Health

Summary

C complained that the practice failed to provide them with reasonable care and treatment. C attended the practice with symptoms of an ear infection. C said that they were not prescribed appropriate medication and were unreasonably diagnosed with an outer ear infection. C felt that a swab that was taken damaged their ear.

We took independent advice from a GP. We found that while their communication could have been better, the practice provided reasonable care and treatment in line with the history and information available at the time, and the relevant guidance. The evidence does not suggest that the ear swab caused C’s hearing loss and the practice's rationale for performing the swab was in line with local guidance. We found that the treatment provided was reasonable. We did not uphold C's complaint.

Summary

C complained about the treatment provided to their late parent (A) when they attended hospital with shortness of breath and abdominal distension (swelling). Following assessment, A was prescribed a blood-thinning medication and was discharged with a plan to return for a scan within 48 hours to look for blood clots in the lungs. A deteriorated within hours of returning home. They were taken to hospital by ambulance and admitted for treatment. Their condition deteriorated significantly. Investigations revealed worsening heart failure and they died within a few days. The board initially considered sepsis to be A's cause of death but a post mortem later established this as congestive heart failure.

We took independent advice from a consultant cardiologist (specialists in diseases and abnormalities of the heart). We found that it was reasonable for A to have been prescribed blood thinners and referred for a CT scan when they first attended hospital. However, on the basis that A’s clinical observations were abnormal, in particular their blood gas results, we found that A should have been admitted as they required oxygen. Therefore, we upheld this part of C's complaint.

C complained that the board failed to provide appropriate care and treatment in response to A's deterioration. We were critical of the board for gaps in A’s records, meaning we were unable to establish what nursing checks were carried out on the day A deteriorated. However, we found that medical staff acted appropriately in response to A’s deterioration. A’s deterioration was a result of heart failure, leading to multi-organ failure. A’s family felt that there was a lack of clarity regarding A’s condition and what they were being treated for. The board recognised that there had been communication failings, apologised and confirmed that learning had taken place. We found that the plans for investigation and treatment were appropriate. It was reasonable for clinicians to suspect sepsis when A’s condition deteriorated, and to commence treatment with broad spectrum antibiotics. There was no evidence that the outcome in this case could have been avoided. We did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for not admitting A when they attended hospital. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and C’s family for the poor complaints handling in this 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:

• Clinical staff are confident about when to admit patients with respiratory failure who do not have a specific diagnosis.

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 a family member (A) about the care and treatment that A received during two presentations to hospital following a fall at their home. Prior to their fall, A was fit and well and independent for activities of daily living.

During our investigation the board had accepted that there were failings and had taken action to address these. This included using this case as a case study to ensure any training and development requirements were implemented, delivering training sessions on significant adverse events review and carrying out a review of the duty of candour arrangements which would include training.

We took independent advice from a consultant in emergency medicine and a trauma and orthopaedic consultant. We found serious failings in A’s care and treatment and that a number of red flags (specific symptoms or signs that indicate a potentially urgent or serious underlying condition requiring immediate medical attention) had been missed in this case. In particular, we found that there was a failure to take into account relevant national guidance and to perform imaging which meant that the fractures of the vertebrae in A’s thoracic spine were undiagnosed. There was also a failure to take account of the National Institute for Health and Care Excellence guidance which the board had accepted.

We found that it had been unreasonable that A had been left to sit during their second visit to hospital for a prolonged period before being assessed given their symptoms. There were also missed opportunities to complete a more thorough neurological examination with a failure to appreciate the presence of a spinal injury and to realise the significance of the signs of limb weakness and incontinence. We also found that the board failed to immobilise A while awaiting the results of a CT scan and during their transfer between hospitals. In view of the failings identified, we upheld C's complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidance on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients attending the emergency department should be appropriately assessed and thoroughly examined, taking into account relevant guidance and, where appropriate, imaging performed. Account should also be taken of presenting symptoms, for example where a patient is presenting with ongoing back pain and new incontinence they should be laid flat and where appropriate immobilised, for example during patient transfer.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. When an incident occurs that falls within the Duty of Candour legislation, the board’s Duty of Candour processes should be activated without delay. Staff should be aware of the board's adverse event review processes and ensure they are appropriately applied.

