Health

Summary

C complained about the care their parent (A) received during an admission to Queen Elizabeth University Hospital. A was admitted following a fall at home and had a further fall in hospital, resulting in a fracture to their right shoulder. C complained that A’s fall in hospital could have been prevented, if ward staff had followed the board’s falls prevention protocols, had correctly assessed A’s risk of falls and had taken appropriate measures to ensure their safety on the ward.

We took independent advice from a nurse. We found the record-keeping was unreasonable and not of the required standard in relation to the assessment and prevention of A’s fall and also the incident reporting of the fall. The falls risk assessment was completed within the stipulated policy timescale of 24 hours from admission. However, the decision not to undertake this during the immediate admission appeared to have been taken by a student nurse without oversight from a registered nurse. We found no evidence to confirm what interventions, besides bed rails, had been put in place to prevent A from falling.

The incident report of the fall lacked clarity and consistency. The incident was initially miscategorised as minor and was not updated to serious when the fracture was diagnosed, so the relevant escalation and review was not triggered. The board indicated that a review had subsequently taken place, but we saw no evidence of this or of the learning and improvement derived from it. The adverse event review findings were not discussed or shared with C, as they should have been in keeping with national Being Open in NHS Scotland guidance. We upheld this complaint. We also found that the board did not respond to C’s complaints in a timely and robust manner.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the identified inadequacies in record-keeping surrounding A’s fall; for the lack of supervision of the student nurse who assessed A; for failing to share with C a copy of their adverse event review; and failing to investigate C's complaint in a timely and robust manner. 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 review their performance with regard to the Being Open principles to ensure that appropriate systems are in place to share the outcome of incident reviews with patients and family members.
• The board should review their procedures to ensure accurate reporting, and appropriate review and investigation, of adverse events.
• The board should review their record-keeping in this case to ensure that nursing staff are meeting the standards required of them in this respect.
• The board should take steps to ensure that appropriate supervision of student nurses is 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 complained about the care and treatment provided to their late parent (A) during an admission to Aberdeen Royal Infirmary. C complained that during the admission, they did not see A being provided with nebulisers (a device which helps to moisten the airways; or allow medicine to be administered as a vapour) or oxygen therapy. C also felt that A was not given appropriate pain relief, particularly towards the end of their life, and that A’s condition and potential outcome were not explained to C and their family.

We took independent advice from a consultant in acute medicine. We found that the management of A’s need for oxygen was reasonable. The evidence that had been provided suggested that A was receiving regular nebulisers, however there was no medication record to confirm this and this was unreasonable.

There was no evidence that A was in unrelieved pain towards the end of their life and the prescription of medication and documentation regarding this matter was reasonable.

We considered the timing of the conversation with A’s family regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) was likely reasonable, but some of the documentation around this conversation was not reasonable.

On the basis of the lack of evidence regarding the prescription of nebulisers, and poor documentation of the initial DNACPR conversation, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide a record of the nebulisers prescribed for A; and for the lack of documentation around the initial Do Not Attempt Cardiopulmonary Resuscitation conversation.nThe 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:

• DNACPR conversations should be documented with an appropriate level of detail.
• There should always be complete records of prescribed medication.

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 advocate, complained on behalf of their client (A). A was given a diagnoses and later the board provided A with a second opinion. During the consultation the board say A became angry and behaved in a threatening way. The board said they would be happy to offer treatment to A, but this would be dependent on A following a set of recommendations. A said that during the second opinion consultation they were being called a liar, and while they raised their voice, they were not threatening. A told us that they had tried to meet the board’s recommendations, but that the board would not accept that they complied with the recommendations made.

We took independent advice from a consultant psychiatrist (a doctor who specialises in the diagnosis, treatment and prevention of mental ill health conditions). We found that the board’s response to A’s behaviour was reasonable and in line with NHS policy. We did not uphold this aspect of the complaint. The recommendations the board made to A were reasonable. Due to A’s diagnosis, treatment would be most successful if A was able to make some changes to their behaviour. We did not uphold this aspect of the complaint.

Summary

C complained about the care and treatment provided to their late parent (A) who died from an aggressive and complicated form of cancer. C considered that there was a lack of urgency in the board’s actions and there was no clear plan for A’s treatment.

