Health

Summary

C, an independent advocate, complained on behalf of their client (B). B’s adult child (A) died from an overdose of dihydrocodeine (opioid prescribed for pain or severe shortness of breath). A had been prescribed a number of different medicines by their GP practice including painkillers and benzodiazepines (depressants).

B complained that the practice did not appropriately manage the risks of prescribing A such medication. B questioned why prescriptions were issued to A on a monthly basis, rather than weekly or even daily. B also complained that the practice had insufficient regard to A’s history of overdoses and that A should not have been given additional prescriptions on request, as had happened on multiple occasions. Lastly, B was concerned that A had remained with the practice despite having moved a significant distance away.

In their response to the complaint, the practice stated that weekly or dispensing does not necessarily prevent the hoarding of medication, and that A had been maintained as patient due to their local GP being staffed primarily by locum doctors lacking a familiarity with A’s situation. They said that while they were aware of A’s overdoses these were often also due to alcohol or illegal drugs. The practice said that they felt A’s requests for additional medication had been genuine and that they needed to balance the risk that A would seek illicit drugs or street medication if suffering from withdrawal. The practice also stated that following this incident they had reviewed their approach to such patients and had recently refused a number of requests to keep on patients living remotely.

We took independent advice from a GP. We found that the kinds of medication prescribed to A are implicated in many drug related deaths, often in combination with other substances such as alcohol. Taking into consideration A’s history, their mental health, alcohol misuse and history of multiple drug overdoses, early prescriptions should not have been given to A and instalment dispensing should have been used to reduce risk. We also found that the evidence did not suggest that A remaining as a patient with the practice had kept them safe, and had influenced the decision not to provide weekly dispending. While it was not possible to say whether this decision had contributed to A’s death, overall, the practice had not provided A with reasonable care and treatment with regard to their prescription medication and on this basis, we upheld B’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings identified in A’s care and treatment with respect to the prescription medication issued to A. 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.

Summary

C’s parent (A) was admitted to the hospital and diagnosed with a urinary tract infection (UTI) and sepsis. A was transferred to the acute medical unit (AMU) that night and died later the next day. C was concerned about the care and treatment provided to A.

C raised a number of complaints with the board regarding the care and treatment that A received, including the provision of oral care. The board accepted that there had been issues with the prescription and administration of anticipatory medication and the care provided to A, and outlined steps that would be taken to prevent any recurrence. C was dissatisfied with the board’s responses and actions and raised their concerns with SPSO.

We took independent advice from a nursing adviser. We found that the investigation already carried out by the board, and the steps taken to address the areas for improvement identified were reasonable and did not require further investigation by the SPSO. However, we found that the action taken did not address the issue of the provision of oral care to A and investigated this matter further.

In responding to our enquiries, the board accepted and apologised that there had been issues with A’s oral care during their admission. Therefore, we upheld the complaint that the board did not provide A with reasonable oral care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not provide A with reasonable oral care. 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:

• Training is delivered to all relevant nursing staff in the Acute Medical Unit regarding mouthcare in palliative care. This should include structured educational or awareness sessions covering common mouth problems in such care (dry mouth, painful mouth, infections, bad breath, changes in taste and drooling).

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 on behalf of their spouse (A). A was taken into hospital with COVID-19 and low blood sugar and was discharged after two days. That night C was concerned that A’s condition had deteriorated. A was taken to ICU and died 4 days later. The cause of death was recorded as COVID-19, ketoacidosis (where a lack of insulin causes harmful substances called ketones to build up in the blood) and renal failure. C considered that A had been discharged inappropriately in the first instance.

The board explained that A was frail. They came into hospital with chest pains from COVID-19 and were checked for pulmonary embolism. A was discharged appropriately but unfortunately deteriorated rapidly at home. Every effort was made to treat A on readmission.

We took independent advice from a consultant physician, specialising in acute medicine. We found that A had a poor state of health prior to admission, that their discharge on the first occasion was reasonable and that there was no way the discharging team could have predicted A’s subsequent deterioration. Upon A’s second admission, medical teams and intensive care teams provided a reasonable standard of management and care. Overall, we considered that the care and treatment had been reasonable and that there was no requirement for a Severe Adverse Event Review or Duty of Candour to be initiated. Therefore, we did not uphold the complaints.

Summary

C complained about the care and treatment that they received from the dentist during a period of eight months. C is a bariatric patient and is unable to recline due to their medical condition. C attended for an examination with the dentist and complained of a broken front tooth and decay on the upper left second molar. Treatment options were discussed and it was agreed that at the next visit, the dentist would apply fillings to both teeth.

C attended for treatment to both teeth 11 weeks later. The dentist explained to C that a referral to the Public Dental Service (for individuals who cannot access an independent dentist) would likely be the best option going forward as they were unable to gain proper access to treat C. C agreed to a referral and the next examination was scheduled for six months’ time. C attended for an emergency appointment six weeks later, complaining of pain. The tooth was filled and the dentist made a referral to the Public Dental Service, resending it six weeks later.

C emailed complaints to the practice on two occasions but did not receive a response to either.

