Health

Summary

C complained about the post-operative care and treatment that they received from the board after they suffered a leg and ankle fracture. C said that unreasonable post-operative care led to a poor recovery and the requirement for an additional operation.

We took independent advice from a consultant orthopaedic surgeon (specialists in the treatment of diseases and injuries of the musculoskeletal system). We found that the board failed to report some x-rays and to reasonably explain why further x-rays were taken and who had reviewed them. We also found that there had been an unreasonable delay in carrying out a CT scan and in discussing C’s case at a Morbidity and Mortality meeting. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board handled C’s complaint reasonably and 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. 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 patient’s medical records should document the reasons why a scan(s) has been taken and who has reviewed them. The results should be recorded on the hospital’s clinical portal system.
• There should be processes and guidance in place to ensure when it is appropriate to carry out a CT scan.
• Where a patient’s case is appropriate for discussion at a Morbidity and Mortality meeting, this should take place as soon as possible.

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 reasonable care and treatment to their late parent (A). A became acutely unwell with uncontrollable diarrhoea, severe abdominal pain and vomiting. After visits from both a community nurse and out-of-hours GP, C called for an ambulance. The ambulance crew called ahead to the hospital to have A admitted, as per the board’s alternative admission pathway. As agreed during the call, A was taken to the Acute Medical Unit (AMU) but there was no bed for A on arrival. Initial observations and ECG/bloods were taken but A was found unresponsive a short time later and died of a cardiac arrest.

The board apologised that no bed was available for A. They reviewed A’s case and concluded that the appropriate referral pathway was followed. However, they acknowledged that patients with undifferentiated (undiagnosed) abdominal pain should not be admitted to the AMU.

We took independent advice from a consultant physician in acute and general medicine. We found that the board failed to obtain key information to determine which pathway should be followed. This resulted in A not entering the correct pathway. We found that the board failed to escalate A’s care and treatment in line with relevant guidance and with their own policy. We found that A’s care was compromised by the board’s alternative admission pathway. It is possible that the outcome may have been different had the correct pathway been accessed. We upheld this part of C’s complaint.

C complained that the board unreasonably failed to carry out a Significant Adverse Event Review (SAER) following A’s death. After being notified of our investigation, the board commissioned a SAER. Although we welcomed this, the board did not provide assurance that they have adequate systems in place to identify, investigate and learn from adverse events. The board’s failure to commission a SAER following A’s death did not meet the standards outlined in the relevant guidance, and was unreasonable. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a SAER. 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 for the failings our investigation has 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:

• Patients should be admitted to the correct care pathway on the basis of their presenting symptoms. When accepting patients with undifferentiated gastrointestinal symptoms, local teams should be aware of the presence or absence of abdominal pain. Teams should ensure that they ask this specific question when accepting patients.
• Patients should be managed in line with their presenting symptoms. Observations should be carried out in line with the board’s escalation policy.
• There should be a robust process in place for reviewing all unexpected deaths, and, where appropriate, prompt commissioning of SAERs. Learning from these events should be disseminated and shared across teams in line with national guidance.

In relation to complaints handling, we recommended:

• Complaint investigations and case reviews should respond to all of the main points raised, identify failings where appropriate and take learning from what happened. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 late parent (A). Scans revealed findings that were suggestive of bladder cancer. Over a number of further admissions, A received treatment to resect (remove) a bladder tumour, fit and remove catheters, treat infection and generally manage A’s condition. Eventually, it was decided that A’s condition should be managed palliatively, and A was discharged home.

C complained that the medical and nursing care and treatment A received from the board was unreasonable and that the communication with A and their family was unreasonable.

The board said that A was not medically or psychologically fit for further management of their condition and they were not a candidate for chemotherapy or radiotherapy. A was referred to palliative care once it was identified that they were also not a candidate for surgery. The board said A chose not to share their diagnosis for a number of weeks and were unwilling for discussions to take place with their family.

We took independent clinical advice from a consultant urologist (specialists in he male and female urinary tract, and the male reproductive organs) and a registered nurse. We found that the surgical care was of a reasonable standard and that the board adopted a holistic approach. However there was a failure to detect the bladder tumour when it was initially suspected and a failure to follow up with A about their nephrostomy (a thin tube inserted through the skin directly into the kidney to allow urine to drain into an external drainage bag) and JJ stents (a thin flexible tube placed to help urine flow). We also found that there was a delay in organising an inpatient CT scan, failures in relation to discharge planning and a failure to care for A’s skin and pressure damage.

