Health

  • Report no:
    201901758
  • Date:
    May 2021
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health

Summary

Mr and Mrs C complained about the standard of care and treatment that Lothian NHS Board (the Board) provided to their child (Child A) in relation to their hearing from June 2012 until January 2018. Mr and Mrs C believed that Child A had a significant hearing impairment from two and a half to three years of age. They complained that this went undiagnosed, despite Child A undergoing multiple tests over a number of years with the Board’s Audiology Service. Mr and Mrs C said that the Board’s failure to diagnose Child A’s hearing impairment within a reasonable timescale affected Child A’s communication skills and, potentially, their ability to learn.

Mr and Mrs C explained that Child A had complex needs, including cerebral palsy and learning difficulties, and was also non-verbal. Child A failed the initial hearing screening test and was referred to the Board’s Audiology Service, who found that Child A may have some mild hearing loss in both ears. Child A was then seen by clinicians at the Board’s Audiology Service several times over the following years, and the audiologists told Mr and Mrs C that they frequently found it difficult to obtain reliable test results due to Child A’s communication difficulties. However, Child A was discharged from the Audiology Service twice as a result of staff being satisfied that they did not have any significant hearing loss.

Mr and Mrs C did not accept the test results, saying that the audiologists were not taking into account Child A’s symptoms and additional needs during testing. Following continued concerns being raised by Mr and Mrs C and Child A’s school, Child A was eventually referred to audiologists at another health board for a second opinion. A number of tests were carried out and Child A was diagnosed with severe to profound hearing loss in both ears. Child A was eight years old at that point. Child A was subsequently fitted with hearing aids which Mr and Mrs C observed appeared to have helped their hearing.

We took independent advice from a specialised audiologist. We found that there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process. We also found significant failings in the Board's investigation of Mr and Mrs C's complaint. The Board failed to identify even the most basic errors in the service they provided, as they should have done as part of their duty of candour, and the standard of their response to Mr and Mrs C was very poor.

We upheld Mr and Mrs C's complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr and Mrs C:

Recommendation number

What we found

What the organisation should do

What we need to see

1

We found there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process.

We also found significant failings in the Board's investigation of Mr and Mrs C's complaint in that they failed to identify even the most basic errors in the service they provided as they should have done as part of their duty of candour and that the standard of their response to Mr and Mrs C was very poor

Apologise to Mr and Mrs C for the failings identified in this investigation and inform Mr and Mrs C of what and how actions will be taken to prevent a reoccurrence.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

A copy or record of the apology.

By: 30 June 2021

We are asking the Board to improve the way they do things:

Recommendation number

What we found

Outcome needed

What we need to see

2

We found there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process

Review the failures in the diagnostic and testing process identified in this investigation to ascertain: how and why the failures occurred; any training needs; and what actions will be taken to prevent a future reoccurrence

Evidence that the diagnostic and testing failings have been reviewed and learning taken from them to improve future service.

By: 19 November 2021

3

We found there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process

Arrange for an external audit of the testing of patients from 2009 until 2018 to be carried out to ensure there is no systemic or individual issue which may have affected other patients, and inform this office of the results

Evidence of the audit and its results.

By: 19 November 2021

4

We found there was a significant and unreasonable delay in the diagnosis of Child A’s hearing impairment resulting from unreasonable, sustained and significant failures in the diagnostic and testing process

Feedback the findings of our investigation in relation to the failures in the diagnostic and testing process to relevant staff for them to reflect on

Evidence the findings of our investigation have been fed back to relevant staff in a supportive manner.

By: 30 June 2021

We are asking the Board to improve their complaints handling:

Recommendation number

What we found

Outcome needed

What we need to see

5

We also found significant failings in the Board's investigation of Mr and Mrs C's complaint in that they failed to identify even the most basic errors in the service they provided as they should have done as part of their duty of candour and that the standard of their response to Mr and Mrs C was very poor

Review the complaint handling failures to ascertain: how and why the failures occurred; any training needs; and what actions will be taken (or since then have been taken) to prevent a future reoccurrence

Evidence that the complaint handling failings have been reviewed and action taken to prevent a future reoccurrence.

