Health

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.

Summary

C complained about the care and treatment that their late parent (A) received. A had Muir-Torre Syndrome (individuals with this diagnosis are more likely to develop certain types of cancers).

We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), a consultant dermatologist (a doctor specialising in the disease and treatment of the skin, hair and nails) and from a consultant haematologist (a doctor specialising in the disease and treatment of the blood and bone marrow). We found that A received appropriate monitoring and treatment in respect of their Muir-Torre Syndrome. We did not uphold this aspect of C's complaint.

C also complained about the care and treatment that A received for arm pain. We took independent advice from an orthopaedic surgeon (a surgeon specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that a clinic letter was typed two weeks after an urgent appointment and that the time between a scan being performed and potentially receiving the results was unreasonable because it fell outside of the 18 weeks referral-to-treatment standard. We upheld this aspect of C's complaint.

Lastly, C complained about the care and treatment A received for cancer. We found that it was reasonable that no further investigations were arranged to try and identify the primary source of A's cancer, given that A was too unwell for treatment. It was reasonable that A did not receive chemotherapy in the circumstances, and the communication with A and A's family about the possibility of chemotherapy was also reasonable. We did not uphold this aspect of C's complaint.

During the course of our investigation we identified aspects of the board's complaint handling which could have been better; in particular that C was not provided with a written record of the complaint meeting with the board, contrary to the NHS Scotland Complaints Handling Procedure. Also, the board's complaint response did not address all of the concerns that C raised. We made recommendations to the board in respect of their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the length of time taken to type the clinic letter following A's appointment with the Trauma and Orthopaedics service; for the length of time A had to wait for a follow-up appointment with the Trauma and Orthopaedics service; for not providing a written record of the complaint meeting; and for not addressing all the concerns that C raised. The apology should meet the standards set out in the SPSO guidelines on apology available at or www.spso.org.uk/information-leaflets.

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

• In line with Scottish Government standards, where possible, no patient should wait longer than 18 weeks from referral to treatment.
• When a clinic appointment has taken place following an urgent GP referral, a letter setting out the clinic findings and the plan for any diagnostic investigations should be sent promptly to the patient's GP.

In relation to complaints handling, we recommended:

• Responses to complaints must address all areas that the board are responsible for.
• Written records of complaint meetings should be completed and provided to the person making the complaint.

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 planned laparoscopic cholecystectomy surgery (surgery to remove the gall bladder through several small cuts made in the abdomen) at University Hospital Crosshouse and was dissatisfied with the care and treatment they received. C stated that prior to discharge they felt unwell but asserted that their concerns and symptoms were dismissed, their request for review by a doctor was dismissed and they were forced out of recovery for discharge home. C experienced worsening symptoms thereafter and was readmitted to hospital ten days later. C underwent further care and treatment in the hospital setting.

The board said that there were no complications during C's planned surgery or thereafter. C met discharge criteria, so it was appropriate that they were discharged. The board acknowledged that C was readmitted and underwent further treatment but said that the only potential explanation was that a recognised complication arose.

We took independent advice from an appropriately qualified adviser. We found that the standard of C's planned surgery, performed by a registrar, was reasonable and supervised by the consultant. There was no evidence to suggest that the surgery was done without care nor that there were any problems. We noted that complications can occur despite a reasonable standard of surgery. During the immediate postoperative period, the management and provision for C's pain control appeared reasonable; C was regularly reviewed and given adequate pain control with satisfactory support from nursing staff. Despite this, C's symptoms should have prompted a review by a member of the clinical team. However, we noted that nurse-led discharge criteria give broad latitude to judgement on when to call the medical team and give inadequate guidance about when to seek support. On balance, we did not uphold this complaint. However, we provided feedback to the board with suggested improvements to their discharge criteria.

Summary

C complained about the care and treatment provided to their relative (A) during two hospital admissions with the board. C considered that the care that was given to A under the Adults with Incapacity (AWI) Act without consultation with C and their partner was unreasonable, given they were A's guardians. C also complained that the nursing and medical treatments provided to A were unreasonable. C raised concerns about A's arm during their admission and considered that these were not reasonably investigated or responded to.

We took advice from appropriately qualified advisers. We found the board failed to keep reasonable records of the AWI. The board acknowledged that a key piece of paperwork was missing, which suggested that while the assessment had been undertaken, it could not be evidenced. We, therefore, upheld this complaint.