In relation to communication, we found that the board failed to tell A that there was a suspicion of bladder cancer at an appropriate time and it was unreasonable for the board not to communicate with A’s family when arranging discharge.

We considered that the board failed to provide reasonable care and treatment to A and failed to communicate reasonably with A. Therefore, we upheld these parts of C’s complaint.

C complained that the board failed to handle their complaint reasonably. We found that the board’s investigation and response contained a number of factual inaccuracies, particularly with the accuracy of dates and order of events, and that important information was omitted from the response. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable care and treatment to A, failing to communicate reasonably with A and their family, and failing to provide a reasonable response to C’s complaints. 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:

• Discharge planning should take into account the patient’s ability and motivation to complete required self-care tasks such as catheter and nephrostomy care. Patients should be issued with a copy of the discharge letter where appropriate. When a patient does not live independently family members should be informed of their discharge to ensure there is appropriate care in place.
• There should be nurse specialist support for patients with urological cancers. Nurse specialists should contact the patient within a reasonable timescale. Patients should be assessed to ensure suitability before phone consultations are carried out. Patients should be supported, where possible, when bad news is being communicated to them. Relevant updates should be given to a patient in a timely manner.
• There should be adequate trainee supervision during surgical procedures in keeping with the trainee’s experience. Patients should be informed of investigation findings if they are suspicious of a cancer diagnosis. When there is a suspicion of cancer further investigations should be carried out with due diligence. Relevant findings should be discussed with the patient and recorded in the medical notes.
• A pathway should be in place to ensure that patients with nephrostomies and/or JJ-stent are followed-up in line with best practice time frames.
• Inpatient scans should be carried out within a reasonable time frame.
• Wound charts should be in place for pressure wounds and there should be subsequent weekly assessments. Care rounding should be delivered to the frequency required to prevent pressure damage. Patients should be appropriately moved position to avoid worsening pressure damage.

In relation to complaints handling, we recommended:

• Complaint responses should be factually accurate. Details such as dates and the order of events should be supported by what is recorded in the medical records, and these should be checked for accuracy before the response is issued. Complaint responses should be completed in line with the NHS Model Complaints Handling Procedure.

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 reasonable physiotherapy care and treatment to their child (A) and failed to maintain reasonable clinical records.

We took independent advice from a physiotherapist. We found that some aspects of A’s care were reasonable, particularly in relation to ongoing treatment at school, and the adjusting of equipment and personal care access was in line with normal practice. However, it was unreasonable that no paediatric physiotherapy programme was provided and delegated to school staff initially to support classroom and curriculum access and that clinical notes only mentioned a programme taught to support staff in school following the change in physiotherapist. Therefore, we upheld this part of C’s complaint.

In relation to the clinical records, we found that there were omissions in the completion of documentation and poor physiotherapy clinical record keeping. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board’s actions in relation to the handling of C’s complaint were reasonable and did not uphold this part of C’s complaint. We also noted that the board had taken learning and improvement action which we welcomed.

Recommendations

What we asked the organisation to do in this case:

• Apologise 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.

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

• Clinical notes should be comprehensive as set out by the Charted Society of Physiotherapy (CSP)/Health and Care Professional Council (HCPC) standards and include action plans. Senior managers should be aware of their role in relation to monitoring the quality of record keeping (in line with the Records Management Code of Practice).

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 appropriate orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) care and treatment following a fall. The board operated on C’s left wrist the day after the fall. Two days later, they performed revision surgery on C’s wrist and operated on their left elbow. C said that they had been advised by an orthopaedic surgeon at the board that their initial wrist surgery had not been done correctly. C said they had developed nerve compression pain issues and would require further surgery.

We took independent advice from an orthopaedic consultant. We found that C’s initial wrist surgery was reasonable. However, the tilt of the radius was slightly beyond the normal range, which carried a minor increased risk of longer term functional impairment in the wrist. We considered that, if C had not required additional surgery for the elbow, the initial wrist fixation might have been left unchanged, as any potential long-term dysfunction could still have been treated later if necessary. However, given that C was already scheduled for elbow surgery, the decision to proceed with revision surgery on the wrist was considered reasonable. We also noted that key indicators related to pain were appropriately assessed in C’s case, and there was no indication that the surgery had been performed in a manner likely to cause excessive pain. Therefore, we did not uphold C’s complaint.

