Health

Summary

C was a patient of the practice for a number of years where they were treated for thyroid (a gland in the front inside area of the neck) problems and anaemia (a deficiency in the number or quality of red blood cells in the body). C began to experience changes in their behaviour. Following an incident, the police and social work became involved and C was admitted to hospital. C was discharged the following day after a psychiatric assessment. However, C subsequently had to attend court. When gathering information for their court appearance, C obtained a copy of their medical records from the practice. Upon reviewing these, C considered that there had been failures to diagnose deficiencies of vitamin B12 and vitamin D. C also considered that there had been issues with the practice's management of their anaemia and thyroid problems and the long-term prescription of a proton-pump inhibitor (a class of medications that cause a profound and prolonged reduction of stomach acid production).

C submitted a formal complaint to the practice regarding their care and treatment and their handling of C's medical records. C said that, whilst the practice responded to their concerns about the medical records, they did not address the complaints about C's care and treatment due to the time that had passed.

We took independent advice from a GP. We found that, whilst C did have some abnormalities in their blood tests, these were relatively minor and would not have caused the behavioural changes C experienced. We found that the long-term proton-pump inhibitor prescription was reasonable and that C's thyroid problem was routinely monitored and managed. We found that the practice failed to notify C of their low vitamin D results, but concluded that the implications of this oversight were minimal. We did not uphold this aspect of C's complaint.

With regard to the practice's handling of C's complaint, we found that that their decision to rule the complaint as outwith the time limit was reasonable in the circumstances and in line with their complaints handling procedure. We did not uphold this aspect of C's complaint.

Summary

C complained about the care and treatment that their adult child (A) received from the board over a two year period. A had previously suffered an acquired brain injury and since then had developed obsessive compulsive disorder, post-traumatic stress disorder and anxiety, as well as experiencing delusional thinking and periods of psychosis (a mental disorder in which thought and emotions are so impaired that contact is lost with external reality). C raised a number of concerns, including that the board claimed A was reviewed regularly when they were not, that no psychological support was provided for A, that there was a lack of support from the local mental health team, that there was no clear local treatment plan and that in the care programme approach, needs identified were not met, matters were not escalated and no solution was found.

We took independent advice from a consultant psychiatrist (a medical practitioner specialising in the diagnosis and treatment of mental illness). We found that A's records showed that they received regular reviews during the period in question and that the letters on these showed a high level of clinical input. However, the evidence showed that there was a delay of over five months from the date of A's discharge from psychiatric hospital and the issuing of the discharge letter, which we found was unreasonable and, for a patient with less clinical/multi-professional input and family interaction, would likely have resulted in significant clinical risk.

We found that the overall level of support A received was reasonable. However, we found that there was a lack of focus by the board on the organic elements of A's presentation and how these may have contributed to their psychosis and we were critical of the board's failure to utilise locally available specialist advice which resulted in a lack of psychology and neuropsychiatric input in A's case. We found that these failings were significant and, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to focus on the organic elements of A's presentation and failing to utilise locally available specialist advice on psychology and neuropsychiatry in A's case. 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 such as this, the board should consider organic elements of patients' presentations and utilise locally available specialist advice on psychology and neuropsychiatry.
• The board's patient discharge letters should be issued in a timely fashion.

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 they had been unreasonably removed from the practice list without prior warning due to alleged verbal abuse.

We reviewed the guidance provided by the General Medical Council (GMC), British Medical Association (BMA) and the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2018. We took independent advice from a GP. While we appreciated that C disagreed that their behaviour was inappropriate, this is how the staff at the practice perceived the behaviour. This was also supported by extracts from the contemporaneous records detailing that the practice found C's behaviour to be abusive and upsetting.

The Regulations and the guidance from the GMC and the BMA indicate that a warning should be given to the patient, giving the reasons for the possibility of removal from the practice list. The only exceptions to the requirement to give a warning appear to be on the grounds of violence where the police and/or the procurator fiscal are involved, or where the practice believes that issuing the warning would put the safety of members of the practice or those on the premises at risk or it is, in the GP's opinion, not otherwise reasonable or practical for a warning to be given.