The board confirmed that they carried out a number of investigations and referred A’s case to the National Sarcoma Team in order to seek their view. Further tests were requested and a referral was made to the Acute Pain Service. The board said that while no definitive diagnosis was reached, there had been a plan to pursue radiotherapy; however, A’s condition quickly deteriorated and they died.

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 the treatment plan of A’s condition was reasonable and we did not consider there was a lack of urgency. However, we concluded that, at the point when significant changes were observed in a scan compared to a scan performed some months prior, the board should have held a local multi-disciplinary team (MDT) discussion and/or referred to a cancer of unknown primary (CUP) (where the place cancer began is not known) MDT to discuss A’s case. This may have resulted in a more faster and possibly would have led clinicians to concentrate more on pain relief. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to hold a local MDT and/or refer to a CUP MDT at the point the significant changes were observed in the scan. 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:

• Clinical managers should reflect on this case with regard to whether there was a missed learning opportunity at the point the significant changes were observed in the scan.
• The board should give consideration to how they could strengthen their multi-disciplinary teams to enable them to meet more regularly to discuss cases with different specialists.

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 provided to their parent (A) after A suffered an unwitnessed fall. C said that A had deteriorated continuously from this point, whilst the board said that A had not shown any significant signs of distress until later, when they began to deteriorate significantly. A was transferred to Forth Valley Royal Hospital, where they were found to have fractured ribs and a pneumothorax (collapsed lung). C did not believe that A was examined quickly enough after their fall and considered it unreasonable that the examination had failed to identify the serious injuries A had sustained.

We took independent medical advice. We found that A’s care and treatment fell below a reasonable standard. There was an excessive delay in providing A with a medical examination and there was inadequate investigation of A’s subsequent symptoms. In addition, A’s mental deterioration and existing diagnosis of dementia were not taken into consideration in the assessment of their condition or in the communication with their family.

We upheld both of C’s complaints on the basis that A’s care and treatment was not of a reasonable standard. As the board had concluded staff had followed the board’s procedures after A’s fall, we found that these procedures were not adequate and required review.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A’s care and treatment.
• Apologise to C for the procedural inadequacies identified by 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:

• National Early Warning Score monitoring should be increased when appropriate, demonstrating that the patient’s condition and medication have been taken into account.
• Pain in patients with cognitive impairment should be managed effectively, taking their impairment into consideration.
• Possible delirium should be identified and investigated.
• Staff should be aware of the potential for a typical presentations of acute illness in frail older people and when further investigation should be considered.

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 child (A). A was admitted to the Neo-Natal Unit at Forth Valley Royal Hospital due to prematurity and respiratory (the branch of medicine that deals with conditions affecting the lungs) distress and was a few weeks later admitted to the Children’s Ward. A was later diagnosed with cardiac (heart and its blood vessels) conditions. A underwent open heart surgery at the Royal Hospital for Children but later died.

C complained that the care and treatment provided to A was unreasonable because there were missed opportunities to diagnose A’s cardiac condition and that, had it been diagnosed earlier, there would have been a positive outcome.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth) and from a consultant in respiratory medicine. We found that overall the care and treatment was reasonable. In particular, there was no evidence that would suggest A’s heart condition had been missed in the neonatal period. We also found that, based on the available evidence, it was not possible to say conclusively that there had been an unreasonable delay in diagnosing A’s cardiac condition from a paediatric perspective. We did not uphold the complaint.

Summary

C was admitted to the Queen Margaret Hospital where they were detained under an Emergency Detention Certificate (EDC). C complained about the nursing care provided during their admission. They said that staff did not interact with them or show them around the ward; they did not receive adequate food; they did not have clothes or toiletries; and that staff searched their bag and removed medication.

The board said there were attempts to offer food to C, however this was sometimes refused. They said there was evidence of good nursing care provided to C and that they did attend for meals. The board confirmed C’s bag was not searched and that they do not hold a supply of clothing for patients.

We took independent advice from a mental health nurse. We found that, while some aspects of the nursing care provided to C were reasonable, there was no evidence that a nutritional screening tool was used to assess C’s nutritional state, and this should have been done within the first 24 hours of admission. We concluded the board failed to adequately assess and record C’s nutritional needs and, as such, the nursing care was below the standard expected. We upheld C's complaint.

