Health

Summary

C was admitted to New Craigs Hospital following an overdose. They complained about the care provided, specifically the assessment of their condition, the suggestion to take part in a group class and a lack of access to pain medication for their migraines. C also complained about the boards response to their complaint.

We took independent advice from a consultant psychiatrist. We found that appropriate assessments were carried out and the working diagnosis was supported by the notes. The suggestion of a class was not unreasonable and C was able to decline to participate in that option. There was limited evidence about the prescription/requests for pain medication. We found the care provided to be reasonable and did not uphold this complaint.

In relation to complaint handling, we found the board did not proactively update C as often as they should have. We also found that the complaint was not fully responded to and the information given about bringing pain medication from home was not accurate. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to handle their complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Staff should ensure complaints are fully responded to and the information given is accurate.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, a support and advocacy worker, complained on behalf of their client (B) in relation to care and treatment provided by the board to B's parent (A). C complained that the board had delayed in performing a CT scan when A presented at Belford Hospital with symptoms associated with a stroke. When a CT scan was performed four days after A's admission, it confirmed that A had suffered a stroke.

C also complained that the board again delayed investigating symptoms suggesting that A had suffered a further stroke when A was re-admitted to Belford Hospital the following month. A CT scan performed three days after A's re-admission showed that A had suffered a new stroke or a worsening of the previous one. C also said that the specialist stroke team based at another hospital had not been contacted for clinical input in A's case.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that, in relation to A's first admission, A was not examined with sufficient care and that the clinicians involved did not act upon symptoms commonly associated with a stroke. As a result, performance of a CT scan had been unreasonably delayed. In relation to A's second admission, we found that A's new symptoms were also inadequately investigated, which led to an unreasonable delay before a further CT scan was performed. We also noted that A's clinical records indicated A's case would be discussed with the specialist stroke team at another hospital but this did not appear to have taken place. We upheld C's complaint but were unable to conclude if A's outcome had been made worse as a result of the shortcomings in the care provided.

When reviewing the complaint, we also found that the board's investigation into C's complaint was unreasonably delayed and that C was not provided with sufficient information about the reasons for the delay or a revised timescale as to when the investigation would be completed.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in performing CT scans following A's admissions to hospital, the failure to fully consider the possible causes of A's stroke and the failure to seek input in A's care from the specialist stroke team. 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 relevant clinicians should reflect on the standard of care and treatment provided to A and give consideration as to where improvements could be made in their practice to ensure that (i) symptoms of stroke are adequately investigated as soon as possible; (ii) once a diagnosis of stroke is made, consideration is given to the possible causes of the stroke in accordance with SIGN and NICE guidelines; and (iii) input from stroke specialists is obtained in clinically appropriate cases.

In relation to complaints handling, we recommended:

• Where a response to a complaint cannot be provided within an agreed timescale, the complainant should be provided with adequate information to let them know the reasons why the timescale cannot be met. In such circumstances, complainants should also be provided with an updated timescale as to when they can expect to receive a response. Where an investigating officer is unable to complete an investigation due to absence through long-term sickness, the complaint should be reallocated to a suitable alternative investigating officer to complete the investigation.

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 actions taken in initiating a child protection assessment following an attendance at A&E at Raigmore Hospital with their young child (A) were unreasonable and excessive. A attended with an oral wound and head injury following a fall. During the attendance C also raised concerns about A bruising easily, which prompted the child protection assessment.

We took independent medical advice from an emergency medicine consultant. We considered that the actions taken were reasonable; both in relation to the presenting injury and the concerns surrounding bruising. We noted that medical staff had a professional obligation to report any child protection concerns, and considered they took appropriate action in this regard.

We also took advice from a paediatric consultant regarding the actions following A's admission to the children's ward. We considered that the actions taken were reasonable and in line with relevant guidance. However, we found elements which could have been better, particularly surrounding the communication with C. There was no evidence of medical staff having discussed with C some of the recorded bruises. We noted that clear communication should take place with parents regarding any injuries that cause concern, so that an explanation can be sought to clarify concerns. We fed this back to the board. However, on balance, we did not uphold this complaint.