The practice decided that a warning letter did not apply due to how upset a staff member was. We found that the practice appeared to have taken the view that issuing a warning to C would not be appropriate due to the impact of this incident on the member of staff. We found that the practice acted reasonably (by requesting C's immediate removal from the practice list) and within established rules for removing a patient from the list.

We did not uphold C's complaint.

Summary

C complained about the care provided by the board to their parent (A) whilst admitted at Glasgow Royal Infirmary. A had been admitted with low blood iron levels and a two-week history of back pain, queried to be a spinal fracture of osteoporotic (weakened bones) or pathological (caused by a disease) origin. Following A's admission, they suffered a “controlled fall”. Twelve days later, A complained of being unable to move their legs. An MRI scan of the spine was carried out, which confirmed that A had suffered a fractured vertebra causing spinal cord compression affecting A's ability to move their lower limbs and control bowel and bladder functions. A was subsequently treated conservatively due to their age and comorbidities.

C complained about the circumstances surrounding the fall A suffered and that staff had not recorded details of the incident under the Datix reporting system as required. C considered that A had sustained the spinal injury during this incident and that the lack of Datix report meant that there had been a delay in identifying the injury.

The board accepted that a Datix report had not been completed as required at the time of A's fall but that this had not prevented A from being assessed. The board also stated that a Datix report had been completed retrospectively and that the incident had been reviewed by the hospital falls team. The board stated that it was not believed that A's fall had caused the spinal fracture, which may have been present in advance of A's admission.

We took independent advice from consultants in emergency and general medicine. We found that despite A presenting to the A&E with a queried spinal fracture, no neurological examination was carried out nor was any consideration given to performing an X-ray of A's spine. This was unreasonable practice. In addition, the board's failure to complete a Datix record of the fall A suffered was also unreasonable although it was impossible to say with any certainty that this incident had caused A's spinal fracture.

We found that the board were unable to produce any evidence to show that a Datix record into A's fall had been completed retrospectively or that the incident had been reviewed by the hospital falls team.

In view of the above failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably failing to carry out a neurological examination of A, for not considering whether an X-ray of A's spine was required following their presentation to the A&E at Glasgow Royal Infirmary and for providing inaccurate information in their complaint response. 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 patients who present to A&E with new onset back pain, a neurological assessment should be performed as part of baseline medical examinations. Where the cause of new onset back pain in patients is suspected to be an osteoporotic or pathological fracture, consideration should be given to performing X-ray imaging to investigate the possibility. Any decision not to proceed with X-ray imaging, should be documented in the clinical records.

In relation to complaints handling, we recommended:

• The board should ensure that information provided in response to complaints is factually accurate and that, where the board has confirmed specific actions have been taken in response to a complaint, evidence of this can be provided.

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 concerned about the care and treatment that their late spouse (A) received at Inverclyde Royal Hospital following a surgery for a hip fracture. C complained that A did not receive appropriate post-operative rehabilitation and physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery). We took independent advice from a physiotherapy adviser. We found that the physiotherapy assessments and treatment were appropriate. Therefore, we did not uphold this aspect of C's complaint.

C also complained about the nursing care that A received. In particular, C was concerned that proactive steps were not taken to prevent A falling and that A was not supervised to take their medication. We took independent advice from a nursing adviser. We found that the board acted reasonably by implementing appropriate and proportionate actions to mitigate the risk of A falling. However, there was no record that A was supervised to take their medication and this was unreasonable given A's cognitive impairment and physical frailty.

In light of the above, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not supervising A taking their medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 provided to a family member (A) at Woodend Hospital and Aberdeen Royal Infirmary. Immediately prior to the episode of care we considered, medical investigations had been performed which indicated that A had metastatic cancer (cancer which has spread from one part of the body to another). A was then referred to the urology department (specialists in the male and female urinary tract, and the male reproductive organs).