Recommendations

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

• The board should take steps to ensure that nutritional care is in line with national standards, and in particular that all patients are subject to nutritional screening within 24 hours of admission.

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 to the practice about a consultation they had. They said that they reported symptoms of severe pain and swelling of the abdomen and that they were grey in colour and had difficulty standing up. C said the practice prescribed them with laxatives (medication to help increase bowel movements). C continued to deteriorate and days later was admitted to hospital as an emergency, where it was found they had perforated diverticular (diverticula are small bulges or pockets that can develop in the lining of the intestine as you get older) disease. C said they had to undergo emergency surgery and were an inpatient for a month. C felt that the practice should have diagnosed their serious condition and arranged an urgent hospital admission.

We took independent advice from a medical practitioner. We found that the GP involved had carried out an appropriate examination based on C’s presenting symptoms and that a diagnosis of constipation was reasonable. There was no clinical indication that C’s health was going to suddenly deteriorate with severe diverticular disease and that they would require a hospital admission. We did not uphold the complaint.

Summary

C complained about the care and treatment their ex-partner (A) received from the board during a hospital admission. A was taken to hospital after self-harming. They had also written a suicide note, which was taken to hospital with them. After being assessed by psychiatric clinicians, it was decided that A did not require hospital admission for psychiatric observation or detoxification. It was also concluded that A showed no evidence of a specific plan or intent to carry out suicide and did not present with a mental illness. A was discharged that day but completed suicide the following day.

C complained to us about the general care and treatment provided to A and the fact that they were discharged home. In addition to this, C complained that they were not informed that A had been admitted to and discharged from hospital, given that they were still A’s next of kin.

We took advice on this complaint from an appropriately qualified adviser with a background as a consultant psychiatrist. We found that staff carried out an appropriately detailed assessment of A and made decisions that were in line with relevant guidance, based on the information available to them at the time. The board had previously acknowledged that the suicide note had not been reviewed by the clinicians who attended A and we agreed that this was a shortcoming. However, despite the outcome, we were satisfied that the board had provided a reasonable and appropriate level of care and treatment to A overall. Therefore, we did not uphold this aspect of the complaint.

In respect of whether C should have been notified of A’s admission and discharge, we concluded that the board’s actions were reasonable. Although C was listed as A’s next of kin, A was living with their father at the time. It was reasonable for the hospital to conclude that A’s father was the most appropriate point of contact at that time. Therefore, it was reasonable for the hospital to discuss matters with A’s father rather than with C. With this in mind, we did not uphold this aspect of the complaint.

Summary

C, an advocacy worker, complained to us on behalf of their client (B) about the care and treatment the board provided to B's spouse (A). During our investigation, we took independent advice from an adviser in respiratory and internal medicine.

In 2011, A's GP referred them to the board, after an x-ray showed irregularities in their lungs. For around two years, A was followed up at the respiratory medicine clinic with chest x-rays. Medical staff concluded the lung irregularities were unlikely to be cancerous and A was discharged. Around that time, A was diagnosed with rheumatoid arthritis (a long-term condition that causes pain, swelling and stiffness in the joints). In late 2017, A was diagnosed with small cell lung cancer at Ninewells Hospital that had already spread to their liver. A died shortly afterwards.

C complained that between 2011 and 2013, the board failed to diagnose A with lung cancer. We found A was given appropriate follow-up with chest x-rays and it was reasonable the lung irregularities were not considered to be cancerous. We did not uphold this complaint.

C complained that between 2013 and 2017, A was experiencing symptoms of lung cancer that were wrongly attributed to rheumatoid arthritis. We found that it was reasonable A was diagnosed with rheumatoid arthritis. We found A had not reported cancer related symptoms at their rheumatology reviews. We also found that as small cell lung cancer is very aggressive, the symptoms would usually develop over months and not years. We did not uphold this complaint.

C also complained that A's discharge letter from Ninewells Hospital was unreasonable, as it contained incorrect information about A's condition. The board acknowledged there was an error in the discharge letter. We found the discharge letter was unreasonable due to the error and we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings in the board's complaints handling. 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' discharge letters should contain accurate information about their condition and the outcome of investigations.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Model Complaints Handling Procedure (MCHP). The MCHP and guidance can be found here: https://www.spso.org.uk/the-model-complaints-handling-procedures.

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.