Health

Summary

C complained about the care and treatment provided to their late spouse (A) by the board in relation to the diagnosis, treatment, and management of A's cancer, especially regarding a delay in A receiving a Positron Emission Tomography scan (PET, a scan that produces detailed 3D images of the inside of the body). We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that A's cancer pathway took 17 months, which was significantly longer than it should have taken. We found that the most significant issue for the delay in the process was the error which resulted in the PET scan not being booked, as requested by the multi-disciplinary team (MDT). Additionally, the PET scan should have been requested on a suspected cancer pathway and we were critical that this was not the case.

We found that the delay in A's diagnosis was unreasonable and on balance, due to the increase in size of A's tumour during the delay, it is likely this negatively impacted on their outcome. We considered that the care and treatment A received from the board was unreasonable and upheld this aspect of C's complaint.

C also complained about the out-of-hours service (OOHS). A developed a postoperative wound infection, and was admitted to hospital. C complained that the OOHS, who saw A prior to admission, requested a non-life-threatening response from the Scottish Ambulance Service (SAS), rather than a life-threatening ambulance. We took independent advice from a GP. We found that the OOHS GP requested the ambulance in line with the SAS guidance, and any delays in the ambulance attending were outwith the GP's control. Therefore, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable 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:

• MDT requests for investigations, booking of investigations, results being shared, and follow-up MDT discussions should be actioned as soon as possible in cancer pathways.
• Patients and their family should be appropriately involved in discussions regarding their condition and management and these discussions should be recorded in the patient's notes.
• Requests from MDTs should be emailed directly to the clinicians to be actioned, rather than being sent to the gastrointestinal secretaries to be passed to the consultants.
• Where cancer is being considered as a strong possibility within the differential diagnosis, a PET scan should be requested on a suspected cancer pathway.

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 told us that their spouse (A) had been under the care of a cardiologist (a specialist that deals with diseases and abnormalities of the heart) who saw them at least once a year for review appointments following surgery, until their death twenty years later. A scan taken six years before their death showed a chronic dissection of the descending thoracic aorta (a serious condition in which there is a tear in the wall of the major artery carrying blood out of the heart). Clinicians decided to manage A's condition conservatively, but C told us neither they nor A were aware of this or the findings of the scan. C was also concerned that clinicians failed to carry out regular scans to monitor A's condition until shortly before their death and that communication between different specialists had been poor.

We took independent advice from a consultant cardiologist. We found a number of failings that had an impact on the board's ability to monitor A's condition which in turn meant that their treatment plan was not fully informed. These failings included: lack of records relating to A's operation and x-rays which made interpretation of later scans more difficult; lack of follow-up on whether additional imaging and/or cardiac opinion was needed following the scan showing the dissection; results of a CT colonoscopy (a procedure that uses a CT scanner to produce detailed images of the colon and rectum) were not shared or acted upon. We also found that communication between the relevant healthcare professionals was not as effective as it should have been given A's complex clinical condition. We upheld both of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. 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:

• Ensure communication between clinicians from different specialisms is effective.
• Ensure record-keeping by healthcare professionals is of a reasonable standard.
• Ensure that significant test results are followed up appropriately.
• Feedback the findings of our investigation in relation to further tests and referrals to other specialists to relevant staff for them to reflect on.

In relation to complaints handling, we recommended:

• Ensure board investigations identify and address incidents covered by the duty of candour with the relevant Scottish Government guidance.

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 about the standard of medical and nursing care and treatment provided to their client (A) during A's hospital admissions at Victoria Hospital and Cameron Hospital over 11 months. The concerns raised cover numerous aspects of the care and treatment provided by clinicians at A&E and the intensive care unit at Victoria Hospital, and clinical staff at Cameron Hospital. These include unreasonable failures in relation to the response to A's deterioration, medication including dosage, communication, bedsores, rehabilitation, and discharge. C also said that the board failed to handle A's complaint in a reasonable way. C told us that as a result of the failings, A developed complications which have had a profound impact on them and their spouse's life.