By: 30 June 2021

6

We also found significant failings in the Board's investigation of Mr and Mrs C's complaint in that they failed to identify even the most basic errors in the service they provided as they should have done as part of their duty of candour and that the standard of their response to Mr and Mrs C was very poor

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

Evidence that the failure to comply with the duty of candour has been reviewed and action taken to stop a future reoccurrence.

By: 30 June 2021

Related reading

  • Report no:
    201809851
  • Date:
    May 2021
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health

C complained about the care and treatment provided to their spouse (A). A developed Cauda Equina Syndrome (CES, narrowing of the spinal column where all of the nerves in the lower back suddenly become severely compressed) in September 2018. C believed there were avoidable delays in diagnosing and treating A, which meant the damage A suffered was more severe and the outcome worse than it might have been.

A was originally referred to Royal Alexandra Hospital (Hospital 1) by their General Practitioner (GP). C believed that A was displaying red flag symptoms of CES at this point. A attended Hospital 1 on 20 September 2018, but was discharged without consultant review or imaging of their spine.

A continued to deteriorate and attended Hospital 1 again on 28 September 2018 at 09:00 hrs. A Magnetic Resonance Imaging (MRI) scan (a scan using power magnetic fields to generate images of the inside of the body) was carried out at 15:00 hrs. The neurosurgical team at Queen Elizabeth University Hospital (Hospital 2) were contacted, but they declined to accept A for transfer. A was discharged at around 21:00 hrs. They did not have a treatment plan and had not been reviewed by a consultant.

C took A to Hospital 2's A&E the following day. A was admitted to a neurosurgery ward and reviewed by a junior doctor. On 30 September 2018, A was referred for a further MRI by the Consultant Neurosurgeon. A underwent surgery on 1 October 2018. 

A was discharged without any follow-up care being arranged. This was later arranged by their GP. They were admitted a month later as a spinal emergency, and again A was discharged without any follow-up care being arranged.

Relevant to this report was case 2016084301; a public report we issued about the Board previously. This investigation looked into a complaint of unreasonable delays in the treatment of CES by the Board. The investigation found that the Board failed to provide spinal surgery in a reasonable timeframe to the complainant. This was despite clear guidance that surgery needed to be performed as an emergency on an incomplete CES. This also included a failure to provide the complainant with adequate information about their condition or make the necessary referrals for postoperative care.

This report was published in January 2018. The case was closed after the Board provided evidence it had complied with our recommendations, which was largely done by April 2018. This is significant, because A's first attendance at hospital was in September 2018, after the Board was meant to have implemented changes to reduce delays for patients with CES.

We took independent advice from a consultant orthopaedic surgeon and a consultant neurosurgeon. Both advisers identified avoidable delays in A's care and treatment. The orthopaedic adviser said that A had been displaying red flag symptoms of CES when they first attended hospital on 20 September 2018. The delays in scanning A were unreasonable and A's treatment had not been in line with national guidance on the management of possible CES cases.

The neurosurgery adviser said that it was unreasonable for the Neurosurgery Department at Hospital 2 to refuse to provide diagnostic advice, or accept A for transfer on 28 September 2018. A should have been admitted as a neurosurgical emergency and undergone decompression surgery on 28 September 2018. It was also unreasonable to have delayed A's surgery further once they were admitted to a neurosurgical ward.

We found that there were significant failings by the Board in the care and treatment that was provided to A. These included the failure to recognise that A was displaying red flag symptoms of CES, unreasonable delays and incorrect decisions to discharge A, as well as avoidable delays to performing surgery on A, once the severity of their condition had been grasped.

We also found that the Board had failed to investigate C's complaint appropriately or adequately. The Board did not appear to be aware of Public Report 201608430, even though it was closely related to the issues raised by C in this case, and the Board had previously confirmed they had taken action to address the failings identified in that report.

