Health

Summary

C complained about the care and treatment that they received from the board. C said that following gynaecological surgery, they were left with side effects including recurrent pain and the need for further treatment.

C complained that the board failed to provide them with adequate care and treatment in relation to the operation. The board did not identify any failings in C’s care, but did apologise for communication failings relating to the operation. They said that C had experienced a rare complication, but that this had been recognised and treated appropriately.

We took independent advice from a consultant gynaecologist. We found that C’s care and treatment during and after their operation was reasonable and noted that the complication that occurred was swiftly identified and managed. However, we also found that prior to their operation, C was not provided with adequate information about other possible treatment options, including a lack of discussion about the surgery. We also found that the surgical consent process was inadequate.

The board accepted that discussions relating to informed consent and counselling to support patient decisions should be fully documented, and that this had not occurred in C’s case. The board also acknowledged the importance of discussing and documenting all potential post-operative complications with the patient, so that the patient has informed choice when agreeing to a management plan.

We found that there were aspects of C’s care and treatment prior to their operation that fell below a reasonable standard. Therefore, 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/meaningful-apologies.

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 sibling (A) received whilst in hospital following a fall. C also raised complaints about communication issues with the board. The board accepted that there had been poor communication with A’s family but did not indicate any concern regarding the care and treatment of A. C and their family were dissatisfied with the board’s responses and brought their complaints to the SPSO.

We took independent advice from a nursing adviser. We found that A did not receive timely medical intervention due to documentation and assessment gaps, particularly in relation to A’s positioning, their need for increased oxygen support, falls prevention and support for hydration. We upheld this part of C's complaint.

In relation to communication and complaints handling, we found that the board did not respond within reasonable timescales. We also found that it was unreasonable that the board did not apologise for the time taken to provide their response, that they did not take action to prevent any recurrence, that they included an inaccurate statement and that they did not respond to all of the complaints that they had clarified with C. We upheld these parts of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family 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.
• Apologise to C that they did not respond reasonably to their complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• The board review the handling of C’s complaint to understand why there had been a delay in the drafting and approval of the response and devise an action plan to prevent any recurrence.

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 practice failed to handle their telephone call reasonably. C called the practice while being discharged from hospital to speak to a GP about an urgent review of their GP prescribed medication. In particular, regarding the safe discontinuation of pregabalin (an anti-epileptic drug that can also be used to treat nerve pain and anxiety) following surgery.

We found that the call did not address C’s concern that C needed advice about how to safely discontinue GP prescribed medication. C was also not told that further fit notes could be accessed by requesting one through the practice website or that they needed to wait until they had received a discharge letter so that the pharmacy team and the GP had the correct information.

C was not informed that they could call for a same day triage appointment on their discharge from hospital. Although C was offered a routine appointment which is consistent with the practice’s policy on GP access, C was not given the chance to say whether they wanted to accept this before the call was terminated by the practice.

We found that no offer was made to send a message to a GP informing them of the problem, to be actioned by the GP as and when appropriate. No explanation was provided to C about why their request to speak to the Practice Manager was refused and no consideration was given to requesting someone else (such as the Team Leader) to call C back. Therefore, we upheld this part of C’s complaint.

C also complained that the practice failed to handle their complaint reasonably. We found that the complaint response did not address all the issues that C raised. The response also made statements about what C was told that were not supported by the recording of the telephone call to the reception team. We upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not addressing C's concern that they needed advice about how to safely discontinue GP prescribed medication, not informing C that further fit notes could be accessed by requesting one through the practice website, not informing C that they needed to wait until they had received a discharge letter so that the pharmacy team and the GP had the correct information, not informing C that they could call for a same day triage appointment on their discharge from hospital, not giving C the chance to say whether they wanted to accept the offer of a routine appointment before the call was terminated, not offering to send a message to a GP informing the GP of the problem, to be actioned by the GP as and when appropriate, not explaining why their request to speak to the Practice Manager was refused and not giving consideration to requesting someone else (such as the Team Leader) to call C back, not addressing all the issues they raised in the complaint response, and making statements in the complaint response that were not supported by the recording of the telephone call to the reception team. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients should be provided with appropriate explanations and advice when they contact the reception team.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, ensure responses are supported by the relevant records, identify and action appropriate learning and apologise where issues have been identified. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 was Power of Attorney (POA) for the patient (A). C complained about the care and treatment that A received in hospital. A suffered two falls, resulting in five fractured ribs. A also acquired pressure sores, contracted pneumonia and died shortly after discharge. C that they were not timeously informed of the falls or A’s deteriorating health. C also complained about the board's handling of their complaint.

