Health

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.

Summary

C underwent an emergency caesarean section (an operation to deliver a baby. It involves cutting the front of the abdomen and womb). Following this, the stitches holding C's wound together failed. C believed they had not been properly cared for after their surgery. They said they had experienced abnormal levels of pain and discomfort. These had been incorrectly attributed to other causes such as constipation, but C believed they were a sign their wound closure was failing. C also noted significant amounts of fluid had leaked from the wound. C felt this was excessive, but that it had not been properly considered by nursing or medical staff. C said the experience had been very traumatic for them and for their spouse.

The board had conducted an internal review into the failure of the stitches. C felt they had not been properly involved in this and that it had not recognised properly the seriousness of the incident, or the implications of its conclusion that incorrect suture material was used.

We took independent medical advice which stated the complication suffered by C was rare. C's condition was monitored appropriately postoperatively, including escalation for medical review due to the concerns about wound leakage and pain levels. Although the documentation was poor, there was no evidence of operator error, or that the specific suture material used had contributed to the failure of the wound. We found C's care and treatment had been of a reasonable standard. Therefore, we did not uphold the complaint.

The board had acknowledged there had been confusion between the complaints process and the serious adverse event review process and that this had led to delays and poor communication with C. We found that the board's handling of the complaint had been unreasonable, but they were able to demonstrate that they were taking steps to address this issue.

Summary

C complained on behalf of their spouse (A). A was admitted to University Hospital Wishaw (the hospital) with severe pancreatitis (inflammation of the pancreas). At that time, this was attributed to recent alcohol intake. They developed multi-organ dysfunction (respiratory, cardiovascular and renal) over the ensuing 24 hours, but subsequently made a slow but full recovery.

Three years later, A developed abdominal pain whilst on holiday abroad. They were again diagnosed with severe necrotic pancreatitis, which was attributed to raised triglycerides (a fatty substance similar to bad cholesterol), rather than alcohol. It was subsequently documented that they had not drunk alcohol since the earlier episode of pancreatitis. They were admitted to an intensive care unit, intubated and ventilated and managed with conservative supportive therapy. An ultrasound scan during this admission did not show that they had any gallstones. Once A was sufficiently well to travel, they were transferred to the hospital, where they remained until discharge.

A subsequently had an ultrasound and this demonstrated a thickened gallbladder containing sludge. They then underwent cholecystectomy (gallbladder removal).

C complained on behalf of A that the board unreasonably delayed in performing a test to establish the cause of A's pancreatitis. We found that the board failed to follow national guidelines by not performing ultrasound scanning at the time of A's first admission to hospital with acute pancreatitis. Ultrasound scanning might have resulted in the identification of biliary sludge within the gallbladder at that time and prompted gallbladder removal, thus potentially avoiding the more severe episode of recurrent acute pancreatitis. It should also be stressed, however, that a negative scan at that time would have been unlikely to change A's subsequent clinical course. There was little documentation of discussions with A and their family. In view of these failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to perform ultrasound scanning during A's first admission to hospital and the lack of documentation of discussions with A and their family in relation to the cause of the pancreatitis. 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 cases where the cause of an illness or disease is unclear, or where a diagnosis potentially confers a degree of stigma to the patient, tactful discussions should take place between the medical team and the patient and their relatives with such a discussion being carefully documented afterwards.
• Patients presenting with acute pancreatitis should undergo ultrasound scanning during their admission in order to consider gallstones as the potential cause.

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 held power of attorney for their parent (A) and complained about the management of A's medication during a hospital admission for treatment of a chest infection. A's medication Furosemide and Ramipril (both used to treat heart failure) were stopped for eight days. A was readmitted to hospital again having suffered a heart attack and died.

The board acknowledged it was not recorded who stopped A's medication and why they did so, and that there were failings in how A's medication was reviewed and managed prior to discharge.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). After review of relevant medical records and statements, we found that while it may have been reasonable to stop A's medication at the time, there was a failure to record who made the decision and their rationale for the decision.

We also found the board did not give adequate consideration as to whether the cessation of A's medication may have had an impact on A's readmission, further heart problems and subsequent death.

We also found that A's discharge letter was not appropriately updated prior to discharge. We upheld three of C's complaints, however we concluded that the board's communication with C about the changes to A's medication was not unreasonable in the circumstances and this complaint was not upheld.