We took independent advice from a urology adviser. In response to C's complaint, the board acknowledged that there had been a failure to request a CT scan as planned and apologised for this. We found that there was a failure to expedite a flexible cystoscopy (bladder examination using a narrow tube-like telescopic camera) and keep A informed about their care. In addition, we found that A should have been referred to oncology (specialists in the diagnosis and treatment of cancer). In view of these findings, we concluded that the care and treatment was unreasonable and we upheld C's complaint.

C also complained about the board's actions leading up to the decision whether or not to carry out a full post-mortem examination following A's death. C considered that the board had failed to follow the procedure that applied in the circumstances that the nearest family members did not agree about a post-mortem. C was also unhappy with the lack of communication about this matter. We considered a number of pieces of relevant legislation and guidance and took into account comments from the adviser. The circumstances leading to the decision about post-mortem were complex. On balance, we found that the board acted reasonably in this instance and we did not uphold the complaint. We provided feedback about good practice for the board to consider.

Finally, we found that the board's response to C's complaints could have been clearer in one respect. We also found that the board did not respond to a related complaint (about A's treatment a number of years prior) and inform C whether they would extend the timescale for accepting a complaint or not. We made a recommendation to address this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in performing an urgent CT scan; the failure to ensure that A was adequately informed about the plans for a CT scan; and the lack of referral to oncology. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Inform C of their decision whether or not they are extending the timescale (in relation to their complaint about A's historical treatment), and provide a reason for this.

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

• Care plans agreed at multi-disciplinary meetings should be implemented and followed up to ensure appropriate communication takes place with the patient/patient's representative and that timely investigations and referrals take place where relevant.

In relation to complaints handling, we recommended:

• Complaint responses should be comprehensive and transparent. In line with the NHS Model Complaints Handling Procedure, the timescale for acceptance of a complaint may be extended if the Feedback and Complaints Officer considers it would be reasonable in the circumstances. Where a decision is taken not to extend the timescales a clear explanation of the basis for the decision should be provided to the person making the complaint, and the person should be advised that they may ask this office to consider the decision.

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 practice about the lack of treatment when they attended two consultations reporting a breast lump. C felt that the GPs they saw gave them false reassurance that there was nothing to worry about. C then attended the hospital specialists for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body), biopsy (tissue sample) and mammogram (an x-ray of the breast) and received results which showed evidence of a cancerous lump which required chemotherapy (a treatment where medicine is used to kill cancerous cells) and surgery.

We took independent advice from a GP. We found that the GPs involved carried out appropriate examinations and that it was appropriate to refer C to the hospital specialists for further examination.

We did not uphold the complaint although some feedback was provided to the practice in an effort to improve learning.

Summary

C complained to us on behalf of their child (A) about the care and treatment A received from child and adolescent mental health services (CAMHS). Specifically, C complained that A was unreasonably discharged from CAMHS.

We took independent advice from a child and adolescent psychologist and also from a mental health nurse. We found that there was a delay in CAMHS offering A video appointments following the COVID-19 lockdown but we found that the delay was not unreasonable, as they needed time to set up the necessary IT systems. We also found that all relevant information was taken into account about A's condition before CAMHS decided to discharge A. Therefore, we did not uphold the complaint.

Summary

C complained about the treatment a family member (A) had received from the board. A was admitted to hospital three times over a short period with severe stomach and back pain. Following A's third admission, they were diagnosed with kidney failure and discharged to receive palliative care. A died a short time later. C complained that the board had missed opportunities during A's earlier admissions to identify their deteriorating kidney function. C said that an earlier diagnosis could have prolonged A's life expectancy as treatment could have commenced sooner.

C also complained that on A's second admission, their discharge had been unreasonably managed by the board. C complained that A was left all day in the discharge lounge in their nightwear and that staff failed to properly communicate A's discharge arrangements to the family. A was later returned to their nursing home in a taxi instead of an ambulance. C said that this was extremely distressing and undignified for A, and had been unacceptable given A's age and poor health.