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 on behalf of their client (B) about the care and treatment provided to B's late family member (A) during their admission to hospital. In particular, in relation to pain management, standard of care and communication.

In response to the complaint, the board apologised for the failings identified in nursing care and communication. As a result of the failings the board had taken action. This included reiterating the importance of following the National Early Warning Score (NEWS) policy, reminding nursing staff of their obligations to comply with their code of professional conduct in the workplace, and reflecting on A’s care for the purpose of improving person centred care. B was dissatisfied with the board’s response and brought their complaint to the SPSO.

During our investigation, the board accepted that aspects of A’s care and treatment should/could have been better and explained that reflection had taken place, and learning had been taken forward for the purpose of improving the level and standard of person-centred care provided to other patients. In addition, relevant staff had been given the opportunity to reflect on their communication with A’s family.

We took independent advice from a consultant general and colorectal surgeon (specialist in in conditions in the colon, rectum or anus). We found that there had been a number of failings in the care and treatment A received. In particular, we found that there had been a delay in carrying out a CT scan and in diagnosing that A had a bowel obstruction. We found that this may have impacted on their management, including giving consideration to conservative/non-surgical intervention. We also found that A’s pain management had been unreasonable and that an adverse event review should have been conducted, particularly around a diagnosis of bowel obstruction and its management. In view of the failings identified, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for these failings. 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:

• There should be appreciation and awareness of analgesic requirements in patients with suspected mechanical bowel obstruction and on long term medications for chronic pain.
• There should be appreciation and awareness of a diagnosis of mechanical bowel obstruction and its timely management including the use of Gastrograffin (ASGBI guidelines) and NELA score.

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 carry out their sibling (A)'s hip replacement surgery within a reasonable time. C said that A had made no progress with their surgery since their pre-assessment appointment.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that A's surgery was Category 2 (urgent) which meant it should have been carried out within 90 days. Given A's significant mobility issues and difficulties with day-to-day living, it was unreasonable to leave their case for more than 90 days. We were concerned that A waited 15 months for their surgery and that the surgery only took place after intervention from this office.

Although the board apologised for the delay in A's surgery, we found that the reasons given were unreasonable. The board had a contract with another health board to provide the type of surgery A required during the time period under consideration and as A met the criteria for acceptance, it was unreasonable that the board did not explore this avenue of care. We noted that the board could also have explored an out of area and exceptional referral for A to another health board and considered the use of non-NHS providers who specialised in filling gaps where there were staffing issues due to staff absences.

We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• The board should put in place a short/medium term solution, in the form of a recovery plan, to prevent this failing from happening to other patients, whether that be three session day operating or six day a week operating, potentially supplemented by other providers if the staffing issues persisted. [In response to a draft copy of this decision notice that was issued to both parties, the board provided some evidence of action they have already taken in relation to this matter.]
• In cases such as this, the board should explore alternative pathways to manage urgent cases in a timely manner.

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 them by their dental practice. C complained about a tooth extraction and the potential failure to fully remove the root of the tooth. The dentist performed an x-ray and examined C’s mouth but did not identify any evidence of infection or retained tooth or bone.

We took independent advice from a dentist. We found that there were insufficient records relating to the tooth extraction. Based on the limited evidence available, we concluded that the care and treatment was reasonable. However, the standard of record keeping fell below the required professional standards. This was likely an isolated incident as other records provided were completed to an appropriate standard. We upheld C's complaint based on the poor record keeping but did not make any recommendations as we were satisfied the dentist had appropriately reflected on their practice.

Summary

C complained that the board unreasonably failed to provide appropriate care and treatment to their late parent (A). A attended A&E with an injured arm after a fall at home. A was treated and sent home but was admitted to hospital a few days later with low sodium and anaemia. A was discharged after a short stay but re-attended A&E a few days later. An abdominal x-ray showed dilated loops of bowel and blood tests taken showed acute kidney injury. A’s condition deteriorated and they died later that day.