Summary

C complained about the care and treatment provided to their parent (A). A was reviewed in the A&E department of a GP led community hospital with epigastric pain (pain or discomfort right below the ribs in the area of the upper abdomen). A felt that the pain was coming from their gallbladder. Tests for a urinary tract infection (UTI) were carried out and A was admitted to a ward for fluids and treatment with an antibiotic. A few days later, the decision was taken to transfer A to another hospital. Further tests carried out there revealed A's gallbladder had perforated causing an abscess on their liver. They were then subsequently diagnosed with gallbladder cancer.

C complained about the care and treatment provided to A at the community hospital. The board said that gallbladder pain usually radiates to the shoulder which was why this was considered unlikely in A's case. A was stable but diagnosis was unclear so they were admitted for observation and antibiotics for a UTI, which had been confirmed on testing.

We took independent advice from an appropriately qualified clinical adviser. We found that A did not have specific clinical features of a UTI and urinalysis was not convincing for a bacterial infection. The clinical presentation of nausea, sweating and epigastric pain accompanied by the finding of the right upper quadrant tenderness was more in keeping with gallbladder pain and infection. We also noted that once A's abnormal blood results were known, the decision should have been taken on that same day (the day following admission) to consider transferring A to secondary care, because their clinical condition and abnormal blood results suggested something that could not be managed properly or adequately in a GP led community hospital. We also found that A was given too much IV fluid during their admission. Given A's known history of heart failure, the administering of fluid should have been regularly reviewed. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failure to acknowledge that A did not have specific clinical features of a UTI and recognising that urinalysis did not indicate bacterial infection; failure to appropriately consider gallbladder pain and infection; administering too much IV fluid during A's admission and for not reviewing this regularly; failure to take A's abnormal blood result seriously; and failing to appropriately consider transferring A to an acute hospital once their blood results were known, given their clinical 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:

• The board should implement clear guidance within the GP led community hospital to make clear who can be admitted along with clarity on the level of care that can be provided. The guidance should include criteria under which transfer to an acute hospital should be considered.
• The board should share this decision with the doctors involved 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 underwent treatment for abnormal cervical changes. Around nine years later, a cervical smear test showed borderline changes and they were scheduled for follow-up six months later. Their next smear showed changes requiring investigation and C was seen for a gynaecology (relating to the female reproductive system) scan, at which the consultant also carried out a colposcopy (a simple procedure used to look at the cervix). Everything appeared normal but taking C's history into account they were followed up six months later. The follow-up smear showed severe dyskaryosis (change of appearance in cells that cover the surface of the cervix), prompting an urgent referral to colposcopy. C was seen six weeks later and was later informed that they had adenocarcinoma (a type of cancer), and required a radical hysterectomy (surgery to remove the uterus) and adjuvant chemoradiation (additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back).

C complained that their history of three abnormal smears in the ten preceding years should have led to a referral to colposcopy after their first abnormal smear. C believes that if they had been referred to colposcopy and had a biopsy taken earlier, the need for adjuvant chemoradiation could have been avoided. They complained that the board failed to take account their medical history when considering whether to refer to colposcopy or take a biopsy. C also complained about the board dropping them from cancer tracking, and about the delay between biopsy and treatment.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that referral to colposcopy was not indicated earlier, explaining that the first smear was the first abnormal smear in a new episode and the recommendation for repeat in six months was in keeping with the cervical screening programme. We also found that C's examination following the second smear was satisfactory and it was reasonable not to carry out a biopsy at that time. We did not uphold these aspects of C's complaint.

In relation to the cancer tracking, the board accepted that C should not have been dropped as, given C's pathology results, they clearly required further treatment. Tracking is carried out to ensure patients are followed up timeously and within national targets. We considered that it was unreasonable to drop C from tracking, and we therefore upheld this aspect of C's complaint.