We considered that this case raised significant concerns, given the failings in care and the failure by the Board to identify these, despite their lengthy complaint investigation. This took place within months of the Board having provided this office with assurances that they had taken action to improve the identification and treatment of patients with CES symptoms.

We upheld all of C's complaints.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C and A:

Complaint number

What we found

What the organisation should do

What we need to see

a)

A's care for CES was not in line with the appropriate standards

Apologise to C and A for failing to provide care for A in line with the appropriate standards.

The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets

A copy or evidence of the apology.

By: 19 June 2021

b)

The Board's actions resulted in an unreasonable delay in admitting and treating A

Apologise to A for the unreasonable delay in admitting and treating them.

The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets

A copy or evidence of the apology.

By: 19 June 2021

c)

The Board have not explained why A was discharged on 28 September 2018

Apologise to C and A for failing to provide an adequate explanation for the decision to discharge A.

The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets

A copy or evidence of the apology.

By: 19 June 2021

d)

The Board failed to refer A to the appropriate specialisms for ongoing care, resulting in further delays to their treatment

Apologise to C and A for failing to refer A to the appropriate specialisms for ongoing care resulting in further delays to their treatment.

The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets

A copy or evidence of the apology.

By: 19 June 2021

e)

The Board failed to handle C's complaint reasonably

Apologise to C and A for failing to handle their complaint reasonably.

The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets

A copy or evidence of the apology.

By: 19 June 2021

We are asking the Board to improve the way they do things:

Complaint number

What we found

Outcome needed

What we need to see

a), b) and c)

A's incomplete CES was not recognised as a neurosurgical emergency

Relevant staff understand the standard operating procedure, based on the British Association of Spine Surgeons guidelines for the care and management of CES, and provide appropriate treatment in line with it

Evidence of staff knowledge of the standard operating procedure, including guidance for staff and an explanation of how its application will be monitored.

By: 19 July 2021

a), b) and c)

A's referral from the Orthopaedic Department to the Neurosurgery Department was not fully documented

Document referrals to the Neurosurgery Department accurately and comprehensively by medical staff in the Orthopaedic Department

Evidence the Board are monitoring the documentation of referrals to ensure they are comprehensive and accurate.

By: reporting monthly for the next six months

a), b) and c)

Orthopaedic staff were unclear what to do when A's referral to Neurosurgery was refused

Orthopaedic staff should have a clear procedure to follow when a referral is declined by the Neurosurgery Department

Evidence of a clear procedures, including an explanation of how the Orthopaedic and Neurosurgery Department have collaborated in its creation.

By: 19 August 2021

a) and b)

A's surgery was unreasonably delayed

Surgery for CES must be performed within recommended timescales

The Board must evidence they have systems in place to ensure that patients are operated on within reasonable timescales and that these are being monitored on a monthly basis for the next twelve months.

By: 19 June 2021

d)

No referrals or aftercare arrangements were made for A

Discharge should be planned with prompt referral to appropriate services. The Board should ensure that patients have the appropriate referrals made to community based services to support their care on discharge from hospital. This should include the transfer of care plans with the patient, where appropriate, to ensure continuity and consistency of care

Evidence the Board have taken steps to address the difficulties in providing coordinated care for CES patients and that the effectiveness of these measures is monitored on a monthly basis.

By: 19 June 2021

We are asking the Board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see

e)

The Board's complaint investigation failed to identify that treatment of CES by the Board had been the subject of a public report a matter of months before A's case

To ensure the Board has effective complaint monitoring arrangements in place to identify when a new complaint concerns the same issues or clinical matters (CES in this case) as previous complaints, and that the relevance of outcomes and learning from previous cases are considered, as appropriate, in any new investigation

Evidence the Board have effective complaint handling and monitoring systems in place.

By: 19 August 2021
e) The Board's Morbidity and Mortality meeting was unreasonably delayed and did not involve all relevant staff Morbidity and Mortality meetings should be held timeously and should involve representatives of all specialisms involved in a patient's care

Evidence that Morbidity and Mortality procedures require the involvement of all relevant specialisms.

