Health

Summary

C complained that their adult child (A)'s dyslexia was not taken into account when the board provided them with care and treatment, and that the care and treatment was not of a reasonable standard. C believed that if A's treatment had been better, then they would have had a better chance of surviving their cancer diagnosis. C felt that A's condition had been misdiagnosed because of A's age, as they were much younger than most people who suffered from this type of cancer.

We took independent advice from an appropriately qualified adviser. We found that the board accepted that they had not been aware of A's dyslexia. We also found that there was no evidence that A lacked the capacity to make decisions about their care and treatment and that at the majority of their appointments, they had been accompanied by their other parent. Therefore, we did not uphold this aspect of C's complaint.

In terms of their care and treatment, we found that A had been difficult to diagnose because the options were limited for medical staff, due to A's unwillingness to agree to treatment. However, it would have been appropriate for A's case to have been discussed earlier at a multidisciplinary team meeting. This might have resulted in A's cancer being identified sooner. We upheld this aspect of C's complaint. However, this did not mean that the outcome for A would have been different, as the cancer was very aggressive, and it was unlikely that its progression could have been slowed or halted.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not having held a multidisciplinary team meeting to discuss A's case at the earliest opportunity. 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 ensure clinicians have time to access multidisciplinary team meetings including all appropriate specialties to discuss unusual cases.

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's child (A) was born with a rare congenital condition where the urethra does not develop properly and underwent reconstructive surgery as a baby. A's doctors said that A had a 60% chance of being dry by the age of ten but would need further surgery when they are older. A had been potty trained, and no longer wore nappies, however they experienced incontinence leaks during some activities. A's health visitor referred A to the board's incontinence service to receive continence products.

The board's continence service said A did not meet the criteria for continence products as they had not reached the age of four, as per the guidance for the provision of continence containment products to children and young people. C complained that A was eligible under the guidance after two years of age, given A's disability. C also complained that the decision on A's eligibility was made against advice of the health professionals working with A.

We took independent advice from a paediatric nurse. We found that the guidance says children under four would not normally be given continence containment products, however this could be considered where continence issues are as a result of a child's disabilities. We also found that the board failed to complete a comprehensive paediatric continence assessment in A's case. We were also critical that the board did not take in to account the clinical opinion of the health professionals working with A. As a result, we found that the board did not reasonably assess A's eligibility for containment products and upheld this element of the complaint.

C also complained that the board's handling of their complaint was unreasonable. We found that the final complaint response was issued without taking into account the comments from A's GP. Additionally, we found that the board did not handle C's complaint in line with the NHS Model Complaints Handing Procedure (MCHP). As a result, we upheld this element of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apology 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.
• Assess A's eligibility for containment products in accordance with the guidance.

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

• Children and young people should be assessed for containment products in accordance with the guidance, including carrying out comprehensive paediatric continence assessments when indicated.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the NHS MCHP.

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 were unreasonably diagnosed with bicuspid aortic valve (a type of abnormality in the aortic valve in the heart where the valve has only two small parts (leaflets), instead of the normal three). C was diagnosed with bicuspid aortic valve by the board and as a consequence, made significant changes to their life and retired early. C was later given a different diagnosis (when they were under the care of a different NHS board) and took the view that the diagnosis given previously was, therefore, incorrect.

We took independent clinical advice from a consultant general cardiologist (specialist in diseases and abnormalities of the heart) and a consultant cardiologist with particular experience in the reading of echocardiograms (a scan used to look at the heart and nearby blood vessels). We found that C had been diagnosed previously with bicuspid aortic valve when they were resident in Wales. Relevant information was passed to C's new GP when they moved to Scotland who made a referral to Perth Royal Infirmary for continued follow-up. A further echocardiogram was performed at that time, which was reasonable and appropriate. We confirmed that although interpretation of C's echocardiogram was not necessarily straightforward because of calcification (a build-up of calcium in body tissue) and the fact that C was not echogenic ('echogram-friendly'), the conclusions reached (of bicuspid aortic valve) and reported to C at the time were entirely reasonable in the circumstances.

While C's diagnosis had since been amended, this did not mean that the diagnosis given by the board was an unreasonable one. We noted that it was not unusual for diagnoses to be amended. Therefore, we did not uphold C's complaint.

Summary

C complained about the board's management of a retinal detachment (when the thin layer at the back of the eye becomes loose) and other issues affecting their eye. C attended hospital with a small hole in the centre of the retina and subsequently attended a number of appointments with the board's ophthalmology department (specialists in the study and treatment of disorders and diseases of the eye). Due to the condition of C's eye, a “watch and wait” approach was taken.

C later experienced a deterioration in their eye and attended an emergency clinic. A scan was carried out and C was discharged home on the basis that the eye remained stable. C was concerned that the examining consultant did not carry out additional tests or provide any treatment in light of the deterioration in their vision. C travelled abroad on holiday the following month and their eye deteriorated further. They attended a local ophthalmologist who identified a full retinal detachment. C underwent retinal reattachment surgery.