We took independent advice from a consultant in emergency medicine and a consultant geriatrician (specialist in medicine of the elderly). In relation to A's first admission, we found that the management of A’s sodium levels was reasonable. However, there was a lack of accurate charting of A’s bowel movements. We also found that medications to address A’s constipation were not provided at discharge. Therefore, we concluded that the care and treatment with respect to A’s constipation was unreasonable and upheld this part of C's complaint.

C also complained that the board failed to provide A with appropriate care and treatment during their second attendance at A&E. We found that there was an unreasonable delay in A being seen by a doctor on arrival. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in the investigation. This should also include the apologies that were included in the correspondence to our office in response to our enquiries. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Bowel charts should be routinely and accurately completed for patients admitted to hospital. Patients should receive appropriate treatment including assessment and relevant examinations to assess known symptoms.
• Patients should receive appropriate treatment including triage and medical assessment in accordance with their symptoms, when attending A&E. The board should have appropriate staffing to allow timely assessment and treatment of patients in A&E, and escalation plans to address instances where patient numbers become unmanageable. The board should have an escalation plan for instances where overcrowding / patient numbers reach critical levels.

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 by the board in relation to excision of a right sided neck lesion.

C had been undergoing monitoring for a neck swelling thought to be a benign tumour. After a number of years of monitoring, C reported that they were experiencing pain and asked to have the mass removed. C underwent surgery to have the mass removed. The lesion had grown on the vagus nerve (the main nerve of the parasympathetic nervous system, which controls some body functions including digestion) and encased it, so the vagus nerve was cut in order to remove the lesion. Following surgery, C experienced gastroparesis (paralysis of the stomach, resulting in food and liquid remaining in the stomach for a prolonged period) and vocal cord palsy (where the vocal cords are unable to move properly).

We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that the care and treatment that C received was unreasonable because there was a failure to recognise the lesion involved the vagus nerve and a failure to adequately discuss risks and consequences with C prior to listing them for surgery. We considered that it should have been made clearer to C that the surgery was likely to lead to injury or loss of function of the nerve. We also found that the events should have triggered the Duty of Candour process and that there was a failure to acknowledge the failings had occurred. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment in relation to excision of their right-sided neck lesion. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Structures involved in benign neck lesions should be carefully considered, and risks and consequences of removal of benign neck lesions should be clearly explained to patients prior to surgery.

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 nursing care provided to their late parent (A) whilst in hospital. They complained about a lack of adherence to infection control, poor staff attitude and breaches of uniform policy. C also complained that A had been issued a zimmer frame without appropriate assessment and guidance, and that staff inappropriately handled A when transferring them to a hospital trolley. C also raised concerns about the management of A’s medicines. A did not receive their prescribed medications and were able to self-administer after medicine was left in their possession.

Through the board’s own investigation of the complaint, they identified appropriate improvements to areas including staff behaviour, infection control, breaches in uniform policy, and moving and handling. C was unhappy with this response and brought their complaint to this office.

We took independent advice from a senior nurse adviser. We found that the nursing care provided to A had been unreasonable. The board were unable to evidence basic nursing care in A’s case due to poor documentation. We identified significant failures highlighting that appropriate assessments did not appear to have been carried out for A or documented during the admissions. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Nursing documentation should be completed to the required standard.
• Patients should be issued mobility aids after proper assessment and instruction 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 complained about the care and treatment the board provided to their late spouse (A). A had a history of heart failure and severe left ventricular systolic dysfunction (LVSD, a severely weakened function in heart pumping) as well as other chronic health conditions.

C complained about the cardiac (heart) care and treatment that A received prior to their death from cardiac failure.

We took independent advice from a consultant cardiologist. We found that clinical aspects of A’s care were reasonable; however, the board’s communication was unreasonable in relation to a prescription for A’s heart medication, an echocardiogram (an image of the heart) and a possible referral to a specialist heart failure service. We upheld this part of C’s complaint on the basis of unreasonable communication.

C also complained about how the board handled their complaint.We found that the board’s handling of the complaint was reasonable. We did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Discussions and outcomes from multi-disciplinary team meetings should be clearly documented in medical records and patient notes.

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.