Recommendations

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

• Individual staff, particularly the consultant responsible for A's care, should show they have included this complaint in their annual appraisal as part of reflective practice.
• That it has been considered whether the failures relating to the management of A's medication had an impact on A's need for readmission and ultimate death.

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) at University Hospital Monklands. During their admission, there was an incident involving A in the early hours of the morning. The board said that A was mobilised to a commode and, at A's request, given privacy to use it. The board said that A fell during this time and sustained injuries. C was sceptical of the account given by the board of how A sustained their injuries. A remained in hospital until their death a little over a week later.

C complained to the board that A was injured, about medical treatment and nursing care after A was injured, and about the attitude of a specific doctor. In response, the board advised C of their view of what had happened, apologised that A had fallen and assured C that work was ongoing in relation to reducing the number of patient falls at the hospital. C was dissatisfied with the board's response and raised their complaints with this office.

We found that the board had not reasonably assessed A's falls risk, had not reasonably undertaken staff handovers in respect of A, unreasonably mobilised A to the commode without their hip brace and unreasonably allowed A to use the commode alone and unsupervised. We upheld C's complaint about the care provided to A in respect of their falls risk.

There was disagreement between C and the board about the circumstances of particular parts of A's care and treatment following their injury but, notwithstanding this, we found A's care and treatment following their injury was reasonable. We did not uphold C's complaints about the care and treatment of A following their injury.

In relation to C's complaint about the attitude of a specific doctor, the recollections of C and the doctor about a specific discussion are contradictory but the evidence available of board staff's communication with C shows these were reasonable. We did not uphold C's complaint about the attitude of the doctor.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for providing A with unreasonable care in relation to their falls risk. The apology should make clear mention of each of the failings identified and 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:

• Relevant staff should be properly trained regarding the completion of neuro observations in line with SIGN 110, the need for accurate record-keeping in line with the Nursing and Midwifery Council code, specifically around recording all conversations with families and adding times to all records and risk assessments, and the appropriate action to take, and record, regarding the administration of pain relief following injuries.
• Relevant staff should be properly trained regarding the safe positioning of commodes, and the management of delirium and the appropriate completion of the '4AT' bundle in line with the delirium toolkit.
• Relevant staff should be properly trained in the completion of care plans to reflect need in relation to cognition, mobility and maintaining a safe environment.
• Relevant staff, including allied health professionals, should be properly trained regarding assessment of mobility and risk assessment of moving and handling (including following a fall).
• Situation, background, assessment, recommendation (SBAR) transfer handovers are recorded for relevant staff regarding falls risk and safety interventions in place.
• The board should ensure their falls risk assessment procedures are compliant with the Scottish Patient Safety Programmes (SPSP) guidelines 'Prevention of falls driver diagram and change package' (2013) and include a prompt for staff regarding bathroom safety.

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 and their child (A) by the board during their pregnancy and after A's birth. A was diagnosed with microcephaly (a condition where the head circumference is smaller than normal) and associated issues around six weeks after their birth, and C felt that the diagnosis could have occurred at an earlier point.

During our investigation, we took independent advice from a midwife, an obstetrician (a doctor who specialises in pregnancy and childbirth) and a neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns).

In relation to the care and treatment provided to C during their pregnancy, we identified the following failings:

A lack of documentation in the care plan in relation to detail surrounding verbal discussions midwives had with medical staff during the antenatal period.

A lack of a planned schedule for obstetric reviews as per the 'Keeping Childbirth Natural and Dynamic' (KCND) pathways.

No scan carried out at 36 weeks as per the plan and no documentation to support the reasons for not adhering to this planned care pathway.

Lack of clear documentation resulting in it being difficult to accurately determine if or when an obstetric doctor saw C, and what they communicated to the midwives or C.

Lack of documentation regarding information given to C about the External Cephalic Version (ECV) procedure (a process by which a baby in the womb can sometimes be turned from buttocks or foot first to head first), delivery options, and induction.

No evidence within the files that there were discussions about risks associated with shoulder dystocia (when one or both of a baby's shoulders get stuck inside the mother's pelvis during labour) or that risk assessments in relation to previous pregnancy outcomes were undertaken.

As a result of an external Significant Clinical Incident Review (SCIR) carried out by the board, some improvement actions had been taken to address the issues identified with the lack of documentation of discussions between midwives and medical staff, and the failure to discuss induction of labour. However, we upheld this aspect of C's complaint and made further recommendations to the board.

