it was documented regularly over A's admission.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nurse. We found that the medical care and treatment provided by the board, including changes in medication, was reasonable. However, the overall nursing care, and particularly the record-keeping, was unreasonable. We also found that the board did not communicate reasonably with C about A's care, discharge, or their ongoing needs

Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures which the board have not already offered an apology for in previous correspondence. 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:

• Communication with those with POA should be of a reasonable standard. When a patient has been assessed as not having capacity, POA holders should be included in discussions and arrangements for a patient's care and discharge. The board should follow their process for assessing capacity including obtaining a copy of the POA paper work and keeping it within the clinical record of the patient.
• Patients with increased confusion should be appropriately assessed in line with Healthcare Improvement Scotland guidance and relevant records (such as the TIME bundle) completed as appropriate.
• Pressure ulcers should be assessed and appropriately graded, in line with the board's guidance for pressure care management.
• Records should be accurate and up-to-date. All charts should be completed appropriately and consistently. Patients who are experiencing issues with continence should receive appropriate support. Fluid balance charts and care and comfort checklists should be utilised to help support effective management of incontinence.
• The board should communicate with family members regularly and effectively, and the detail of conversations should be recorded. Families, where appropriate, should be involved in the discharge planning process, especially for people with a diagnosis of dementia.

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 that their child (A) received from a dentist at the dental surgery. C raised a number of concerns, including that the dentist failed to detect decay in A's tooth and provide appropriate treatment for this, and failed to carry out a radiograph (a type of dental x-ray) on A's tooth sooner.

We took independent advice from a dentist. We found that the dentist failed to record the presence of a mark on A's tooth during their third appointment, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs at an earlier stage. We also found that the dentist's notes had extremely limited detail added and were below the expected standard. Given the failings in the detection and treatment of the decay in A's tooth and in carrying out a radiograph sooner, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failing to record the presence of the mark on A's tooth, assess if there had been any deterioration of that mark, carry out further investigations and carry out radiographs at an earlier stage. 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:

• In cases of this type, dentists should assess if there have been any deterioration of marks on patients' teeth and carry out further investigations, as appropriate.

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 that they received from the board during an in-patient stay at Forth Valley Royal Hospital. C was admitted to the hospital while in the early stages of labour. C gave birth a few days later and was discharged to their home the following day. After discharge, C's health began to deteriorate and were later admitted to a different hospital, where they received a blood transfusion and treatment for an infection.

C complained that the board had failed to inform them that they had a yeast infection and failed to provide them with any treatment for this. C also complained that a clinician knowingly recorded an inaccurate pulse rate on their records and that the board failed to appropriately treat their post-natal high blood pressure and/or blood loss.

We took independent advice from an obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the board had failed to inform C that they had a yeast infection. Therefore, we upheld this aspect of their complaint.

We found insufficient evidence to establish that an inaccurate pulse rate had been recorded on C's records. We also found that C's blood pressure and/or blood loss were within normal limits when they were discharged from hospital. Therefore, we did not uphold these aspects of C's complaints.

However, we did find that clinicians failed to reasonably respond to C's high pulse rates at one point during their admission. While this issue was not raised by C in their complaint, we considered that it was reasonable to make recommendations to the board in relation to this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately monitor and respond to their condition. 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 should closely monitor Modified Early Warning Scores (MEWS) and appropriate action should be taken in light of them.
• When a candida (yeast) infection is identified, patients on the ward should be informed.

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 board regarding the care and treatment provided to their late parent (A). Following a diagnosis of bladder cancer, the board identified that A would require heart surgery before they would be fit enough for bladder surgery. They referred A to another health board to provide that surgery, but this took a number of months to arrange and carry out. C told us that, by the time the heart surgery was completed, A's cancer had progressed to a point where treatment was no longer possible.

We took independent advice from an oncology consultant (a doctor who specialises in the diagnosis and treatment of cancer). We found that the board failed to identify radiotherapy as a possible alternative treatment, despite this advice being given by their oncology team. In addition, we found that the board had mishandled the referral to the other health board for heart surgery, failing to ensure that the other board were made aware of the urgency required. Then, when there were inevitable delays in surgery as a result, the board failed to identify that the window for treatment was closing.

For these reasons, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of cancer treatment. 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 full range of treatment options should be considered when deciding on a treatment plan, and reconsidered if the viability of the original plan changes.
• All referrals made to other boards for treatment should include full details of any time sensitivity around treatment. Where it is unclear if treatment can be provided quickly enough, direct communication should occur between the relevant teams to explore this and alternative treatment options.