C complained that the retinal detachment should have been diagnosed at the emergency appointment and that, had it been diagnosed, they would have undergone surgery, avoiding the expense of private treatment abroad.

We took independent advice from a consultant ophthalmologist. We found that changes to the eye were visible on the scan taken at the emergency appointment. We considered that this should have led to a more detailed examination of the eye and that a retinal detachment would likely have been identified at that point. We upheld C's complaint. However, even if a retinal detachment had been identified at that point, it would have been a matter for the professional judgement of the surgeon as to whether surgery was advisable. It would not have been unreasonable for the surgeon to have advised against surgery, given the condition of C's eye and the risks association with surgery.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to identify and act upon the changes visible when they attended the emergency clinic. 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:

• Share this decision with the staff involved in C's treatment with a view to identifying ways of avoiding similar problems for future patients.

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, a support and advocacy worker, complained to us on behalf of their client (B) about the care and treatment provided to their child (A). Over a ten-year period, A had several referrals to the board's children and adolescent mental health services (CAMHS) on both a routine and emergency basis. C raised various concerns, in particular about delays in diagnosing A and that A was not admitted for in-patient psychiatric treatment following incidents of self-harm or attempted suicide.

We took independent advice from an adviser in child and adolescent psychiatry. We found that aspects of A's care and treatment were unreasonable. In particular, we found that there was an unreasonable delay in assessing A for adult attention deficit hyperactivity disorder (ADHD, a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness); that A was given an emergency assessment that fell below a reasonable standard; the other professionals involved in A's care did not have a clear understanding of the level of input they could expect from CAMHS; and that there was a lack of evidence CAMHS tried to adapt their approaches to better engage A. We upheld the complaint.

In relation to complaint handling, the board provided us with additional electronic records when they responded to our draft decision and not at the outset of our investigation. We have made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B 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:

• When a young person has regular multidisciplinary meetings, CAMHS should have a clear understanding of the level of input they will be required to provide from the outset in consultation with the other professionals, and provide appropriate input in line with this clarification. This should be documented appropriately.
• When a young person with autism spectrum disorder and/or ADHD is not engaging with treatment, clinical staff should recognise this might be because of their condition(s) and try to adapt their approaches to better engage them.
• Young people presenting with symptoms of ADHD should be appropriately and timeously assessed, taking into account relevant clinical guidance.

In relation to complaints handling, we recommended:

• Full documentation, including electronic records, relating to the matters under investigation should be collated and supplied to this office in response to our initial request for information.

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 spouse (A). A suffered from progressive lung disease and required prostate surgery. There was a significant delay in performing A's surgery, during which time A's health deteriorated. A was discharged home following their operation, but was readmitted the following day and died shortly afterwards.

C believed that A would have survived had the operation been performed sooner, as their health would have been better. C also said that A's death certificate was inaccurate, as it stated that A had died from community acquired pneumonia. C said that A had not been well when they were discharged, had been at home for less than 24 hours and had spent the majority of that period in bed.

We took independent medical advice. We found that A's condition had not been properly monitored following their operation, as the board's assessment had been based on assumptions about A's condition prior to admission. This meant that A had been discharged without evidence of a deterioration in their condition being properly considered. We also noted that it was not possible to determine that A's pneumonia was 'community acquired'.

We considered that A's care and treatment had fallen below a reasonable standard. However, we noted that it is not possible to be certain what the outcome would have been had A been operated on sooner.

We also found that C's complaint had not been handled to a reasonable standard. The board had initially informed this office that it had nothing to add to its response to C's complaint. However, following our enquiries, the board accepted that it was unlikely that A had acquired pneumonia in the community. Additionally the board's complaint investigation had failed to identify that A's condition was not properly assessed prior to discharge.

We upheld both of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to asses A's condition, incorrectly describing their pneumonia and issuing an inaccurate death certificate. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Assist C with obtaining a corrected death certificate.

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

• Medical staff should correlate information about a patient's condition on admission, such as oxygen saturation levels as part of the patient's assessment prior to discharge.
• The board should remind relevant medical staff that, when issuing a death certificate, careful consideration needs to be given to ensuring it accurately reflects the cause of death.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all of the points of complaint raised by a complainant.

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 psychiatric care and treatment that they received during an admission to University Hospital Wishaw. They complained about the way they had been treated by staff, claiming to have been assaulted and injured. C also complained about their medication regime, stating that they had been given too much medication which caused them to become ill.

In their response to our enquiries, the board set out the circumstances in which C had been restrained, explaining that C tried to run away from the ward and became verbally and physically aggressive. As C was detained under the Mental Health Act, their refusal to return to the ward resulted in the use of restraint using prevention and management of aggression techniques. The board said that the restraint techniques utilised by staff were appropriate and all staff involved were appropriately trained. They expressed regret that C's jacket had been damaged, advising that reimbursement for C's loss had not been paid because C had failed to provide a receipt as requested. While C complained about a separate incident in which they said that they were injured, there was no record of this and as such we could make no finding on this.

