Health

Summary

C has been diagnosed with Emotionally Unstable Personality Disorder (EUPD). C was admitted to a specialist mental health facility on two occasions. Whilst there, C was under the care of a consultant psychiatrist.

C complained to the board about various matters including the decisions to discharge C to care in the community, given C's EUPD diagnosis, and that the community mental health team (CMHT) were providing support only by telephone, rather than face-to-face contact, due to arrangements in place during the COVID-19 pandemic. In their response, the board explained that international evidence advised that patients with EUPD should be cared for in the community wherever possible and that the board had sought to offer C the most appropriate care when they encouraged C to leave the ward.

C was dissatisfied and raised their complaints with this office. We found that C's discharges were reasonable in terms of the planning undertaken, discussions held and arrangements made both in terms of C's diagnosis and the particular circumstances of the time. We also found that these decisions were in line with relevant guidance. We did not uphold this complaint.

Summary

C complained on behalf of their late spouse (A) about the treatment provided to them. A had a history of breast cancer and attended the practice with back pain. A was treated for simple back pain with some sciatic nerve irritation (nerve in the lower back area) and prescribed pain relief. A was later diagnosed with kidney failure caused from metastatic disease (secondary cancer) and died. C complained that the practice had failed to give proper consideration to A's history of cancer when assessing their back pain. C considered that an earlier diagnosis may have increased A's life expectancy as treatment could have been commenced earlier.

We took independent advice from a GP. We considered that A's symptoms had been reasonably assessed and that A's reoccurrence of cancer was not foreseeable any earlier than diagnosed. When A's presentation changed, appropriate steps were taken, with further investigations and referrals to hospital speciality care. As such, we did not uphold this complaint.

Summary

C complained about a failure to diagnose that their new born baby (A) had a dislocated hip from birth. A was reviewed by a physiotherapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) at the Royal Hospital for Sick Children, and C raised concerns that their request for an ultrasound scan was refused despite the presence of a number of red flag risk factors for hip dysplasia (where the 'ball and socket' of the hip are not properly formed). A's condition was not diagnosed until some months later.

The board noted that the physiotherapist found A's hips to be functioning normally. They accepted that initial screening will always have the opportunity for human error. They said that this is mitigated by regular teaching and peer review, and ensuring staff are competent in examination before reviewing patients. However, as a result of this complaint, they made changes to their hip screening procedures.

We took independent advice from a paediatric physiotherapy specialist. We considered that the presence of a number of recognised risk factors of hip dysplasia, together with a doctor's prior positive clinical assessment of hip instability, should have led the physiotherapist to arrange an ultrasound. The decision not to carry out a scan of A's hips was unreasonable and resulted in a delayed diagnosis. We upheld this complaint. We were advised that the changes already made by the board to their hip screening procedures should improve the clinical process going forward.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to arrange an ultrasound scan, and the resulting delay in diagnosing A's 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:

• An audit process should be established to ensure that improvements in teaching and peer review are followed through and that staff continue to meet their competencies.
• The board should share this decision with the physiotherapist in a supportive manner, and ask that they reflect on A's case.

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 attended hospital on a number of occasions for the removal of some teeth. At one consultation staff said C was aggressive and asked C to leave the department. C complained about the care and treatment provided to them and that the zero tolerance policy was applied unfairly to them. At a further consultation, C said they were told the hospital would not be able to provide further treatment for them.

We took independent advice from a dentist. We found that the care and treatment provided to C was appropriate and the record-keeping was of high quality. There was good evidence of staff spending time with C to explain their treatment options. We found that staff were entitled to ask C to leave when they perceived C's behaviour to be aggressive and threatening. We also noted that the board had reassured C that they could receive treatment at the hospital, but this would be reviewed if C behaved aggressively again in the future. We did not uphold C's complaints.

Summary

C complained to us on behalf of their late relative (A) regarding treatment A received from the board leading up to their death. C said that the board had failed to provide reasonable nutritional care and treatment after A was admitted to the Royal Infirmary of Edinburgh suffering from complications due to poor nutritional intake. They considered that the board had unreasonably delayed in diagnosing the likely cause of this nutritional deficit. C also said that the board had failed to reasonably communicate with A and their family, as they were only informed of the likelihood that A would die with around 48 hours' notice, previously believing A was due to be discharged.

We took independent advice from an appropriately qualified adviser. We found that the board had provided reasonable nutritional care and treatment, with no delay in diagnosis. We therefore did not uphold those aspects of the complaint.

However, we also found that the board had failed to appropriately assess A's likely prognosis and communicate this to them or to their family. As such, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A's family for failing to reasonably identify and communicate their 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:

• The board should carry out reasonable and realistic assessments of a patient's prognosis, clearly communicate those assessments to the patient and, where appropriate, to their family, and make a record of these discussions.

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 care and treatment. C experienced a sudden loss of sensation in their left leg. C initially contacted their GP and after sypmtoms did not improve, they were referred to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) and reviewed by the on-call orthopaedic service at Royal Alexandra Hospital. C was examined by a junior doctor.

C told us they were concerned that their back was not examined; that they did not received a scan, that they were not reviewed by a senior orthopaedic doctor or a neurosurgeon, that there was a failure to contact them after a multi-disciplinary team discussion was held, that there was a delay in receiving a scan as an out-patient, that there was a significant delay between the reporting of the scan and C (and their GP) being made aware of the results and that there was a delay in receiving an out-patient appointment.