We also found that the board failed to reasonably assess A's capacity. We noted that there were records of some discussion, however there was no evidence that the key paperwork for this was completed. We, therefore, upheld the complaint.

We found that the board provided reasonable treatment to A during their admission. This particularly related to how a cannula (a thin tube inserted into a vein or body cavity to administer medication, drain off fluid, or insert a surgical instrument) was utilised. The adviser considered the use of this was reasonable. It was acknowledged that the cannula shifted, however, this was a known risk and it could not be determined what caused it. Therefore, we did not uphold this complaint.

We found that while there were a number of areas of nursing care which were reasonable, the board failed to provide reasonable nursing care, in particular in relation to the recording and management of A's pressure ulcers. We upheld this complaint.

We found that the board provided a reasonable explanation to C regarding the deterioration of A's arm during their admission. While they could not definitively determine what had occurred, it was reasonable based on the information available. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to keep reasonable records regarding the AWI. 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:

• A patient's assessment of capacity should be clearly documented, along with the wishes of any guardian/POA.
• Nurses should follow the tissue viability nurse's documented plan of care.
• Nurses should follow tissue viability advice or escalate the issue to senior management where there is dispute between a family member and a clinical expert.
• Use of the AWI legislation should be appropriately recorded in patient records.
• Wound charts should have tissue type recorded by percentage.

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 treatment provided by the board's community eating disorder service. They complained about the length of time it took the board to diagnose them and about the various referrals among clinicians involved in their care. C said that their mental health had deteriorated during the treatment period; their eating disorder was exacerbated and they had suicidal thoughts.

We took independent advice from a consultant psychiatrist. We found that C presented with a number of mental health issues and had been managed at times by different teams within the mental health service. Although there was a period during which there was a lack of clarity regarding the overall management of C's care, generally we considered C's treatment to be reasonable and consistent with good practice. We found that the assessment of complex psychiatric presentations, where there is a history of multiple mental health issues, can be prolonged, with diagnosis and treatment modified or refined over time. Therefore, we did not uphold this aspect of C's complaint. We did, however, provide feedback to the board on short-comings identified: failure to obtain permission for a student to attend an assessment, which caused C distress and anxiety, and poor communication in relation to treatment aims during the initial phase of treatment.

C also complained about the board's handling of their complaint. When the board first responded to C's complaint they failed to address most of C's questions. C's MSP became involved and the board then responded in full around eight months after C complained. We were critical of the board's complaints handling, noting that the matters C complained about were of a serious and sensitive nature and the delays in responding added to their distress. Although much of the delay in preparing the response was outwith the complaints team's control, we found that they could have kept C more regularly updated. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable handling of their complaint, with a recognition of the impact the delays had on C. 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:

• Complaints should be handled in line with the Model Complaints Handling Procedure. In the event that designated timescales cannot be met, complainants should be kept updated. Complaints should be responded to fully.

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 spouse (A). A had surgery to remove their gallbladder. A's recovery from surgery was difficult but they were deemed fit enough to be discharged.

However, A had to be readmitted four days later after becoming unwell, and was discharged again two days later. A deteriorated at home and was readmitted two days later and was diagnosed as suffering from a significant bleed. A was taken to the operating theatre but died later that day.

C complained to the board that A's symptoms indicated severe illness, that they were not fit enough to be discharged from hospital and that had treatment been provided sooner, they may have survived.

The board explained to C the complications with the initial surgery, why they considered discharge was appropriate on each occasion and that the source of the bleed could only be identified during the post mortem. The board acknowledged that there had been delays in A being assessed and treated on their final admission. They apologised for the delays and explained they identified learning as a result. The board's view was that given that the type of bleed was very rare, earlier intervention was unlikely to have resulted in a different outcome for A.

We took independent advice from an appropriately qualified clinical adviser. We found that whilst there was complications with the initial surgery, and A's recovery was difficult, the care and treatment provided, including the decisions to discharge A on both accounts, was reasonable.

However, on A's final readmission, there was an unreasonable delay in assessing A, diagnosing that their symptoms were caused by a significant bleed and subsequently moving A to theatre for investigations.

Whilst earlier treatment was unlikely to have altered the outcome for A, this delay was so serious that we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay between A's diagnosis and in A being moved to theatre for further investigations to take place. 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 clinicians and clinical managers should reflect on this case and give consideration as to whether there are aspects of their provision for gastrointestinal bleeds and major haemorrhage pathway which may reduce the likelihood of delays between diagnosis and intervention.

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.