C attended for a further examination complaining of ongoing pain. Treatment options were discussed and the dentist booked C in for an appointment for treatment.

C emailed the practice to ask for a response to their previous two complaint emails. C was advised by the practice to speak with the dentist during their appointment the following day. However, C decided to cancel future treatment as they had lost faith in the dentist.

C received a complaint response from the dentist and contacted the practice the following day to express their dissatisfaction with the response. The dentist issued a further response in an undated letter. C wrote to the practice again and the dentist subsequently issued a further letter to C saying that they believed they had already addressed all of C’s concerns.

In considering C’s complaint, we took independent advice from a dentist. We found that overall, the care and treatment provided to C by the dentist was reasonable and that there was no unreasonable delay in referring C for treatment. We did however find that C’s complaints were not appropriately identified and responded to in line with the complaint handling procedure and upheld this complaint. We also provided feedback to the dentist in relation to communication.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. 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 dentist should ensure complaint investigations conform to the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. They should review their handling of this complaint with a view to identifying areas for learning and improvement.

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 they received from the board. C underwent a left total hip replacement but returned to the consultant orthopaedic surgeon for follow-up three months later as they were continuing to experience pain and mobility problems. C complained that they were told there was nothing the surgeon could do for them. C sought a second opinion and learned that they had impingement (pinching or rubbing together inside a joint) which would require further surgery. C said that they had been significantly impacted by the initial surgery, both mentally and physically.

In their original complaint response, the board acknowledged the poor outcome of the surgery. Following our formal enquiry the board acknowledged that a different choice of acetabular (socket) implant would have been appropriate. The surgeon acknowledged that this case was one where they would have benefited from advice from a more experienced surgeon. They accepted that they had failed to discuss with C that a poor outcome from surgery was a risk, and failed to document decision making and consent discussions in C’s clinical records. They apologised for failings in communication with C during their post-operative consultation. They also apologised for record-keeping failings. The board said they should have discussed this case at a departmental Morbidity and Mortality meeting once it became clear that there were ongoing problems requiring further surgery. They considered that not doing so represented a failure of process, prompting them to review their relevant structures and processes. The board confirmed comprehensive measures to address what had gone wrong in C's case.

We took independent advice from a consultant orthopaedic surgeon (specialists in the musculoskeletal system). We concluded that the board had now appropriately acknowledged the multiple failings in this case, apologising and confirming extensive learning and improvement. Taking all of this into account, we upheld C's complaint and asked the board to apologise but did not make further recommendations for learning and improvement.

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.

In relation to complaints handling, we recommended:

• Complaints are investigated with sufficient rigour to identify failings where appropriate. Complaints handling procedure timescales are met.

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 nursing care and treatment provided to their late parent (A). A had a fall during an admission to hospital. Their condition deteriorated and a large intracranial (brain) bleed was identified. A died shortly after. C complained that the nursing staff provided unreasonable care and treatment as they did not put the correct safety measures in place, given A's frailty and instability on their feet.

The board said that A was reviewed by physiotherapy who assessed A as being safe and able to mobilise independently with a walking stick. The board said that nursing staff carried out care rounding and that A was checked 30 minutes prior to their fall. Following the fall, it was noted that A was able to get up with assistance and an assessment was completed by nursing staff. When checked later, it was found A had become unconscious. The board carried out a scan of A’s head and found a large intracranial bleed.

We took independent advice from a registered nurse. We found that there was a lack of documentation and documented evidence of action taken by staff in response to cognition and mobility. Care rounding documentation was not completed to a reasonable standard or carried out to the prescribed frequency. When A’s needs changed, the care rounding was not increased. We found that the nursing staff failed to complete the mobility risk assessment, consider the use of bedrails and identify A required more help when their condition changed. We noted that the care provided by nursing staff when the fall happened and after the fall was reasonable.

We also found that the Significant Adverse Event Review that was carried out after the fall was not carried out in line with national guidance. The Duty of Candour process should have been followed in this case and it was unclear from the documentation whether this had been activated or not. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified by the 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:

• SAERs should be completed in line with the national framework and the board’s own protocols.
• Assessments, evaluations, and intervention bundles should be completed in line with guidance. Nursing documentation should include evidence of action taken due to changes observed, such as, change in cognition, change in mobility, use of oxygen, and factors that may impact safety such as the ability to use a call bell.
• The frequency of care rounding required for a patient should be prescribed and recorded accurately in the care rounding documentation. Once prescribed, the care rounding should be completed within the frequency identified. This should be recorded in the documentation to demonstrate care rounding has happened. Frequency of care rounding should be reflective of need. When there are changes in need, the frequency prescribed should change to meet the patients needs.

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 partner (A) who was admitted to hospital due to abdominal pain, severe lower back pain, weight loss and reduced appetite. A CT scan identified a left hepatic vein thrombosis (a blood clot in the vein draining the liver). A was commenced on anticoagulant (blood thinning) medication. A further CT scan showed that A had new thrombus in the portal vein (the main vein draining into the liver). Following discussion with haematology (specialists in conditions of the blood), A’s anticoagulation medication was changed.