We did not identify any failings in relation to the care and treatment provided to C during labour; C and A's discharge from hospital; or the care and treatment provided to A after discharge. We did not uphold these aspects of C's complaint.

However, we found that there was an unreasonable failure to identify A's tongue tie when still in hospital after being born. Therefore we upheld C's complaint that the board failed to provide reasonable care and treatment to A whilst in hospital after being born.

C also complained about the board's involvement in the external SCIR, and the board's handling of their complaint. We found that the board's involvement in the SCIR was reasonable and did not uphold this aspect of C's complaint. However, we considered that their complaint handling was unreasonable, as C was not informed of their right to bring their complaint to us in a timely manner, and the board did not reasonably manage the multiple streams of communication during the complaint process. We upheld this aspect of 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 during C's pregnancy in relation to documentation, schedules for obstetric reviews and scans, communication, and risk assessments; the failure to identify a tongue tie; and the failure to handle C's complaint reasonably. 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:

• Clear documentation should be made when care plans change, which reflects the rationale for change and the new plan to be followed.
• Discussions between midwives and medical staff, and medical staff and patients, should be clearly documented.
• ECV procedure and delivery options should be discussed and documented as appropriate.
• Obstetric reviews should be scheduled in line with the KCND pathways.
• Risks associated with previous shoulder dystocia should be discussed, and risk assessments in relation to previous pregnancy outcomes undertaken.
• The names and roles of all providers of clinical care should be identified within the records, and discussions.
• Tongue ties should be identified as promptly as possible.
• Where meetings are held between patients and clinicians, the discussions should be documented.

In relation to complaints handling, we recommended:

• Complainants should be informed of their right to take their complaints to the SPSO in a timely manner.
• Efforts should be made to manage communication when there are multiple streams of communication during the complaint 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 complained that they were unreasonably discharged from the pain clinic on two occasions. C had their first session with the pain clinic and then their first telephone session with a nurse the following month. In the interim, C was admitted to hospital for their mental health. At a multidisciplinary team meeting (MDT) it was decided to discharge C from the pain service due to their psychiatric admission.

C was later reinstated to the pain service and was offered an appointment but later complained about the service. C was discharged from the service again because of a statement they made in their complaint which led the board to believe C did not want any further contact from the pain service. C complained about both decisions to discharge them from the pain service.

We took independent advice from a consultant psychiatrist. We found that it is routine management to prioritise one acute (immediate) health issue over other longer term issues. Those longer term issues may complicate the management of the immediate health issue. In this case, that would have been C's recent mental health admission. We also noted that the board had acknowledged and apologised for communicating their decision about the first discharge poorly. We found that C had said in their complaint to the board that they did not want the services of the pain clinic anymore. While it would have been good practice to clarify what the patient truly wanted before discharging them from the service, it was not unreasonable to take C's statement at face value. We did not uphold C's complaints.

Summary

C was referred to a consultant obstetrician and gynaecologist (specialises in the medicine of the female genital tract and its disorders) regarding a skin lesion they had on their vulva. At the first appointment, the consultant removed the lesion under local anaesthetic. C complained to the board that the consultant decided to remove the lesion without properly examining it, that proper anaesthesia was not applied, and the consultant and nurse demonstrated a lack of preparedness.

The board provided assurances that the consultant did examine the lesion and proceeded with the procedure after discussing the options with C. Additional anaesthesia was applied when C said they could feel the incision. The board also explained that equipment had to be retrieved from the theatre.

We took independent clinical advice and reviewed the medical records. We found that the consultant failed to offer a third treatment option which was to have a smaller biopsy taken for the purpose of making a formal diagnosis and arranging a full excision at a later date. This may or may not have been the best choice, however it would have allowed C to make a more informed decision. There was no evidence to suggest C was not examined properly and we noted the consultant did apply further anaesthesia when C reported feeling pain. Overall, we concluded the General Medical Council principles of decision-making and consent were not fully met and as such the care and treatment provided was unreasonable. We upheld the complaint.

Recommendations

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

• All procedures should be carried out following full discussion and informed consent.
• The board should consider using leaflets to supplement the verbal information given to the patient at the time of biopsy with clear instruction on what to expect and how to obtain advice after going home.

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.