Finally, we considered that the delay in seeing C for colposcopy following their severely dyskaryotic smear, and further delay between diagnosis and treatment, was unreasonable. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in commencing treatment, recognising the impact this matter had on them. 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 meet national targets for the first appointment following referral with an abnormal smear, and following a positive cancer diagnosis.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board's significant clinical incident investigation and complaint investigation unreasonably failed to identify all the failings regarding the care and treatment provided to their spouse (A). We took independent advice from a general surgeon. We found that the Significant Clinical Incident Review did not identify that:

it was unreasonable that no clinical observations or clinical review took place when A developed an acute onset of pain on the surgical ward;

it was unreasonable that A's case was not discussed earlier with a consultant on the surgical ward; and

it was unreasonable that a request for an urgent CT scan was not made earlier.

We upheld C's complaint in this regard and made recommendations to the board.

C also complained that the board failed to take reasonable action to address the failings identified following the significant clinical incident investigation and complaint investigation. We took independent advice from a nursing adviser with experience of working in and managing an Intensive Care Unit. We found that the board had taken reasonable action to address these failings. While we fully appreciated that actions taken by the board will not change A and C's experience, we were satisfied that learning and improvement had taken place which should prevent the same situations from arising again. We did not uphold C's complaint in this area.

We also considered how the board had handled C's complaint. We found that the board did not provide a revised timescale for when C could expect to receive the response to their complaint and made recommendations to the board in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a clinical observations or a clinical review when A developed an acute onset of pain on the surgical ward, failing to discuss A's case with a consultant earlier on the surgical ward, failing to request an urgent CT scan at the relevant time, and not providing a revised timescale for when they could expect to receive a response to their complaint. 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:

• Deteriorating patients should be escalated to a senior clinician especially in those with ongoing low blood pressure. Where appropriate in these cases, a senior doctor should carry out a physical examination.
• Patients who have an acute onset of severe pain should be reviewed by a clinician and the findings should be documented.
• Significant Clinical Incident Reviews should be robust and, so far as is possible, identify all failings in clinical care to ensure there is appropriate learning and improvement.
• Urgent CT scans should be requested where a diagnosis of ischaemic bowel is being considered.

In relation to complaints handling, we recommended:

• Where the 20 working day timescale for a response cannot be met, the complainant must be kept updated on the reason for the delay and given a revised timescale for completion.

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 adult child (A). A was admitted to the Royal Alexandra Hospital via A&E after four weeks of diarrhoea and vomiting where they were diagnosed with Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). It was suggested for A to have medical treatment with infliximab (a medication used to treat autoimmune disorders) which might prevent the need for surgery. This was prescribed for A and A was discharged to receive the second dose at an out-patient clinic. When A attended the out-patient clinic for the second dose, the hospital would not administer it as A had an existing infection.

A was re-admitted to hospital and a dose of infliximab was given. A was told that as they had not responded to infliximab, the board would perform a sub total colectomy (a surgical procedure to remove all or part of the colon) which would be reversible after 12 months. A had their surgery and a few days later their condition deteriorated and they required emergency surgery. It was found that A had a duodenal peptic ulcer (an open sore inside the lining of the stomach or small intestine) which had burst and caused sepsis (a serious reaction to infection). C complained about the medical and nursing care that A received.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and a nursing adviser. We found that there was a lack of clarity about whether the first infliximab dose was administered, the second dose was unreasonably delayed, there was miscommunication about A's surgery and concerns about how A's condition was monitored overnight when their condition deteriorated. There also was no evidence that a medical/surgical review had taken place when it should have. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for unreasonable care and treatment provided to A, communication failures and the lack of clarity about whether key medication was administered. 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 staff are aware of how the error in communication occurred and how to prevent a reoccurrence.
• The board should reinforce the national guidelines 'Professional Guidance on the Administration of Medicines' RPS & RCN Jan 2010 and local policy 'Safe and Secure Handling of Medicines in Wards, Theatres and Departments' NHSGGC 2008 (currently under review).

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). A was diagnosed with oesophageal cancer (tumour in the tube which connects from throat to the stomach) and later underwent chemotherapy and radiotherapy. Over a year later, A had a CT scan but the results were not reported for around three weeks. The CT scan found evidence that the cancer had spread to the liver. It was no longer possible to cure the cancer and A's care became palliative (managing pain or related symptoms, but not treating the underlying disease or condition). A was admitted to the Queen Elizabeth University Hospital where they later died.