We took independent advice from four advisers: consultants in emergency medicine, psychiatry and anaesthesia, and a nurse specialist in tissue viability. We found that A had not been regularly reassessed as they should have been in A&E for a number of hours during which time their condition deteriorated and their transfer to the intensive care unit was delayed, and that staff in A&E failed to communicate with A's spouse in a reasonable way. We found that clinicians failed to take reasonable action to prevent hospital-acquired pressure damage to A and then failed to investigate and treat A's pressure ulcers, which led to severe and extensive pressure damage to a degree rarely seen in today's healthcare setting. We noted that this was avoidable and that the board's failure to identify these failings in their subsequent review was very concerning. We also found that the board's response to the complaint about A's condition and its cause did not reflect the evidence from the clinical records and advice obtained from specialists. We upheld five of C's complaints.

We did not find failings in relation to medications, communication from clinical staff in intensive care, transfer, handling of A by nursing staff at Cameron Hospital, rehabilitation care and treatment and discharge. We did not uphold eight of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines onapology 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.
• Ensure patients are regularly assessed so that any deterioration is noted and respond to appropriately and within a reasonable time.
• Review the clinical failings to ascertain: how and why the failings occurred; any training needs; and what actions will be taken (or since then have been taken) to prevent a future recurrence. Before doing so, the board should consider why their previous review failed to identify the failings and ensure that the methodology of this review is robust and that whoever undertakes it is appropriately qualified, objective and impartial.

In relation to complaints handling, we recommended:

• Ensure all complaint responses are accurate and reflect the available evidence and information.

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

Mr C complained about the board's weight management service at Queen Margaret Hospital. In the course of our investigation, we took independent advice from a bariatric surgeon (a doctor who specialises in the causes, prevention and treatment of obesity).

Mr C complained that the service refused to offer him bariatric surgery after he attended a weight management programme. We found that the board provided an inadequate reason for not progressing Mr C to the next stage of the pathway, where patients are considered for surgery, and considered that this decision was unreasonable. We found that the board did not give appropriate consideration to Mr C's individual circumstances in making their decision and had failed to offer a second opinion or appeal process. We upheld Mr C's complaint and made a number of recommendations.

Mr C also complained that the board had informed him of their decision not to progress in a public setting, where other patients could overhear. We carefully considered Mr C's account and the board's account of what happened. We were unable to reconcile the differences, and we did not find evidence to conclude that clinicians had failed in their duty to maintain patient confidentiality. Therefore, we did not uphold this complaint.

Finally, Mr C was also unhappy with the way the board handled his complaint. We found that there were short delays in the board informing Mr C about the timescales for responding to the complaint. We also found that the board had not communicated accurately with Mr C about a case conference that was initially offered to him. We noted that the board had apologised for the confusion in relation to this. We upheld this complaint and provided feedback to the board about complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for deciding that he could not progress to Tier 4 of the Bariatric Surgery Pathway solely because he had not lost 5% of his body weight and for not giving reasonable consideration to his other conditions and his weight loss prior to commencing the programme. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide Mr C with an opportunity to seek a second opinion or appeal the decision in respect of his progression to Tier 4 in light of SPSO's findings and taking into account his current circumstances.

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

• Patients should be considered for Tier 4 of Bariatric Surgery Pathway in accordance with the Scottish best practice guidelines and individual circumstances should be taken into account.
• Patients should receive a letter detailing the reasons for failure to progress to Tier 4 which should be in line with Best Practice Guidelines. A second opinion or appeals process should be available to the patient if required.

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 their late relative (A) received at Dumfries and Galloway Royal Infirmary. A reported that they did not feel well, had difficulty pronouncing words and were a little confused. A then had a fall at home before being taken to hospital.

