Health

Summary

C complained about a consultation with a consultant psychiatrist. During the consultation, C discussed a previous incident where their GP prescribed medication without carrying out a review of C's medical records. Following the consultation, the consultant psychiatrist recommended C be prescribed Mirtazapine (antidepressant medicine). C experienced side effects from the medication and subsequently discovered that their GP's records showed they had been prescribed this medication a number of years previously and had experienced adverse side effects. In light of this, C complained as they did not feel the consultant psychiatrist carried out an appropriate check of C's medication history before recommending that Mirtazapine was prescribed. C also complained about the time taken by the board to investigate their complaint and the thoroughness of their investigation.

In respect of C's first complaint, we took advice from an appropriately qualified independent adviser with a background as a consultant psychiatrist. We found that the course of action taken by the consultant psychiatrist was appropriate and reasonable. We recognised that the decision to recommend Mirtazapine ultimately had a negative outcome for C, but we concluded that the decision-making and process leading to this recommendation was reasonable. We considered the consultant psychiatrist took appropriate action to ensure they had enough information to make an informed decision. In light of this, we did not uphold this complaint.

In respect of the C's second complaint, we concluded that the board had carried out an appropriately thorough investigation, but their responses could have been clearer and more detailed. We also considered the time taken for the board to provide both a stage 1 and stage 2 response was unreasonable. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not handling their complaint in a reasonable or appropriate manner. 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:

• The board should reflect on how the complaint was handled from when it was received to when the stage 2 response was issued. Consider what failings took place during the process and what learning and improvement can be put in place.

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 attended Dumfries and Galloway Royal Infirmary (DGRI) for a colonoscopy (a procedure where a camera on the end of a flexible tube is inserted into the rectum). During this procedure, polyps (tissue growths) were found and biopsies (a sample of tissue) were taken. C was told that a polyp showed possible signs of cancer. A second colonoscopy was carried out and the doctor attempted to remove the polyp, however the procedure was painful and was stopped. C was discharged home the next day.

Soon after, C had a bloody bowel movement and went to Galloway Community Hospital where they were then transferred to DGRI. C collapsed and was resuscitated, given a blood transfusion and moved to critical care.

C complained that the colonoscopy was not carried out properly, that it was painful and asked whether it should have been done in the first place. C also complained about the decision to transfer them from Galloway Community Hospital to DGRI and about the care they received on arrival at hospital.

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 considered that the colonoscopy procedure was required as there was evidence C might have cancer. We noted that pain is subjective and the amount of pain relief given to C may not have been sufficient, although it was the recommended dosage. We found that the procedure appeared to have been carried out appropriately.

We also considered that the decision to transfer C from Galloway Community Hospital to DGRI was reasonable. It was possible that C would need surgical intervention which was only available at DGRI. We found that C was promptly assessed and was treated appropriately following their collapse. We did not uphold C's complaints.

Summary

C complained about the care and treatment of their late partner (A) who died from a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs), secondary to a deep vein thrombosis (DVT, a blood clot in a vein). The complaint related to a GP practice run by the board, which A attended feeling unwell. A was given antibiotics for a suspected infection and a sick note for their employer. A phoned the practice the following week, still feeling unwell, and the antibiotic prescription and sick note were extended. A’s condition deteriorated and they died the following day.

C complained that the GP dismissed the recent history of A's long-haul travel and symptoms indicative of a DVT and misdiagnosed A with an infection. They considered that there was a failure to follow the National Institute for Health and Care Excellence (NICE) guidelines for assessing the possibility of a DVT. C also complained that arrangements were not made for A to be seen when they called the practice the following week. They considered A was denied appropriate follow-up care.

We took independent medical advice from a GP. We found that the recorded symptoms that A presented with were consistent with a diagnosis of infection and not DVT. We considered that the GP’s recorded examination, history and working diagnosis were reasonable at that time.

In terms of A’s follow-up phone call to the practice, we were unable to evidence what was said during the call and whether an appointment was requested. We noted that it is common practice for antibiotic prescriptions and sick notes to be extended without seeing the patient, and we considered that the practice’s actions were reasonable based upon the available evidence. We did not uphold C's complaints.

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.