Summary

C complained about the care and treatment that their late parent (A) received while in hospital. A suffered a fall and broke their hip. C complained that A was never provided with a falls monitor despite being assessed as a falls risk. C also said that there was a delay in reporting the fall and having A assessed.

The board apologised to C for the fact that, due to a lack of falls alarms, A had not received one. They explained that additional alarms had been obtained to ensure a sufficient supply on the ward. They also accepted that a ‘top to toe’ examination should have been carried out following A’s fall and that there was a delay in identifying that A had a broken hip. They explained that a full review of A’s fall was underway, and if any learning points were identified, they would be acted upon. In addition, a teaching session had been carried out to ensure best practice was followed at all times. The board provided us with details of the learning points that had been identified as a result of the complaint.

We took independent advice from a registered nurse. We found that there was no evidence that A received timely risk assessments or person-centred care. Although a fall with harm was apparent from A’s misaligned leg, this went unnoticed. Basic assessments, including pain assessment, were not conducted, resulting in a delay in recognising A’s pain. Additionally, wound charts were not completed, and there was a failure to follow policy regarding pressure ulcer prevention, malnutrition, and wound assessment and management. While the board had taken action in response to the complaint, we considered that there were still areas for learning and improvement. Therefore, we upheld C’s complaint.

We also found that the board’s complaint response had not been open, transparent, and accurate. The board had failed to identify a number of failings in A’s care and treatment. Additionally, the board had not provided this office with all relevant information in response to our initial enquiry. A significant number of relevant documents were only made available to us after a follow-up enquiry. We made recommendations to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise 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.

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

• The board should ensure that nursing staff are aware of their responsibilities for completing relevant documentation in relation to person centred care planning, risk assessment and wound assessment and that the documentation is to the standard required. The board should ensure that there is a consistency of approach from nursing staff when a patient places themselves on the floor and the board’s guidance on what nursing staff should be doing is followed.
• The standard and content of patient documentation in relation to person centred care planning, risk assessment and wound assessment should comply with all relevant guidance and policies and with best practice.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. They should be accurate in their findings and conclusions, clear, and supported by relevant evidence, such as medical records.

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 their adult sibling (A) when they attended A&E following an accident. C also complained that the board failed to reasonably investigate A’s symptoms when they attended hospital with headaches on two further occasions the following year. A was later diagnosed with a brain tumour and C feels that there were missed opportunities in identifying this earlier.

We took independent advice from a consultant emergency physician and a GP. We found that the board undertook appropriate assessments and provided reasonable treatment to A when they attended A&E following their accident. We did not uphold this part of C’s complaint.

In relation to A’s first attendance at hospital the following year, we found that the board failed to investigate A’s symptoms. There were clear flags identified in the GP’s referral letter, indicating further investigations should have been carried out, specifically a head CT scan, and this did not occur. Therefore, we upheld this part of C’s complaint.

In relation to A’s second attendance, we found that the board reasonably investigated A’s symptoms as they presented at the time, with appropriate investigations undertaken and follow-up advice provided. Therefore, 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 failing to undertake reasonable investigations when A attended hospital and for the poor handling of C’s complaint about this matter. 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:

• Junior doctors are aware of the importance of considering relevant clinical information from all available sources to guide clinical assessment. Clear red flags outlined in patient referrals and clinical questions resulting in patient referrals should be clearly documented in patient notes and communicated to senior reviewing clinical staff.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and based on all of the relevant evidence.

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 late parent (A). A was experiencing shooting back pain, tingling sensations, abdominal swelling, weight loss, poor balance and constipation. A contacted the practice on four occasions with deteriorating symptoms. By the last contact, A was incontinent and unable to mobilise. After some delay, the practice organised (seated) ambulance transport to hospital. A was diagnosed with malignant spinal cord compression (MSCC) caused by metastatic renal cancer. A was paralysed and incontinent until they died a few months later.