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 provide them with reasonable treatment. C was hospitalised with a right sided homonymous hemianopia (a visual field defect involving the two right, or the two left, halves of the visual fields of both eyes). C believed that a previously diagnosed arachnoid cyst (a non-cancerous fluid-filled sac that grows on the brain or spinal cord) could be the underlying cause of their clinical symptoms. C underwent CT and MRI scanning.

The board concluded that C's arachnoid cyst was stable and unchanged from a previous MRI, and was unlikely to be the cause of their vision loss. Following a deterioration in their symptoms, C sought private neurosurgical opinion (specialist in surgery on the nervous system, especially the brain and spinal cord) and underwent a craniotomy (procedure to open skull to gain access to the brain) to drain the cyst resulting in partial and ongoing recovery of their vision.

C complained to the board that they should have been referred for neurosurgical review and received treatment through the NHS pathway sooner. They said that clinicians leading their care had repeatedly dismissed their concerns that the cyst could be the underlying cause of their symptoms and had excluded several sources of significant information from the clinical decision-making process, including a discrepancy in the scan measurements which had in fact shown the cyst had increased in size.

We took independent advice from a neurosurgical adviser. We found that, despite a marginal increase in the cyst identified through retrospective radiology analysis, C's progressively worsening symptoms could not have been explained purely on the basis of imaging, and there was no evidence to support an argument that an earlier opinion from a neurosurgeon should have been requested. Our investigations found that although multi-disciplinary opinion may have been helpful in this particular case given C's continuing and unexplained neurological symptoms, the board had carried out appropriate investigations and specialist opinions had been sought on multiple occasions to inform decision-making regarding C's care pathway. Therefore, we did not uphold the complaint.

In investigating C's complaint, the board identified that there had been a break in their communications with C. We considered the action taken by the board to address this had been reasonable; however reminded them that in line with the published Model Complaints Handling Procedure, steps should be taken to ensure complainants are kept up to date and given revised timescales for response.

Summary

C complained about the care and treatment their parent (A) received from district nurses in relation to the management of sores/ulcers on their legs while resident at a care home. In particular, C complained that district nursing staff had failed to adequately monitor and treat A's sores/ulcers to such an extent that dressings would become saturated in exudate (fluid), requiring care home staff to apply further dressings. C stated that this had led to A developing significant infection requiring admission to hospital, where they died a short time later. C further complained that district nursing staff had failed to identify the deterioration in A's legs and had not alerted A's GP nor made a referral to a specialist tissue viability practitioner (a specialist in aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration).

In response to C's complaint, the board stated that A had been reviewed frequently by district nursing staff, who had not identified any signs suggesting that A's legs had become infected. The board concluded that district nursing staff had delivered consistent and appropriate care and that referral to a tissue viability specialist had not been indicated.

We took independent advice from a district nursing adviser. We found that there were a number of failings in relation to how A's sores/ulcers had been managed, specifically that wound assessments carried out were incomplete and not carried out at the required frequency and that the wound dressings used were inappropriate, often contradicting the findings of examinations, and contrary to current guidelines. We noted that district nursing staff had failed to carry out baseline observations and tests to check for the presence of infection or sepsis (blood infection) despite noting that A was as “flat” and “lethargic”. We also found that the district nursing staff's record-keeping was poor and not in accordance with relevant professional standards given there was no documented record of interactions with A on certain dates.

For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• 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. The board should comply with their complaint handling guidance when investigating and responding to 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 complained about the care and treatment that they received from the board after they were diagnosed as having a tumour in their bowel.

C underwent surgery to remove their tumour. Following the procedure, they experienced a number of complications that led to extended hospital treatment and the need to be fitted with a stoma (a surgically made pouch on the outside of the body). It was ultimately established that their surgery failed to heal properly, possibly due to a fault with an item of equipment used to staple their bowel. C complained that the issues resulting from their surgery had life-changing consequences.

C raised a number of concerns regarding the care and treatment that they received from the board at the time of their surgery and once they had been discharged. They also did not consider that the board adequately took responsibility for the issues that affected them.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). It was evident from C's complaint that they went into surgery expecting a straightforward procedure. The procedure was complicated by C's high body mass index (BMI, a measure for estimating human body fat) and took several hours longer than they had anticipated. Whilst we were critical of the board for not explaining to C that their BMI was a potentially complicating factor, overall we were satisfied that the surgery was carried out reasonably. During the procedure, the surgeon made reasonable adaptations when issues arose and there was no indication at the time of the issues that would later affect C. We were also satisfied that there was no indication at that time that there was a fault with the equipment being used during the procedure. Therefore, we did not uphold this aspect of C's complaint.

