Health

Summary

C complained about the care and treatment their late partner (A) received during two consecutive admissions to Dumfries and Galloway Royal Infirmary. A had a number of existing medical problems and spent around four weeks in hospital, including 18 days in critical care, before being discharged. C complained that A was inappropriately discharged with pneumonia, and required readmission 12 hours later. A spent almost a further three weeks in hospital before being discharged again, and died two months later. Whilst in hospital, A developed a severe pressure ulcer. C complained that nursing staff failed to take reasonable measures to prevent the pressure ulcer from developing.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that A’s suitability for the first discharge was assessed over a number of days and blood tests and basic observations did not indicate an underlying pneumonia at that time. We considered that it was reasonable for A to be discharged and we did not uphold this aspect of C's complaint.

We also took advice from a tissue viability nursing specialist (a nurse who provides advice and care to patients with, or at risk of, developing wounds). We found that, while the risk of pressure damage was identified and care prescribed to mitigate this, this was not adhered to. Risk assessment, skin inspections and repositioning were not carried out as often as required, and the pressure ulcer was initially graded incorrectly. Inappropriate dressings were also used and there was a delay in providing a pressure relieving mattress. 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 pressure area care to A. 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 take steps to ensure staff are competent in pressure area care, with particular focus on the deficiencies identified in A’s care, and that they are aware of current best practice/adhere to the board’s own guidance (Active Care Prescribing Sheet & Wound Assessment Chart) as well as Healthcare Improvement Scotland’s Prevention and Management of Pressure Ulcer Standards (2016).
• The board should take steps to review why pressure relieving equipment was not readily available in this case and address any system failure which contributed to this 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 brought a complaint to us about the care and treatment given to their late parent (A) at Dumfries and Galloway Royal Infirmary. C complained that there was a lack of communication between staff and the family throughout A’s treatment. In particular, they said that the severity of A’s illness was not explained to A or the family. C stated that the family remained unclear about the specifics of the cancer A had, that there had been no reaction to A’s early symptoms and that A was advised about their diagnosis by phone with no offer of support provided. C also complained that the administration of A’s medication was unreasonable; in particular, that there was inadequate pain control and that no one took overall control of A’s care and treatment. During the board’s own investigation of the complaint, they accepted that A should not have been advised of their diagnosis by phone, and an apology had been given for that. The board had also indicated this was an area for reflection and learning.

We took independent advice from a consultant hepatologist and gastroenterologist (a doctor who cares for patients with benign or malignant disorders of the gastrointestinal tract, liver, pancreas and gallbladder). We found that while there was some learning for the board in relation to aspects of communication, the overall care and treatment given to A was reasonable. While we did not uphold the complaint, we asked the board to provide evidence of the action taken to ensure alternative methods of communicating a diagnosis to a patient had been considered.

Summary

C complained about the care and treatment their relative (A) received from the board; in particular, about the mental health care they received at Borders General Hospital following an impulsive overdose and their subsequent community health care.

The board’s investigation found that A’s care and treatment was appropriate and timely. However, the board suggested exploring possible improvements in information sharing between public and private sector professionals.

We took independent advice from a consultant psychiatrist and a mental health adviser. We found that the hospital care and treatment, including changes to A’s medication were reasonable and appropriate. We considered that there was a shortcoming in care as there was no follow-up out-patient hospital appointment after the discharge from hospital to assess A, despite a significant change in their medication and a new diagnosis. However, we did not consider this was an unreasonable failing given there was a plan for care by community psychiatric nursing who would have had access to psychiatric advice as and when required. We did not uphold this complaint.

In terms of the community mental health care, we were critical that A did not receive a face-to-face assessment even though multiple concerns were raised by various individuals about A’s deteriorating behaviour; and particularly given A had not made themselves available to be seen. For this reason, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to carry out a face-to-face assessment following concerns that were raised by multiple individuals. 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 with Community Mental Health Team follow-up who show evidence of a significant deterioration in mental state or social circumstances, or where a significant deterioration in mental state is indicated by the expressed concerns of family or significant others, consideration should be given to having a face-to-face review and screening for presenting clinical risks/vulnerabilities.

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 they received from the practice. C said that they were ill and had been discharged from hospital following a diagnosis of pancreatitis (inflammation of the pancreas). C saw a GP twice in one month, who diagnosed gastric issues and prescribed Peptac (medication for heartburn/indigestion). C said that they continued to worsen and saw the GP again, who again felt the problem was gastric issues and increased the dosage of Omeprazole (medication for heartburn/indigestion). C said that their condition again worsened and two days later C was admitted to hospital as an emergency where it was found that they had a pancreatic infection, and C remained as an in-patient for some weeks. C felt that their concerns had been dismissed and that, had appropriate treatment been given, their condition would not have been so severe or life-threatening.

We took independent advice from a GP. We found that the practice had provided appropriate care and treatment in view of C's reported symptoms and medical history. There was no clinical requirement that C should have been admitted to hospital at an earlier date. We did not uphold the complaint.

Summary

C, an advice and support worker, complained on behalf of their client (A). A suffered an industrial injury, with a steel beam falling on their head and shoulder. A had been receiving various forms of treatment since, including cortisone injections (an anti-inflammatory steroid injection used to treat a range of conditions), physiotherapy (a therapy to restore movement and function) and surgery. However, A was concerned that they did not receive any treatment for their head injury. A also considered that there were unreasonable delays in providing treatment and that communication with them had been unreasonable.