Several days later A complained of a headache and vomiting and was given pain medication. The following morning A was found to be unresponsive by nursing staff. Levetiracetam (an anticonvulsant medication) was administered and A was taken for a CT scan which showed extensive intracerebral haemorrhage (bleeding into the brain tissue). Protamine (medication that partially reverses the effects of the anticoagulation medication) was administered and advice sought from neurology (specialists in conditions of the nervous system) who said that on review of the scans, the extent of the bleeding was not survivable. A died shortly after.

C complained that the board unreasonably failed to warn A of the risks of anticoagulation medication and unreasonably administered protamine and levetiracetam shortly before A's death. C complained that the board unreasonably failed to include anticoagulation medication on the death certificate and failed to communicate to A’s family that it was a cause of death.

We took independent advice from a consultant in acute medicine. We found that the use and timing of both levetiracetam and protamine was reasonable. We did not uphold this part of C's complaint. However, we found that the board failed to warn A of the risks of the anticoagulation medication before commencing the treatment. We also found that the board unreasonably failed to include the anticoagulation medication on the death certificate and failed to communicate that it was a cause of death to A’s family. Therefore, we upheld these parts of A'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 inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients prescribed anticoagulation medication should be given appropriate information on the risks and benefits of anticoagulants, in line with relevant clinical guidance and this should be clearly documented within the patient records.
• Relevant information about a patient’s death should be effectively communicated to their family.

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, a support and advocacy worker, complained on behalf of their client (A) that the board unreasonably prescribed A with Flutiform (a type of medication to treat asthma). A presented to hospital with symptoms of severe asthma and was admitted to the high dependency unit for management of their symptoms. Following assessment, A was prescribed with Flutiform. A’s symptoms improved and they discharged themselves from hospital.

A complained that Flutiform worsened their symptoms and should not have been prescribed, as they had previously suffered adverse reactions and informed the nurse of this during their assessment at the hospital. In their response to the complaint, the board said that Flutiform was prescribed in line with relevant guidelines and that there was no record of A having indicated that they had previous adverse reactions to Flutiform.

We took independent advice from a consultant physician in respiratory medicine. We found that whilst there is some record that Flutiform had not worked well for A, there was no evidence of an allergy in the clinical records. Whilst A recalled that they raised concerns about the use of Flutiform during the assessment, the contemporaneous assessment records, clinical records available at the time, and relevant guidelines supported the conclusion that there was no evidence against prescribing Flutiform to A. Therefore, we did not uphold C's complaint.

Summary

C complained about the delay in the practice diagnosing their parent (A)'s cancer. C said that A was seen by a GP with recurring chest infections but was sent away with antibiotics and their initial requests for a chest x-ray were denied. When the x-ray was arranged and the results received by the practice, the GP did not contact A directly to discuss the results. Instead, A received a copy of the report from the reception staff, which was not easy to understand. C said the communication issues regarding the x-ray also led to a delay in an urgent prescription for antibiotics being passed to a pharmacy. C said that the delays in diagnosis limited the treatment options available to A.

C complained that the practice failed to reasonably investigate A’s respiratory symptoms. We took independent advice from a GP. We found that while the majority of the care provided to A was reasonable, there was a missed opportunity to refer A for an x-ray, given their symptoms and the lack of success with previous treatments. Therefore, we upheld this part of C's complaint.

C also complained that the practice failed to inform A of the results of the x-ray in a reasonable manner. We found that the x-ray report should not have been provided to A by reception staff and the findings should have been shared in person or over the phone with the GP, including all relevant information. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to consider a referral for a chest x-ray sooner and for failing to provide the findings from the x-ray in a reasonable 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:

• Clinical staff should communicate with patients in line with GMC guidance in relation to sharing the findings of investigations.
• Patients are referred for further investigations in a timely manner, in line with NICE guidance on suspected cancer: recognition and referral.

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 on behalf of their child (A) about the care and treatment A received prior to their surgery. They complained that some procedures had been carried out during the surgery without parental consent. They also said that A had not been examined prior to the surgery and that they had been left with unnecessary scarring. The board stated that written consent had been provided on the day of the surgery and the clinical notes recorded the procedures to be carried out and the risks of surgery had been explained at that time. The board also stated that A had been examined. However, they apologised if the verbal discussion prior to the operation had not prepared C for the outcome and also apologised if some of the scarring following the surgery was unsightly.

We took independent advice from a consultant paediatric urologist (specialist in children's urinary and genital problems). We found that the evidence suggested that the signed consent form had been read by C prior to the surgery and that no unnecessary procedures had been carried out. While there were no records to prove or disprove that A had been examined on the day of the surgery on balance we considered it was likely that A had been examined preoperatively. Although ideally it should have been explained to C during the consent process that there was a possibility that redistribution of the skin could be required during the operation, we found that it was not unreasonable that this was not mentioned. We also found that the care and treatment A had received on the day of the surgery was reasonable and that there was no evidence that the surgery carried out was inappropriate or excessive. Therefore, we did not uphold C’s complaints.