C complained that there was an unreasonable delay in reporting and communicating the results of A's scan. We took independent advice from a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer). The board had accepted there was a delay in formally reporting the CT scan and acknowledged it was a significant failure to report a life changing progression of disease. We upheld the complaint but as the board had already apologised for this error, we did not make any further recommendations. We also noted that the delay in issuing the report did not change the situation for A as the disease was already advanced.

C complained that the board failed to communicate reasonably with A's family during their admission to hospital. We found that there were annotations about discussions with the family in the records and it was routinely noted when family were present. However, there was little in the notes to show what was said or what individuals' concerns were. Therefore, we upheld this complaint.

C also raised a number of concerns about care provided to A during their admission. We found that there were elements of the care provided to A which were not best practice, some of which the board had already acknowledged in the complaints process. However, there were also many elements of A's treatment which were reasonable. On balance, we did not uphold this complaint.

Recommendations

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

• For staff to have the opportunity to reflect on the findings of this investigation.

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 spouse (A) about the care and treatment A received from the board. A has Parkinson's disease (a condition in which parts of the brain become progressively damaged over many years, causing physical and neurological symptoms). A was admitted to the Queen Elizabeth University Hospital with a suspected clot. Staff thought that A had suffered a stroke and physiotherapy was arranged as part of their recovery. Following an MRI, it was found that some of A's vertebrae (the bones of the spine) were displaced and were compressing the spinal cord. A was transferred to a consultant neurosurgeon (specialist in surgery of the brain or other nerve tissue).

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) with a special interest in Parkinson's disease. We noted that A had had Parkinson's disease for 15 years. They had also had surgery to their neck and lumbar stenosis (narrowing of the bone spaces where the nerves leave the spine in the lower back). A was reviewed by the Parkinson's specialist who suggested that a CT brain scan be carried out. This showed a minor change in the brain which could have been consistent with a small stroke. However, a later scan ruled this out. An MRI scan was ordered of the spine and it was following this scan that A's condition was diagnosed.

We noted that A had a complex medical condition and the symptoms they were exhibiting could have come about by a number of different causes. We found that the board worked through reasonable diagnoses and requested appropriate medical imaging. Therefore, we did not uphold the complaint.

Summary

C, an advocate, complained on behalf of their client (B). B's partner (A) was diagnosed and treated for a frozen shoulder (a condition affecting the shoulder, making it painful and stiff with loss of mobility) by the board after attending the emergency department. A's pain and symptoms did not improve so they continued to attend health services. B considered it was unreasonable for A to have been diagnosed with a frozen shoulder based on their level of pain and the board failed to provide reasonable treatment. A's health deteriorated and they were diagnosed with cancer. B said this diagnosis and A's prognosis were not appropriately communicated.

We took independent advice in relation to the complaints.

C complained that the board unreasonably administered a steroid injection to A. We found that A's symptoms were atypical for a frozen shoulder and there were red flag symptoms present. Therefore, the case should have been discussed with the responsible consultant at the clinic and further investigations carried out, prior to a decision on whether the injection should be administered. Therefore, we upheld the complaint.

C also complained that the board failed to diagnose A's cancer in a reasonable timescale. We found that there was a short but unreasonable delay in diagnosing A's cancer. We considered that the actions during most of A's attendances were reasonable. However, they raised concerns regarding no consultant opinion being sought when A attended the emergency department and that there was a missed opportunity to investigate A's atypical symptoms during one of the appointments. We found that there was a lack of clinical ownership for A's case. Therefore, we upheld the complaint.

C also complained the board failed to communicate A's cancer diagnosis in a reasonable manner. There was limited information to consider as the records were not a verbatim account of conversations. We found that there was no evidence to suggest the doctor communicated with A and B in a cold or uncaring manner. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for administering the steroid injection to A and for the delay in diagnosing A with cancer. 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:

• Cases involving multiple specialties should be appropriately managed and atypical signs of frozen shoulder appropriately investigated.
• Registrars should consult with senior clinicians prior to administering steroid injections where there are atypical signs for frozen shoulder.
• Relevant records should be available to clinicians.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all key points raised by the complainant.

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.