We took independent advice from a consultant orthopaedic surgeon (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that the treatment received and communication had been reasonable, with the exception of a problem with a referral for physiotherapy, which the board had already identified as part of their own complaint investigation. In addition, there was no evidence that A had complained of a head injury on first attending. We did not uphold C's complaint.

Summary

C complained about the clinical care provided to their child (A) by the board, specifically, that a Chiari malformation (where the lower part of the brain pushes down into the spinal cord) was visible on a magnetic resonance imaging (MRI) scan performed by the board and that the abnormality was not noted until they insisted on a further MRI scan being carried out many years later.

A suffered from a number of symptoms including headaches, tinnitus (ringing or buzzing in the ears), vertigo (a sensation of loss of balance or that objects around you are spinning) and drop attacks (sudden falls to the ground) for a number of years. A had MRI scans performed by the board to try to determine the cause of these symptoms. A had a further MRI scan performed by a different health board and it was found that A had a Chiari malformation.

We took independent advice from a consultant 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 that it was reasonable to ask only about a possible tumour, and that it would not be possible to make a definitive diagnosis of Chiari malformation from the first MRI images. We concluded that the MRI scan performed then was performed and reported to a reasonable standard. We, therefore, did not uphold the complaint.

Summary

C was an in-patient in a general adult psychiatry ward at a hospital outwith the Lothian NHS board area. A referral was made to transfer C and their baby to the Parent and Baby Psychiatric Unit at St John's Hospital but this was refused. C said that they were finding caring for their baby difficult in an adult environment and complained that the refusal was unreasonable.

We took independent advice from an appropriately qualified adviser. We found that the decision not to approve the transfer was reasonable from a clinical perspective. We did not uphold the complaint.

Summary

C complained on behalf of their late sibling (A). A was admitted to hospital to have their pacemaker and the leads, which attach it to the heart, extracted. There was a 2-3% risk of major bleeding and A signed a consent form for the procedure. During the operation, the surgeon successfully removed one of the pacemaker leads but whilst attempting to remove the final two, A's blood pressure suddenly dropped. This was recognised by the anaesthetist and the major haemorrhage protocol was activated. An emergency call for surgical assistance was placed. Despite chest compressions and fluids, staff were unable to stop the bleeding and A died. When the surgeon had tried to remove one of the leads, a tear had been created in one of the major veins around the heart. C complained that the surgery had not been carried out to a reasonable standard.

We took independent advice from a consultant cardiologist (a doctor that specialises in diseases and abnormalities of the heart). A's pacemaker, at several years old, would be well embedded in scar tissue. There was infection at the site, and the device was pushing through the front wall of A's chest. There were other options for treating this, but laser lead extraction was the best option for a long-term recovery. The operation appeared to have been carried out reasonably, with staff taking prompt and appropriate action when A's blood pressure dropped. There was nothing more the staff could have done to save A's life once the bleed occurred.

We did raise concerns about the consent process. We noted that A had signed a consent form on the day and the risk of major bleeding was noted. However, the board should have used a more detailed consent form with other fields, including alternative treatment options, and that consent should have been obtained prior to the day of surgery as well as the day of it. On balance, we did not uphold the complaint as the evidence indicated that the standard of A's surgery was reasonable.

Summary

C has an adopted child who has a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). A's behaviour is so challenging that both parents fear A will cause serious harm to themselves or to them.

C wished A to be prescribed medication for their ADHD, but Child and Adolescent Mental Health Services (CAMHS) said that they required to carry out a face-to-face assessment before medication could be prescribed. They said they were unable to offer this at present because of COVID-19 restrictions. C considered that A needed urgent input, but the board said that A's need was not considered urgent. The board said that they would see A as soon as they were able to. C complained that the board had failed to assess A's need for CAMHS treatment as urgent.

We took independent advice from a consultant child and adolescent psychologist. We considered that A's need for treatment had been appropriately assessed with reference to COVID-related criteria. We did not uphold C's complaint.

We were, however, critical of the delays in assessment of A's condition and commented that, were it not for these delays, A should by now have had the opportunity of psychiatric review and clinical treatment.

Summary

C had concerns about the care and treatment they received in the A&E at Raigmore Hospital. C had experienced a headache and visual disturbance. After initially attending their GP practice, C was taken to A&E by ambulance. Shortly after arriving at the hospital, C was assessed by a doctor. Later that evening, a CT scan (computerised tomography - a scan that uses x-rays and a computer to create detailed images of the inside of the body) was performed and this showed that C had experienced a type of stroke (a serious medical condition that happens when the blood supply to part of the brain is cut off).

C had concerns that assumptions were made about the timing of the onset of their symptoms. C also considered that there was a delay in them receiving a CT scan, which prevented thrombolysis (a treatment involving a drug that aims to disperse the clot and return the blood supply to the brain. Not all stroke patients are suitable for this treatment). C was also unhappy that the stroke team were not immediately involved in their care.

We took independent advice from an emergency medicine consultant. We found that the history obtained, examination and investigations performed in the emergency department were reasonable. We did not identify a delay in performing a CT scan and we found that the rationale for not offering C thrombolysis treatment was reasonable. Finally, we found it was reasonable that the stroke team were not involved with C's care at the time of admission. We concluded that C received reasonable care and treatment and we did not uphold this aspect of the complaint.

C was also unhappy with the board's investigation and response to their complaint. We were satisfied that all aspects of the board's complaint handling were in accordance with the NHS Scotland Complaints Handling Procedure. We did not uphold this aspect of the complaint.