C complained that the practice failed to spot red flag symptoms for MSCC and cancer, missed opportunities to send A to hospital earlier and failed to appropriately manage A’s transfer to hospital. C said that when A was discharged from hospital their pain, nutrition, appetite loss and low oxygen levels were not effectively managed. They also complained that a GP inappropriately discussed A’s terminal prognosis and do not attempt cardiopulmonary resuscitation (DNCPR) decision at a home visit.

The practice said that, in previous appointments, they had examined A, conducted blood tests, inquired about symptoms of cord compression, and provided advice on what to do if the condition worsened. They recommended going to the hospital only after symptoms deteriorated. They advised that on discharge, the GP had considered it important to discuss prognosis and DNCPR at the earliest opportunity and had made every effort to do so sensitively. They said that they had adjusted A’s pain medication and referred to palliative care nurses. The practice also said that they had referred to a dietician and it would not be standard practice to check oxygen levels as it would not change the overall palliative care.

We found that it had been unreasonable not to arrange a stretcher transfer to hospital at an earlier date. We also considered that it was unreasonable that changes to pain medication had not been timeously reviewed. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for not referring A to hospital sooner, for not timeously organising appropriate ambulance transport on a stretcher, for not contacting a specialist to expedite review on arrival at hospital, and for not appropriately reviewing A’s pain medication. 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:

• All medical staff employed by the practice are familiar with the referral guidelines for possible malignant back pain and cord compression, such as the West of Scotland Guidance and Recommendations| Spinal metastases and metastatic spinal cord compression | Guidance | NICE.

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 their late partner (A) with reasonable treatment for bladder incontinence. A was admitted to hospital following a fall in which they fractured their hip. A was catheterised after undergoing surgery. C complained that when A’s catheter was removed, they developed a bladder problem, and that hospital staff did nothing to rectify A’s inability to control their bladder or investigate what was causing this. C believed if A’s bladder problem had been addressed they may have made a full recovery. A’s condition deteriorated after discharge and they died within a few weeks.

When the board originally responded to C’s complaint they said that it was documented in the nursing notes that A was incontinent on three occasions. The board said a urine specimen was taken which returned a positive result for a urinary tract infection and A was treated with oral antibiotic medication. The board said that prior to discharge, A was mobilising to the toilet and there was no mention of incontinence thereafter.

C highlighted a number of entries in A’s records which referred to incontinence/use of pads. We asked the board to comment on this, noting this contradicted their position in the complaint response. The board confirmed that if all this information had been considered by the multi-disciplinary team, this may have prompted additional continence support and follow-up being arranged on A’s discharge from hospital. The board confirmed that they were taking forward learning points including an action plan for improvement.

We took independent nursing advice. We found that despite a number of references within the multidisciplinary notes to A’s incontinence, there appeared to have been no attempts to explore this further and to provide appropriate support during A’s admission and/or follow-up after discharge from hospital. Although the board missed an opportunity to address these issues, it was not possible to determine the extent of the impact on A, who had a number of significant health concerns. We upheld C’s complaint and made a recommendation for apology. We considered that the action plan appropriately addressed failings so made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable treatment for A’s incontinence and for failing to appropriately identify concerns about A’s bladder issues in their investigation of C’s complaint. 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 and treatment that they received when they attended the board’s urgent care centre with sudden hearing loss in their right ear. C’s hearing loss became permanent and they felt that this could have been avoided.

We took independent advice from a consultant in emergency medicine. We found that the board’s assessment of C was unreasonable. While a clinical assessment was undertaken, a clinical hearing assessment was not, which meant that the cause of C’s acute hearing loss was not ascertained. This could have led to alternate treatment options. The board also failed to provide reasonable advice on what to do if C’s symptoms should continue after five days. The board’s response did not reasonably reflect the records available, and their investigation did not identify the failings in C’s care. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably assess C’s hearing loss and provide appropriate 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.

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

• Guidance is available to staff which provides a localised and helpful pathway as to the action to take when a patient presents with sudden hearing loss.
• Practitioners delivering the out-of-hours/primary care emergency centre service have an appropriate level of training to assess patients presenting with sudden acute hearing loss.

In relation to complaints handling, we recommended:

• Responses to complaints are accurate, identify failings when they occur and seek to take learning from what happened to make similar failings less likely to occur.

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.