By: 19 July 2021
e) The Board failed to properly implement their duty of candour Appropriate implementation of the duty of candour, in line with General Medical Council guidance

Evidence that the need to apply the duty of candour has been fed back to staff in the Orthopaedic and Neurosurgery teams in a supportive manner.

By: 19 June 2021

The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:

Complaint number

What we found

What the organisation should do

What we need to see

a)

The Board said they had already taken steps to ensure that patients with possible CES were not discharged without their case being discussed with an orthopaedic consultant first

Provide evidence that it has been monitoring the effectiveness of these measures

Evidence showing the procedural changes implemented by the Board, as well as the mechanisms in place for monitoring them.

By: 19 June 2021

Related reading

  • Case ref:
    201902491
  • Date:
    March 2021
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Communication / staff attitude / dignity / confidentiality

Summary

C, a support and advocacy worker, complained on behalf of their client (A). A is profoundly deaf and British Sign Language (BSL) is their first language, and so A relies upon BSL interpreters when attending medical appointments. A requested a gender specific interpreter for a GP appointment but when they arrived they found that the interpreter was not the gender they had requested. The interpreter had to leave the room when A required an intimate examination and they were unable to communicate with their GP during this time. C said A felt that they had not been treated with respect and dignity.

We found that A did not receive the level of service they could reasonably expect from the board which led to difficulties in accessing general practice services and significant distress. The failings in the service provided included an unreasonable delay in the provision of an interpreter, misleading information about the status of interpreters, lack of a gender specific interpreter, and an inadequate risk assessment. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to A 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/informationleaflets.

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

  • Ensure that the level of service provided meets the requirements of patients with additional needs to enable them to fully access all services within a healthcare setting.

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.

Related reading

  • Case ref:
    201900740
  • Date:
    March 2021
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment they received at Ninewells Hospital. C was diagnosed with a small renal (kidney) cyst a number of years ago. This was treated at the time, but C complained that it was not subsequently monitored. They later developed a mass in their abdomen that weighed nearly three kilogrammes when it was removed several years later. C considered that the board delayed in operating when C was referred to the urology team (specialists in the male and female urinary tract, and the male reproductive organs) and that there were further delays in providing treatment when they were later diagnosed with cancer.

We took independent advice from a consultant urological surgeon and 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 C's renal cyst was incorrectly categorised as simple, when in fact it had the features of a complex cyst with a risk of malignancy. This should have required a referral to urology for active surveillance or surgical resection at that time. Therefore, we upheld this complaint.

In relation to the delay in operating following a referral to urology, we found that a discussion at a renal multi-disciplinary team meeting and then clinic review and a consent discussion were appropriate when C was subsequently diagnosed with a large left renal mass. We did not uphold C's complaint that the board's urology team had delayed in operating at that time.

Finally, we found that C had a very rare form of renal cancer and that the matter was complex because the final diagnosis was not clear. We did not identify any unreasonable delay in C's diagnosis and treatment of cancer. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the failure to correctly categorise the cyst. 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:

  • Cysts of this nature should be categorised correctly.

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.

Related reading

  • Case ref:
    201900199
  • Date:
    March 2021
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Communication / staff attitude / dignity / confidentiality

Summary

C, a support and advocacy worker, complained on behalf of their client (A). A, whose first language is British Sign Language (BSL), was admitted to Perth Royal Infirmary with concerns about their heart and lungs. During their admission, A's spouse (B) had to translate for them, which they found extremely difficult as B is severely deaf and BSL is their preferred method of communication. C said that this was contrary to the board's policy on their interpretation and translation service and showed a lack of deaf awareness.