A was treated for a chest infection but died the next morning. C raised a number of concerns regarding the care that was provided and the staff's attitude towards A and C.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that A's initial assessment was reasonable; they were appropriately examined, their medical history taken and their existing medication noted. However, we noted that an x-ray taken to help with diagnosis showed appearances that were more consistent with heart failure than a chest infection. From the available evidence, it appeared that A was incorrectly diagnosed as having a chest infection, commenced on a suboptimal treatment pathway and left without being monitored effectively overnight. The true nature of A's condition was only identified when the consultant attended the next morning. A died shortly afterwards.

Whilst clinically the outcome may not have changed for A, had C had accurate information about their condition, they may have been better placed to support A. We considered that the care and treatment fell below a reasonable standard and upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable 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.

In relation to complaints handling, we recommended:

• That the board share this decision with the staff responsible for A's care to ensure that any points of learning are identified and acted upon.

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 they received at Dumfries & Galloway Royal Infirmary, after they had fallen and hurt their leg. C raised various concerns about how their injury was diagnosed and their discharge home.

We took independent advice from an adviser in emergency medicine. We found C was given appropriate care and treatment in relation to their injury. We also found it was reasonable C was discharged home. Therefore, we did not uphold the complaint.

Summary

Mr C was concerned about the care and treatment that his late wife (Ms A) received at Dumfries and Galloway Royal Infirmary.

Mr C complained that his wife was misdiagnosed with pneumonia when she initially attended the Clinical Assessment Unit. We received independent advice from a consultant in acute medicine. We found that the investigations carried out during this attendance were reasonable. We also found it was reasonable to treat Ms A for a suspected infection based on the history, examination and investigations, while arranging a CT scan on an out-patient basis to investigate Ms A's symptoms further. We did not uphold Mr C's complaint regarding this point.

Mr C complained about the delay in reporting an x-ray carried out during this attendance at the Clinical Assessment Unit. We took independent advice from a radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found an unreasonable delay in reporting a chest x-ray and we upheld Mr C's complaint in this regard.

Ms A was subsequently diagnosed with lung cancer and a few months later was admitted to the hospital with worsening shortness of breath. Mr C complained about the care and treatment that his wife received during this third attendance at the Clinical Assessment Unit. We received independent advice from a consultant in acute medicine. We found that there should have been earlier consideration to administering IV fluids and IV antibiotics to Ms A given that her low blood pressure and high heart rate were indicative of sepsis (blood infection). We upheld Mr C's complaint about the care and treatment provided in the Clinical Assessment Unit on Ms A's third attendance.

Mr C also complained about the care and treatment that Ms A received on the respiratory ward at Dumfries and Galloway Royal Infirmary. We took independent advice from a consultant physician in respiratory and general medicine We found that the medical care and treatment was reasonable and did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained about the nursing care provided to Ms A. We took independent advice from a nursing adviser. We found that Ms A's catheter bag was not emptied regularly, there was a delay in Ms A receiving a pressure mattress and the syringe driver was not checked every four hours which was contrary to the guidance that a minimum of four-hourly checks should be carried out within in-patient settings. We upheld Mr C's complaint about the nursing care that Ms A received.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in reporting the chest x-ray and for not giving earlier consideration to administering IV fluids and IV antibiotics to Ms A given that her low blood pressure and high heart rate were indicative of sepsis. 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:

• Checks on syringe drivers should be carried out four hourly as a minimum within in-patient settings in accordance with the relevant guidelines.
• Consideration should be given to administering IV fluids and IV antibiotics to patients who have low blood pressure and high heart rates.
• X-rays should be reported without undue delay.

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 care and treatment they received from the board was unreasonable. C was added to the general surgery waiting list for gallbladder removal via keyhole surgery. The board determined that C would require an Intensive Care Unit (ICU) bed booked for the time of surgery, in case the operation needed to be converted to open surgery. C waited several months for surgery, and the board stated that this was due to a high level of demand for hospital services, including ICU beds. C eventually underwent surgery but did not improve postoperatively and developed a wound abscess (a painful swelling caused by a build-up of pus) and sepsis (blood infection). The abscess was drained, and C was treated with antibiotics. C raised concerns that there were unreasonable delays to their initial surgery, which allowed their condition to deteriorate. C also complained that there was not enough care taken during their two surgeries and they developed sepsis, which they considered could have been avoided.

