Health

Summary

C complained on behalf of their client (B) in relation to the care and treatment provided to B's partner (A) whilst A was a patient at Western Isles Hospital.

C complained that the board failed to provide A with reasonable care and treatment whilst A was a patient in the hospital. In particular, C is concerned that venous thromboembolism (referring to blood clots in the veins) testing (VTE) was not carried out and that there was a delay in coagulation screening (screening laboratory tests which allows an initial broad categorization of haemostatic problems). C considered that if reasonable care and treatment had been provided, A may not have died. C also believed that the board did not reasonably respond to their complaint about this matter.

The board noted that whilst a VTE assessment was not performed, and there was a delay in coagulation screening, this would not have altered A's clinical management or have changed the outcome, as A was extremely ill. The board stated that they considered they had reasonably responded to C's complaint.

We took independent advice from an appropriately qualified adviser who determined that although the overall care and treatment offered to A was reasonable, there was learning for the board.

We found that the board had failed to conduct a VTE assessment and had failed to administer a prophylactic dose of heparin on the evening of A's admission which was unreasonable. However, even if a VTE assessment had been carried out, and a prophylactic dose of heparin given, it would not have altered the clinical outcome in this case. We also found that the board's reason for a delay in coagulation screening was reasonable. We, therefore, did not uphold this complaint. Furthermore, we found that the board had reasonably responded to C's complaint. We identified learning for the board which was provided by way of feedback.

Summary

C brought a complaint to us about the gynaecology (medicine of the female genital tract and its disorders) care and treatment they received when they attended Ninewells Hospital. In particular, C complained that they suffered complications from the surgery they underwent and felt that a number of things had gone wrong due to incorrect procedures. C explained that they felt that they were not listened to, nor were they cared for properly or treated with dignity and respect.

We took independent advice from a consultant gynaecologist. We found that while there was some learning for the board in relation to the saving of ultrasound documentation (pictures or hard drive images) and advising C to check for coil threads, the overall care and treatment given to C was reasonable and the complications which arose in this case were recognised complications. We also found that C had been fully and appropriately consented for these. We did not uphold this aspect of C's complaint.

C also complained about the way the board handled their complaint. We found that the board have already acknowledged and apologised for failings identified and said that changes had been made to individuals' practice and to some systems. In the circumstances, while we upheld the complaint, we had no recommendations to make.

Summary

C had been seeking treatment for urinary incontinence but said they experienced significant delays and were asked to attend unnecessary appointments. C also raised concerns about the standard of communication and treatment decisions during this period. C told us that they had been unable to work as a result of the failings.

We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that when C was referred to gynaecology (specialists in the female reproductive system), no surgical options had been available for the treatment of urinary incontinence in the health board area for a number of years and that this was not explained to C until 21 months after referral, despite C having seen at least two gynaecologists by that time. We also found a lack of organisation in terms of staff identifying and communicating the treatment options available to C and putting a treatment plan in place from an early stage. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with a reasonable standard of care and treatment. The apology should meet the standards set out in theSPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Ensure communication by healthcare professionals is of a reasonable standard and meets the relevant guidelines.

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 Scottish Ambulance Service made the decision that their headache was due to a less serious cause (rather than the serious diagnosis that was later identified), which did not require urgent assessment at A&E. C was also concerned that they were taken to the out-of-hours GP rather than to A&E.

We found that the there was no evidence in the records that the ambulance crew made any decisions about the cause of C's headache. The records indicate that the crew considered the symptoms C was experiencing required hospital assessment.

The records also indicated that a handover was given to a nurse within A&E at the hospital and that the nurse was advised that C had a two day history of headaches. It appeared that the decision to transfer C to the out-of-hours service was made by staff within the A&E department, rather than by the ambulance crew.

We did not uphold C's complaint.

Summary

C complained about the actions of Scottish Ambulance Service (SAS) staff when they attended to their adult child (A) following an epileptic seizure (bursts of electrical activity in the brain that temporarily affect how it works and can cause a wide range of symptoms). A was moved onto a chair to be taken out of the house to an ambulance. When A arrived at hospital they were found to have broken vertebrae (individual bones that interlock with each other to form the spinal column). C complained about the manner in which staff had transferred A and about their clinical assessment of A.

SAS said that staff carried out a risk assessment on how to get A to the ambulance; the moving and handling skills applied were based on the clinical assessment of A and access difficulties at the scene.

We took independent advice from a paramedic. We found that the history assessment and energy involved with A's mechanism of injury made it extremely unlikely to cause a significant spinal injury. Given the age and medical history obtained, there were no risk factors which would lead the paramedic to suspect spinal injury. This, coupled with the restricted space within which they were working, made the use of a carry chair a reasonable means of transferring the patient. Therefore, we did not uphold this complaint.

In relation to the clinical assessment, we found that while A complained of back pain, this was not considered to be a spinal injury. We considered the assessment and management were reasonable for a patient suffering a 'seizure now stopped'. We noted that the paramedic used the finding of motor, sensation and circulation of lower limbs in their risk assessment to help rule out/in spinal injury. Given the history and assessment findings, we considered the care provided was reasonable. As such, we did not uphold this complaint.

We noted there had been complaints handling issues, but SAS had taken appropriate steps to address this and had apologised to C.

Summary

C complained that the board failed to appropriately triage their relative (A) when A self-presented to the Medical Assessment Unit (MAU) at Western General Hospital feeling unwell. A spoke with the receptionist who took details of their symptoms and, having discussed A's symptoms with clinical staff, the receptionist advised A that they should contact NHS 24.

A left the hospital and contacted NHS 24 who advised A to take paracetamol for the pain. A was taken to another hospital in the early hours of the next day and had an emergency operation for a ruptured appendix.