Following their surgery, C experienced a significant amount of pain. We were largely satisfied that the board's staff took this seriously and took appropriate action when it became apparent that the pain was not resolving as expected. C was ultimately found to have a leak from the site of their bowel surgery. We found that this was treated appropriately with further surgery once it was identified. That said, we found that C's symptoms should have led staff to suspect a potential leak sooner than they did. Whilst we found nothing to suggest that the outcome would have been any different for C, had staff considered a leak earlier, an earlier diagnosis could have been made and C's pain may have been relieved sooner. We upheld this aspect of C's complaint.

We found that, four months after C's surgery, the board proactively identified and investigated a cluster of patients (including C) that had experienced bowel leaks following surgery. The board concluded that there was no common factor linking these cases. Two months later, the board were advised by a medical equipment manufacturer that an item of equipment that was used during C's surgery was faulty and should be withdrawn from use. We found that there was no clear link between the faulty device and the leak that C subsequently experienced. However, we were critical of the board for not going back and reviewing the cluster of cases in the presence of the new information regarding the faulty medical device. We also found that the board could have done more to address C's questions about the situation. 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 delay in diagnosing the leak. 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 share this decision with the staff involved in C's care with a view to identifying any aspects of their care and treatment that could have been improved.
• The clinical team should review C's case with a view to ensuring their protocols for considering and diagnosing anastomotic leaks take account of all relevant risk factors.

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 board regarding treatment provided to their late spouse (A) at the end of their life. C was concerned that the board had failed to provide A with reasonable care and treatment, and failed to manage their diet appropriately. C was also concerned about the board's recording of an incident where A fell and broke their hip, as well as that the board refused to allow A to attend a relative's funeral.

We took independent advice from an appropriately qualified clinician. We found that the board had provided reasonable care and treatment throughout, including managing A's diet appropriately and keeping a reasonable record. There was no record in the clinical notes that the board had refused to allow A to attend a relative's funeral.

Given these points, we did not uphold C's complaints.

Summary

C complained to the practice about a delay in prescribing them with medication for high blood pressure, and as a result C suffered a heart attack. C said that they had attended the practice on a number of occasions within a few months with recurring chest pains, breathlessness and dizziness. C had their blood pressure read and electrocardiograms (ECGs) taken a number of times. C saw a GP and reported chest pain and dizziness. The GP put this down to muscle spasm and arranged another ECG and blood pressure reading. C was then given tablets for their blood pressure. The following day, C was admitted to hospital to have a stent inserted as they had suffered a heart attack.

The practice explained that C had had a number of contacts within a few months, and was seen by 11 GPs. Most of the contacts related to C's respiratory problems of Chronic Obstructive Pulmonary Disease (COPD). C's blood pressure was discussed with a GP and further readings were arranged either at the practice or read by C at their home and telephoned to the practice. It was when C reported chest pain a few months later that further investigations were conducted and the decision was taken to provide antihypertensive medication (used to lower high blood pressure).

We took independent clinical advice from a GP. We found that the practice had provided a reasonable standard of treatment to C. Their blood pressure readings were monitored both in the practice and at home and subsequently, arrangements were made to prescribe medication when it was appropriate to do so. We did not uphold the complaint.

Summary

C attended hospital for gastroenterology procedures (medicine of the digestive system and its disorders). Upon waking from the procedures, C reported experiencing a painful tingling sensation in their mouth, left hand and foot. C informed the nurses of their symptoms and a consultant carried out an assessment. Following the assessment, C was deemed fit for discharge as no clinical concerns were identified. However, C's symptoms persisted upon returning home. They attended an emergency GP appointment the following morning and the GP concluded that C had had a stroke. C was readmitted to hospital for further investigations. A CT scan confirmed that C had suffered a stroke.

C complained that the board's staff unreasonably failed to identify that they had had a stroke following their procedure. We found that, whilst staff identified that C's symptoms indicated they may have had a stroke and an assessment was carried out with this in mind, the assessment was insufficiently detailed and, in light of C's presenting symptoms, further investigation by a neurologist (specialist of the nerves and the nervous system, especially of the diseases affecting them) should have been arranged. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to fully consider the possibility of a stroke prior to discharging them and for failing to seek input from the specialist stroke team. 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 involved should reflect on C's case and give consideration as to where improvements could be made in their practice to ensure that symptoms of stroke are adequately investigated as soon as possible and input from stroke specialists is obtained in clinically appropriate cases.
• The board said that they would be running education sessions for all staff to raise awareness regarding early signs and symptoms for stroke and the appropriate action to take.

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.