We took independent advice from a consultant general surgeon and a nurse. We found that the sequence of events, the management of C's booking for surgery, the preoperative assessment, C's medical state, and the anaesthetic view did not support the board's statement that the delay in C's operation was due to lack of ICU beds. In addition, we found that the board failed to meet the Treatment Time Guarantee in C's case and to properly advise them of this under the relevant regulations. We considered that the delays C experienced were unreasonable.

With regard to C's surgery and postoperative infection, we found that the initial surgery and the surgery to drain their abscess was carried out appropriately. The diagnosis and management of their sepsis postoperatively was also reasonable. However, we found that there was a lack of documentation to demonstrate that medical staff discussed C's condition and management with either C or C's partner and this was unreasonable. As a result, we upheld 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:

• Patients who have been admitted as an emergency, as in C's case, and require to be seen in an out-patient clinic for clinical assessment prior to surgery should receive a timely appointment.
• The board should take all reasonably practical steps to manage patients scheduled for gallbladder surgery without delay and in line with the Treatment Time Guarantee with appropriate assessment of risk for ICU beds.

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 which their late partner (A) received when they attended A&E at University Hospital Ayr. C was concerned about A's colour as they had an alcohol problem, but A was discharged by a doctor who said that an in-patient stay was not required. C felt that A should have been admitted for further assessment or treatment. C took A to their doctor a few days later as A continued to show symptoms, and they said the GP was also concerned that A had not been admitted to hospital. A died ten days after the A&E attendance and C felt that had staff taken appropriate action then A would have been more comfortable in the final stages of their life.

We took independent professional advice from a consultant in emergency medicine. We found that there were a number of failings identified at the A&E attendance which included a failure to establish the cause of A's bleeding and what their blood coagulation (clotting) status was. There were also failings in record-keeping and communication. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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:

• Staff should ensure that a full investigation is carried out in regards to a patient's reported symptoms and that record-keeping and communication are completed to the required standards.

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 given by the board to their late parent (A). They made a formal complaint to the board to which the board replied two and a half months later. They were unhappy with the reply and wrote again.

A had been admitted to Ayr Hospital where they were diagnosed with sepsis. They had previously had a heart valve replacement and were taking Warfarin (blood-thinning medication) on a long-term basis for which they required regular International Normalised Ratio checks (INR; checks used to monitor the effectiveness of the medication), especially when they were taking antibiotics.

C believed that during A's admission they were not properly cared for, that inadequate tests and investigations were carried out and that their previous medical history was not taken into account. Staff showed no sense of urgency when A's condition deteriorated.

C noted that A was allowed to deteriorate to the extent that they could not be treated and that they died as a result.

The board's view was that on admission, all of A's symptoms and history were taken into account and that they were treated reasonably, promptly and appropriately throughout.

We took independent advice from a consultant physician and cardiologist (specialises in dealing with disorders of the heart), who identified that A's INR levels were not checked in accordance with the board's standard Warfarin prescription, given that A had been prescribed new medication following the diagnosis of sepsis. When A's INR levels were subsequently checked again, they were found to be rapidly rising before being brought under control two days later. However, A's INR levels were again recorded as being too high within days, at which time A began to display symptoms of delirium. A scan of A's brain was arranged and that confirmed A had suffered a cerebral haemorrhage (bleeding from a ruptured blood vessel in the brain). A later died. Whilst it could not be said with certainty when the bleeding started, we found that the INR levels were likely to have contributed to the brain haemorrhage that A suffered prior to their death. We found that the failure to check and closely monitor A's INR levels was unreasonable and therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Formally apologise to C for their failure to follow standard Warfarin prescription guidance. 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:

• Relevant staff should be aware of and apply Standard Warfarin Prescription guidance.

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.