Health

Summary

C complained that the practice had unfairly accused them of being threatening and aggressive, resulting in their removal from the practice list and that C had been unreasonably placed on an opiate reduction programme. C said that they had been targeted because they had successfully complained about the services provided by the practice in the past. C said that the practice had misrepresented the opiate reduction as mandatory, when in fact they were only required to review opiate use. C said that the practice had not taken into account the impact of the opiate reduction on them.

The practice said that they had a zero tolerance for aggressive or inappropriate behaviour. C had abused the prescription request service and had entered the practice and refused to leave unless they were provided with an additional prescription. The practice had, after review, reinstated C to the practice, but C had continued to request medication early, breaching their agreements with the practice. This had resulted in their removal from the practice lists. The practice had reviewed and reduced C's medication in line with best practice and health board guidance. C had previously sought medication early and was considered by the practice to meet the criteria for opiate reduction.

We took advice from an independent medical adviser. We found that the practice had acted reasonably in seeking to reduce C's opiate use. We also found that arguably the practice should have provided C with a written warning prior to the first decision to remove them from the practice list. When C had appealed against this decision, however, the practice had reviewed it and agreed to reinstate C subject to commitments about their behaviour. C's second removal had been due to the practice's view that the agreements reached with C had been breached. The practice were entitled to reach this decision and had acted reasonably. Therefore, we did not uphold the complaint.

Summary

C's adult child (A) had anxiety and a functional neurological illness (a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts). One morning A was found to be anxious and unwell. A's other parent (B) thought it appeared different to A's previous episodes and called the GP who visited A at home.

The GP believed that A should be admitted to hospital and called 999. An ambulance crew attended the scene. There was some discussion between the GP and the hospital about which department A should be admitted to; the Mental Health Unit or the Clinical Assessment Unit. The ambulance crew transported A to hospital where they were quickly assessed and taken to the Intensive Care Unit. A died later that day.

C complained that the Scottish Ambulance Service (SAS) crew did not take A's observations, failed to follow normal protocols and failed to transfer A to the Clinical Assessment Unit straight away.

We took independent advice from a paramedic. We found that the ambulance crew attended promptly and appropriately transferred A to hospital. However, during their time at A's address they did not carry out or document a thorough patient assessment. There were multiple assessment tools (F.A.S.T; blood oxygen saturation levels) which could have been used and were not. When A's breathing rate was abnormally high, further action was not taken as it should have been.

We found that the SAS had not responded to the complaint reasonably and failed to clearly identify errors and what would be done to remedy them going forward. We, therefore, upheld the 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:

• Share the findings of this investigation with the ambulance crew and those involved in the reflective learning exercise.

In relation to complaints handling, we recommended:

• SAS should provide as full an explanation as possible in complaint responses as to what mistakes may have occurred (where appropriate) and why they occurred in this case, in order to allow complainants a better understanding of what happened.

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 their parent (A) after A was unwell and a GP made a home visit to assess them. The GP called for an ambulance for a 'within the hour' response. The ambulance service called back later and spoke with C to advise that the ambulance was delayed and would attend as soon as possible. C later called 999 and advised that A's condition had deteriorated. This resulted in a higher priority ambulance being assigned.

C complained to the ambulance service about the failure to respond to the requests for an ambulance. In response, the ambulance service acknowledged they failed to meet the initial one-hour response requested, but explained that one-hour ambulance responses are not automatically upgraded. They said that in these circumstances they call back to explain the delay, ask if there is a change in the patient's condition and advise patients to call 999 if there is a change.

C complained to our office that the ambulance service had failed to take account of A's diagnosis provided by the GP, and had therefore not attributed the correct level of priority to the response. C also considered that there was no attempt by the ambulance service to undertake clinical triage of A, resulting in the response level not being upgraded as it should have been. C was unhappy with the investigation and response to their complaint and believed the ambulance service's response to the complaint was not plausible.

We found that whilst there was a significant delay in the ambulance attending to A, this was attributable not to failings on the part of the ambulance service in prioritising the request for an ambulance, but on the lack of available resources at the time.

However, we found that during the welfare call back, the ambulance service should have sought to clarify whether C considered A's condition had deteriorated before continuing with the call. On this basis, we upheld the complaint with respect to unreasonably failing to respond to the request for an ambulance. With respect to the complaint about the complaints investigation, we found the complaints investigation and response was reasonable and did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to confirm whether or not A's condition had worsened before continuing with the call. 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 circumstances where a call handler calls a patient, in line with the Urgent Welfare Call Back Process, they should make reasonable efforts to confirm whether or not the patient's condition has worsened. Where a call handler is unable to obtain clarification as to whether the patient's condition has worsened, the call handler should process the call through the MPDS system in line with the normal emergency call handling process.

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 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.