The board acknowledged that the examination C received was not in keeping with usual process, however, they considered that the junior doctor appropriately discussed C's condition with a registrar and received advice from the neurosurgery team.

We took independent advice from a consultant orthopaedic surgeon. We found that the initial assessment was reasonable and that it was reasonable for a scan to be completed as an out-patient. We considered that it was appropriate for the board to discuss C's case with the on-call neurosurgeon and that the treatment plan agreed was reasonable. However, we found that the delay in acting on the scan report was unreasonable, given that it contained significant findings.

In light of this, on balance, we upheld C's complaint.

Recommendations

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

• The board should take steps to ensure outcomes of multi-disciplinary team meetings are documented, and it is clear whose responsibility it is to contact the patient to communicate the outcome.
• The board should take steps to ensure that the results of urgent scans are managed reasonably, and that the referring clinician is made aware when significant findings are flagged up on a scan.

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 provided to their spouse (A) by the board. C raised a number of issues which included the behaviour and attitude of a psychiatrist during a consultation with A, that the psychiatrist had remained involved in A's care against A's wishes, and that the psychiatrist had made a diagnosis of factitious disorder (serious mental disorder in which someone deceives others by appearing sick, by purposely getting sick or by self-injury), of which they had failed to notify A and the wider clinical team. C also complained about a clinical psychologist's involvement in A's care, specifically that they had prepared a report relating to A which contained a number of inaccurate statements.

We took independent advice from a consultant psychiatrist. We concluded that the board's management of A was appropriate, patient-centred and reasonable. In relation to the specific complaints C had raised, we found there was no evidence within the clinical records to support C's complaint about the attitude and behaviour of the psychiatrist during a consultation with A, although we accepted that some unhelpful language had been used for which the board had apologised.

We found that the records showed that A had generally been kept up to date with changes to their diagnosis, but that A had not been informed about the change in their diagnosis to factitious disorder. Whilst we considered A should have been informed, this was a relatively minor shortcoming in communication and had no detrimental effect on the overall care and treatment provided to A. We also found that the clinical psychologist's involvement in A's care had been appropriate and reasonable. For these reasons, on balance, we did not uphold C's complaint.

Summary

A few hours after a surgical procedure, C underwent a second operation due to an internal haemorrhage (a loss of blood from a blood vessel that collects inside the body). Following the second operation, C complained to the board about the documenting of their operations, the estimation of their blood loss, communication with their spouse and colleagues, the removal of the patient controlled analgesia (PCA, a method of allowing a person in pain to administer their own pain relief) which was installed following the operations, and that a follow-up appointment was not provided in the timescale they had been advised.

The board's response was that the operations had been reasonably documented, except the detail of one of the units of blood transfused to C, and that the estimation of blood loss and the removal of PCA had been reasonable. The board accepted that they had not communicated with C's spouse and colleagues as C had wished, and that C had not been given realistic information about the likely timescale for a follow-up appointment.

C was dissatisfied with the responses they received and raised their complaints with this office.

We took independent advice from an obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system).

Although the date and time of the transfusion of the second unit of blood to C during their second operation was omitted, we found that, overall, the board reasonably documented events relating to C's operations. We also found that the board's underestimation of C's blood loss was less critical than vigilance of their condition, observations and blood count. We found that the removal of C's PCA was in line with relevant guidance and that it was reasonable that C was not provided with a follow-up appointment within six weeks given the circumstances. We did not uphold these aspects of C's complaint.

In relation to communication, we found that C's wishes for communication with their spouse and colleagues had not been observed. We upheld this aspect of C's complaint. However, we did not make any recommendations given the action already taken by the board.

Summary

C attended A&E at Glasgow Royal Infirmary with acute pain in their spine; they were admitted in the early hours of the morning and discharged the same day. During their admission, C underwent a hip x-ray scan.

C complained that the care and treatment they received during their visit was not of a reasonable standard. C found their experience to be traumatic and states that it had a lasting emotional impact on them. C had several concerns about their experience; in particular, their pain management and the board's radiology findings.

We took independent advice from an appropriately qualified adviser. We found that the board's approach to pain management was appropriate but felt that it would have been good practice for the board to document C's pain score and actions taken as a result of that score – this was provided as feedback to the board. We also found that C's x-ray was appropriately assessed and concluded that the management of C's radiology (analysis of medical imaging of the body) findings was reasonable.

We considered that the care and treatment offered to C when they attended hospital was reasonable and we did not uphold this complaint.

Summary

C complained about the care and treatment provided to their parent (A) at Queen Elizabeth University Hospital. A was admitted to hospital for an operation, which required a long period of rehabilitation. A's condition began to deteriorate after the operation and they died a few weeks later. C complained that clinical failings relating to hydration, record-keeping and communication were contributing factors to A's deterioration and death. C was also concerned about the way clinicians communicated with them.

We took independent advice from two advisers: a nurse specialist in critical care and respiratory and a consultant in acute medicine. We found that there were unreasonable failings in nursing care including record-keeping, which had an adverse effect on the management of A's hydration, and that the lack of fluid management had a distressing impact on A and their family at the end of their life. However, these failings did not substantially impact on A's chance of survival or death. We also found that opportunities were missed to inform A's family of their condition which meant that they were unprepared for A's deterioration and death. We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Ensure a reasonable standard of communication which meets the needs of patients and their families.
• Ensure a reasonable standard of fluid management.
• Ensure patients' hydration is managed reasonably.

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.