In response to the complaint, the board explained that the receptionist acted in line with their normal processes. C was not satisfied with the response provided and brought the complaint to our office.

We found that the board were unable to evidence that A was reviewed by a triage nurse or doctor in person as per their protocol. Given there was no evidence that the appropriate protocol was followed, we upheld the complaint. In addition, having reviewed the handling of C's original complaint, we concluded that the board failed to appropriately investigate and respond to C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to follow the protocol when they attended the hospital and for failing to take appropriate records of the assessment and triage. 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 failing to appropriately investigate and respond to their complaint. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly regarding collating and assessing relevant evidence in determining a complaint.

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 (A) about the board's failure to share confidential patient information with A. C said that information was unreasonably withheld and should have been shared as their safety was at risk. C also complained that the board wrongly treated A's complaint as a 'concern' and they took an unreasonable length of time to respond.

The board said that they were not in a position to share the information A had requested, however they recognised there was some learning for the clinical team and they took steps to address this. The board also said they did not treat C's initial email as a complaint as it clearly stated A wanted to “discuss their experience and concerns”. The board recognised their written response was not issued within a reasonable timescale.

We took independent advice from a mental health nurse. We found that it would have likely been reasonable and legally justifiable for some of the information A requested to be shared with them. We identified that staff were not fully familiar with the national guidance on consent, confidentiality and information sharing. We upheld the complaint.

In relation to complaint handling, we concluded that it was reasonable to treat A's initial email as a concern and a request for a meeting. However, matters became confused when the board's written response following the meeting included SPSO referral details, which inferred it was a complaint response. When C submitted a formal complaint, we noted that the board did not meet the required timescales. On that basis, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to consider whether the disclosure to A of confidential patient information was justifiable. 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, an advice and support worker, complained to the board on behalf of their client (A) who had attended A&E at University Hospital Wishaw. A had sustained severe pain and swelling behind their right eye and was concerned that they may have suffered a stroke. A was seen by the stroke team who confirmed that A had not suffered a stroke and A was discharged home with a diagnosis of severe migraine. A began to have the same problems with their left eye two weeks later and by that time still had not regained sight in the right eye. A reattended the hospital. After initially being told it was another migraine incident, which they did not accept, A was referred to another hospital and then to ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) for further treatment including eye drops and laser surgery. A has regained sight in the left eye but will not regain sight in the right eye. A had concerns about the lack of treatment provided at their first attendance at A&E.

We took independent advice from a consultant in emergency medicine. We found that the A&E doctor, although reaching a reasonable diagnosis based on some of A's reported symptoms, failed to conduct appropriate investigations on A's specific eye symptoms which had been recorded by a nurse and a paramedic at the time. This should have resulted in a referral to ophthalmology. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failure to refer them for an ophthalmology review. 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 A&E doctor should be aware of the relevant recorded findings of other health professionals when conducting a medical review of 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 complained about the treatment provided to their spouse (A) by the board. A underwent knee replacement surgery. After the surgery, A's health declined and A died approximately five months later. C raised a number of issues relating to the surgery itself as well as the care and treatment provided afterward.

We took independent advice about this complaint.

We considered C's complaint on how the board failed to carry out the surgery in a reasonable manner. We found the board carried out the surgery in a reasonable manner, based on the experience of the surgeon, operation note and postoperative x-rays. As such, we did not uphold the complaint.

We considered C's complaint that the board failed to provide reasonable nursing care after A's surgery. We found that while some elements of nursing care were reasonable, the main type of care provided by the board; wound care, was unreasonable. We found four key points which were unreasonable and that these could have been addressed if a referral had been made to the tissue viability service once it was clear that the wound was deteriorating. This referral was not made. Therefore, we upheld this complaint.

C also complained that the board failed to provide reasonable treatment to A after the surgery. We found that there was a delay in the provision of A receiving antibiotics and, while this was not best practice, it was not unreasonable. We found that the actions in response to A's deterioration, including transfusions, surgery and medication, were reasonable and A's condition was reasonably monitored. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable wound care. 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:

• Allergies should be consistently recorded in patient's medical records.
• Appropriate wound assessments should be carried out for patients.
• Dressings should be removed immediately if it is known the patient is allergic to them.
• Where appropriate, referrals should be made to a tissue viability nurse specialist.
• Wounds should be treated with appropriate wound care products based on the wound assessment.

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, an advice worker, complained on behalf of their client (B) about the treatment B's spouse (A) received from the board. A had a rare form of dementia and their condition deteriorated to the point where they become a potential risk to themselves. A was admitted to hospital so their medication could be monitored and altered more effectively but they died a few days after being admitted.

B was concerned about the pain relief medication A was given in the final days of their life. In B's view, the pain medication was not administered consistently and A did not receive sufficient medication to alleviate their pain. B felt that a syringe driver should have been used to administer morphine, as they did not feel nursing staff provided pain relief medication as required.

We took independent advice on this complaint from a nursing specialist. We found evidence of good nursing care being provided and confirmed that it was reasonable for a syringe driver not to be used in this instance. However, we also noted a significant gap in the nursing records where there was no evidence of A's level of comfort being monitored. While acknowledging that there was evidence of good care being provide to A, the significant gap in some of the records and the inconsistency in the record-keeping meant we could not conclusively say what happened during this period and what condition A was in. This led us to conclude that the board failed to adequately evidence that A was monitored appropriately and provided with appropriate pain relief during this period. In light of this, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the fact that they were unable to evidence that A was monitored appropriately and provided with appropriate pain relief. 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:

• Appropriate tools should be in place to allow staff to effectively record pain experienced by patients with cognitive impairment.
• Nursing staff should comply with required aspects of record-keeping at all times.

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.