We took independent clinical advice from a consultant geriatrician (a specialist in the care of the elderly). Whilst there had been a reasonable approach to investigating A's symptoms on their first admission, we found that there were missed opportunities by the board to diagnose A's kidney failure and infection, and the family's concerns had not been given appropriate consideration during the second admission. On the third admission, there was a delay in the clinical consideration of A's abnormal blood results, and in recognising the severity of their condition. We also noted from the board's own investigations that there had been a failure to move A's personal belongings between wards. Therefore on balance, we upheld this aspect of the complaint.

We also found that A was not clinically fit to be discharged from hospital following their second admission, and given their age, fragility and poor health, that their discharge arrangements had been poorly managed. These failings included A's lengthy wait in the discharge lounge, and A's transportation in their nightwear via taxi. We further noted from the board's own investigation that A had been discharged with the wrong discharge letter and medication, and that there had been a failure to communicate A's discharge arrangements to the family. As a result, we upheld this aspect of the complaint.

We also provided feedback to the board in respect of their record-keeping, reminding them of the importance of ensuring patient records are detailed and fully documented.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family that opportunities were missed to diagnose A's kidney failure and infection, and for not properly taking account of their concerns during A's second hospital admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for discharging A from hospital when they were not clinically fit, and for the poor management of A's discharge arrangements. The apology should meet the standards setout in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for the delay in the clinical consideration of A's abnormal blood results, and in recognising the severity of A's condition during their third hospital admission. 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 abnormal blood results in a patient's clinical records are followed up appropriately.
• Ensure that relevant staff have appropriately reflected on the complex nature of this case.
• If a patient is elderly, frail or in poor health, patient discharge arrangements should be carefully assessed to ensure that they are appropriate, taking account of discharge wait times, a patient's clothing and methods of transportation.

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 us regarding the treatment that they had received from the board relating to a diagnosis of liver cancer. They told us that there had been significant delays in carrying out appropriate tests and that they considered that their care had been very self-driven, stating that they had to chase up and request treatment on a number of occasions. They told us that they had received an unreasonable prognosis when being given their cancer diagnosis, being told that they were terminally ill with only months to live. They told us that they were only referred to a liver surgeon at their request, who was subsequently able to operate successfully.

They also complained that a consultant had written an unreasonable letter to their GP about one consultation, suggesting that their appearance had given cause for concern.

We took independent advice from a consultant oncologist (cancer specialist). We found that there had been unreasonable delays in carrying out C's tests. In particular, a failure to appropriately refer on the results of a scan, resulting in C having to chase this up and request a referral through their GP, and, a failure to mark the request to carry out a biopsy as urgent, resulting in a further delay.

These failures contributed to a delay in providing both diagnosis and treatment for C which was well out with normal guidelines for cancer treatment. In addition, the fact that C was required to seek a referral from their GP to further consider the results of their scan was considered to be evidence that their care had been unreasonably self-driven. We also found that an unreasonable prognosis had been given to C, as it was clear that the consultant in question was not best placed to provide a prognosis and further consultations were required before an accurate prognosis could be given. We therefore upheld these aspects of C's complaint.

However, while we noted C's strongly held view that the consultant's assessment of their appearance had been unreasonable, we were unable to find sufficient evidence to refute the consultant's record of that consultation. We therefore did not uphold that aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably delaying investigations into C's liver lesion, for failing to refer their MRI results to the Multi Disciplinary Team (MDT), and for providing an unreasonable prognosis. 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:

• Discussions about prognosis should take place with the appropriate clinician in light of a full consideration of the treatment options available.
• Requests for liver biopsies should be marked as urgent where necessary.
• The board should ensure all investigations into possible cancer are completed within the timescales set out in guidelines, wherever feasible.
• Where appropriate, MRI results should be referred to the MDT and actioned promptly.

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.