We took independent advice from a specialist in equality. We found a number of failings that had an impact on the board's ability to meet A's communication requirements effectively which caused distress to A and B. These failings included misleading information about the level of the interpretation translation service provided to patients and staff; and that the level of the aforementioned service was inadequate and not in line with the board's policy. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to A for the failings identified in this investigation and inform C of what and how actions will be taken to prevent a future reoccurrence. The apology should meet the standards set out in the SPSO guidelines on apologyavailable atwww.spso.org.uk/information-leaflets.

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

  • Ensure the board's Interpretation and Translation Policy is implemented effectively by clinical staff.

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.

Related reading

  • Case ref:
    201810152
  • Date:
    March 2021
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Appointments / Admissions (delay / cancellation / waiting lists)

Summary

C was referred to the board's urology service (specialists in the male and female urinary tract, and the male reproductive organs) via an urgent referral due to suspected cancer. C was diagnosed with transitional cell carcinoma (a type of cancer that typically occurs in the urinary system). C underwent laparoscopic (keyhole surgery) nephroureterectomy (a surgical procedure to remove the renal pelvis, kidney and entire ureter, along with the bladder cuff). C then had follow-up appointments and treatment. C complained about delays in diagnosis, in surgery, in follow-up appointments and treatment, along with poor communication from the board.

We took independent advice from a consultant clinical oncologist with specialised urology oncology practice. We found that the board failed to meet the Cancer Waiting Time (CWT) standards with regards to the 62-day timescale from referral to treatment, and the 31-day timescale from decision to treat to treatment. Since C's complaint, the board have taken a number of actions to improve waiting times within the urology service and their communication about waiting times. We considered that the actions the board had already taken were comprehensive and we did not make further recommendations to the board to improve the way they do things. However, we recommended that the board apologise for the failure to meet the CWT standards. As a result, we upheld this aspect of C's complaint.

C also complained that the board's handling of their complaint was unreasonable. We found that the board did not acknowledge C's complaint within the timescales set out in the Model Complaints Handling Procedure, and did not always update C with revised timescales as to when C could expect a response to their complaint. In addition, the board did not reply to two letters from C, sent in reply to the board's response to C's complaint. As a result, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for failing to meet the Scottish Cancer Waiting Time (CWT) standards regarding the timescale for C to begin treatment, failing to acknowledge C's complaint within three working days, failing to provide C with a revised timescale for when they could expect to receive a response to their complaint and for failing to acknowledge or respond to two of C's letters. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.

Related reading

  • Case ref:
    202003555
  • Date:
    March 2021
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C, an advocacy and support worker, complained on behalf of their client (A) who was admitted to University Hopsital Hairmyres with delirium which was found to be caused by a urine infection. A was seen by a doctor who firstly detained them for 72 hours under the Mental Health Act. When the time period ended the detention period was extended to 28 days. A was then transferred to another hospital where the staff did not feel that there was a requirement for the detention and it was rescinded. A felt that the decision to detain them was not clinically required and that the hospital failed to carry out an appropriate mental health assessment on their admission to hospital.

We took independent advice from a consultant psychiatrist. We found that an appropriate mental health assessement was carried out based on A's symptoms. We found that although A did have a urine infection which would have caused their delirium, there was sufficient clinical indication that A was suffering from a mental health problem and that there were grounds to detain them under the Mental Health Act.

We did not uphold the complaint.

Related reading

  • Case ref:
    201911174
  • Date:
    March 2021
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment provided to their child (A) by the dermatology service at University Hospital Hairmyres regarding skin lesions. In particular, C was concerned about the length of time taken to refer their child to paediatric dermatology at a children's hospital, that this referral was not marked as urgent and antibiotics or a steroid cream were not prescribed earlier. We took independent advice from a consultant dermatologist. We found that the length of time taken to refer A to paediatric dermatology was not unreasonable in the circumstances. It was reasonable that the referral to paediatric dermatology was routine rather than urgent given A's clinical presentation, that antibiotics were not prescribed earlier as there was no indication of increased swelling, pain and increasing size or progression of the lesions, and that topical steroids were not prescribed in the absence of a definite clinical diagnosis. We did not uphold C's complaint about the care and treatment provided to A.