We took independent advice from a consultant psychiatrist. We found that the assessment and management of C's symptoms were appropriate. After review of C's medication regime, we found that there was no link with C becoming ill and vomiting. We noted signs of infection which were considered a more likely explanation for C vomiting.

We found that C's care and treatment were reasonable and we therefore did not uphold this complaint.

Summary

C underwent sequential cataract surgery (a surgical procedure to replace the eye lens with an artificial one when the cataract makes the vision cloudy, specifically, in this instance, monofocal lens implantation). C complained that the board had failed to communicate reasonably with them prior to the cataract surgery, including that the risks and benefits were not explained to them and that their concerns following first cataract surgery were not taken seriously.

We sought independent advice from an ophthalmologist adviser (specialist in the branch of medicine that deals with the anatomy, physiology and diseases of the eye). We found that there was no record that C was given information about the risks and benefits of the surgery. The lack of written information about the risks and benefits of the procedure was unreasonable. We noted that this was contrary to the General Medical Council's guidance to keep an accurate record of the exchange of information. We also found that there was no record of what was discussed with C following the first cataract procedure. As there is no written record, we were unable to determine what was discussed with C when they raised concerns.

In light of the above, we considered that there was a failure to communicate reasonably with C prior to the cataract surgery and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not giving them information about the risks and benefits of monofocal lens implantation and for not recording what was discussed with them following the first cataract procedure. 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 with patients following cataract procedures should be clearly recorded.
• Patients should be advised of all material risks and benefits of cataract procedures and the discussion should be clearly recorded, in accordance with relevant standards and 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 complained about the care and treatment that they received from the board when they were admitted to Hairmyres Hospital with a psychotic episode. C raised a number of issues, including that the nursing and clinical staff at the hospital failed to adequately explore the possible link between the unpleasant/harmful physical symptoms C was experiencing, which they said they reported on a daily basis, and the medication they were given.

We took independent advice from a mental health nurse and a consultant psychiatrist. We found that, generally speaking, staff responded appropriately to C's complaints; observations, examinations, investigations and onward referrals were appropriately initiated when C voiced concerns. However, there was a clear failure to carry out daily monitoring of C's pulse and blood pressure in a consistent and reasonable manner, and record the readings and C's resulting National Early Warning System (NEWS, a pro forma for recording patients' physical observations that generates a score to alert staff to potential changes in a patient's physical condition) score on the NEWS chart. We noted that the failings in recording of C's pulse and blood pressure on the NEWS chart and the resulting NEWS score was a potential contributory factor to C developing hypotension (low blood pressure). Interventions to manage this, such as the withdrawal of Olanzapine (an antipsychotic drug), were delayed at a time when this would have been beneficial in alerting the clinical team to physical issues experienced by C. This resulted in C experiencing short term discomfort and distress from hypotension. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to consistently monitor C's pulse and blood pressure and record these, along with C's NEWS score, on the NEWS chart. 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' vital signs observations should be conducted in line with agreed frequency and the readings and resulting NEWS scores recorded on the NEWS charts.

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 a failure to accurately diagnose and treat their parent (A)'s pancreatic cancer. A was being investigated by Raigmore Hospital in the months prior to their death. C complained that too many invasive tests were carried out and an accurate diagnosis was not established.

We took independent medical advice from a consultant surgeon, who noted that A had an advanced pancreatic cancer which can be difficult to diagnose. We considered that repetition of invasive tests was reasonably required in order to pursue a diagnosis. We noted, however, that A's lung abnormalities were discussed by a lung multidisciplinary team (MDT), but an upper gastrointestinal MDT was not involved despite the fact the suspicion of pancreatic cancer could not be ruled out. We fed this back to the board. However, overall, we considered that there was a comprehensive attempt to obtain a diagnosis. On balance, we did not uphold this complaint.

C also complained about a failure to communicate clearly with A and the family regarding the diagnosis. They said that they were never made aware of the suspected cancer diagnosis, despite this having been documented throughout the records. We found no evidence to support that timely and meaningful discussions took place with A and their family. A consented to multiple invasive tests without being made aware that suspected cancer was being investigated. We considered that the risks and benefits of these tests should have been clearly discussed with A, in order for them to have made a fully informed decision as to whether to proceed with them. In the circumstances, we upheld this complaint. We also noted that the board's response to C's complaint did not provide a sufficient explanation of the extent of the tests carried out.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that timely and meaningful discussions did not take place with A and the family to inform them of the suspected cancer diagnosis and make them aware of the purpose, potential benefits and risks of invasive investigations; and that the complaint response did not comprehensively address the specific concerns raised. The apology should meet the standards set out in the SPSO guidelines on apology: www.spso.org.uk/information-leaflets.

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

• Patients should be provided with all the information they need to be able to make informed decisions about their care. This should include information about their diagnosis; any uncertainties in this regard; and a clear explanation of the purpose of any proposed investigations or treatment, including potential benefits and material risks. This should be adequately recorded in the case notes to evidence that meaningful dialogue has taken place.

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.