C also complained about the way the board handled their complaint. We found that one of the board's complaint responses did not address all the points raised by C. We upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for failing to address all the points they raised in the complaint response. 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:

  • Complaint responses should address all the points raised.

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.

Related reading

  • Case ref:
    201908410
  • Date:
    March 2021
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C are asthmatic and suffer from chronic obstructive pulmonary disease (COPD). C was referred to the board by their GP due to a flare up of COPD. C was reviewed by a locum consultant respiratory (relating to or affecting the action of breathing or the organs associated) physician at Monklands Hospital. C was concerned that the decision was made to change their inhalers from Relvar and Incruse to a Trelegy inhaler. C said that this caused their condition to flare up and resulted in their breathing becoming laboured.

We took independent advice from a consultant in respiratory and general internal medicine. We found that a clinic letter from a few years earlier did not make it clear that a diagnosis of asthma (in addition to the confirmed diagnosis of COPD) was suspected nor list the medication with doses that C was receiving. We noted that the lack of clarity regarding C's suspected diagnosis and treatment resulted in C's GP and subsequent hospital consultants not being aware that C had a possible diagnosis of asthma and was on the higher steroid dose of Relvar. Based on the information known to the consultant at the time, it was reasonable to consider combining the Relvar and Incruse inhalers in to a Trelegy inhaler. However, there was no evidence in the records that the change in medication was explained to C in a reasonable way. In particular, we noted that the possible risks and benefits of this change were not explained to C so that they could make an informed choice about whether to make the change.

In these circumstances, we considered it was unreasonable for the board to substitute the medication C was taking for their respiratory condition (Relvar and Incruse) with a Trelegy inhaler. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for failing to make it clear that a diagnosis of asthma was suspected or list the medication with doses that C was receiving on the clinic letter and for failing to make C aware of the possible risks and benefits of changing their inhalers so that C could make an informed choice about whether to make the change. 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:

  • Changes to inhalers should not be recommended without discussing the risks and benefits with the patient first.
  • Clinic letters should clearly list confirmed and suspected diagnoses and treatment (including type of dose).

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.

Related reading

  • Case ref:
    201900799
  • Date:
    March 2021
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment a family member (A) received in Monklands Hospital prior to their death. C raised particular concerns that nursing care was not delivered proactively and that the family had to continually ask for care to be provided, including catheter care, oral care, nutrition and pain management. A suffered a fall while in hospital and C also raised concerns about the adequacy of the medical assessment which was carried out following this.

We took independent advice from a nursing adviser. We found that the nursing care was reasonable overall, with appropriate care rounding evidenced in the records. This covered catheter care, pain management and general care. However, we identified an unreasonable two-hour delay in commencing appropriate medication for pain and agitation due to medical staff being unavailable to prescribe. We also identified that prescribed oral care was not administered as prescribed, and that person-centred care planning did not reflect A's needs with regards to oral hygiene and end of life needs. We considered that this contributed to A's noted discomfort in the final days of their life and, on balance, we upheld this complaint.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) regarding the medical assessment which followed A's fall. We noted that a thorough and well-documented assessment was carried out which concluded that A had sustained minor injuries only and that no scans or further investigations were required. We did not consider there was a clear connection between the fall and its follow-up and A's subsequent deterioration. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the delay in commencing appropriate medication for A's pain and agitation; the failure to administer oral care as prescribed; and for the failure to update the person-centred care plan to reflect A's needs. 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:

  • Person-centred care plans should be updated at every shift change to capture person-centred needs. The board should carry out a review of person-centred care planning in the relevant ward.
  • The board should investigate why medical staff were unavailable to prescribe timely medication for pain and agitation. Measures should be put in place to prevent this happening again; and the board should demonstrate compliance with the Scottish Palliative Care Guidelines 2013.
  • Treatment should be administered as prescribed, or a code entered in the medicine kardex to indicate why this has not been administered. Ward staff should be reminded, in a supportive manner, of their responsibilities and the policy for the administration 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.

Related reading

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