The board advised that A was assessed by a doctor after both falls and pain medication was increased. Due to ongoing pain, x-rays and a CT scan were taken weeks later which showed the injury. The board advised that treatment would have been the same if they had known of the injury earlier. The board also noted that they had increased care rounding following the falls and provided a pressure relieving mattress.

They acknowledged that on some occasions care rounding had been delayed due to clinical pressures. The board apologised that A had developed pressure sores and that they had not communicated effectively with C. They advised that staff had been reminded of falls guidance, pressure ulcer guidance and to contact POAs and next of kin.

We took independent advice from a nurse. We found that the board had not regularly evaluated the risk of falls before A fell and did not appropriately review A after their falls. We found that they had not sufficiently managed the risk of pressure ulcers and did not appropriately manage the pressure ulcers once they had developed. We also considered that POA documentation was not correctly filled in on admission and that C had not been appropriately updated regarding important health matters or A’s falls.

We found that the complaint response had taken too long, that C had not been regularly updated and that the complaint investigation could have been more thorough. We upheld all aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise that C was not appropriately recorded as POA and was not kept informed of A’s pneumonia and pressure sores. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• 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:

• Documentation should meet the required NMC “The Code” standards, in regards to assessment, planning, implementation and evaluation of nursing care (APIE process), including for falls. Care and comfort rounding should be carried out timeously. Wound assessment should be carried out and recorded, to guide treatment. Datix incidents should be escalated to Adverse Events for review when there has been avoidable harm.

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 to their partner (A) while in hospital, which they believe led to A's death. In response to the complaint, the board acknowledged and apologised that communication with C had not been effective. However, A had been aware of the severity of their diagnosis and prognosis and was able to make their own decisions and all communication had been with them.

We took independent advice from a consultant in acute and general medicine. We found that, while significant parts of A’s care and treatment had been reasonable, there was a delay in the diagnosis and initiation of cancer treatment. In terms of the Scottish referral guidelines for suspected cancer, patients referred via the urgent suspected cancer pathway should receive their first treatment within 62 days of receipt of the referral, which did not happen in this case.

We also found that there were unacceptable delays in relation to acting upon the results of the PET scan and a delay in A’s subsequent diagnosis. In addition, we found that at the time of A’s death a morbidity and mortality meeting (M&M) had not taken place. However, the board confirmed that a new M&M process had been implemented so that all deaths were reviewed through this process. We upheld the complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

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 should be treated in line with relevant cancer referral guidelines. Scans should be carried out and reported within a reasonable time frame.

In relation to complaints handling, we recommended:

• There should be a formal review and consideration of a robust investigation process when complaints are received so that any potential learning is identified and actions can be considered to reduce the risk of failures in care in the future.

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 when under the care of orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) for foot surgery.

We took independent advice from an orthopaedic adviser. We found that the bones of C’s toe had been reset in the wrong position and the fixation was unreasonable. We also found that C was unreasonably managed at their first post-operative review, noting that C’s x-rays were described as satisfactory which was not the case. The decision to watch and wait was also unreasonable, as by this point a good outcome from the surgery would not have been possible based on the x-rays. We considered that it was unreasonable for the board to discharge C from orthopaedics at the next review appointment when the problem remained unresolved.

There were aspect of C’s care and treatment which we found were reasonable, particularly in relation to the three further surgeries C received. However, we recognised that that these had only been necessary due to the failure which had occurred during the original surgery. On balance, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board’s response contained factually inaccurate information, that there had been delays in complaint handling and that there had been a failure to update C during this time. We upheld this part of C's 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:

• Patients should receive reasonable surgical care. When an unexpected or unintended incident occurs, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with the Model Complaints Handling Procedure TheModel Complaints Handling Procedures | SPSO. Complaint investigations should fully investigate the matters of complaint made and identify actions for learning and improvement.

Summary

C complained that their GP practice failed to provide them with reasonable care and treatment. C attended the practice with loss of appetite, vomiting, concentrated urine, poor fluid intake, a temperature of 38.7 degrees, and a high heart rate.

C was prescribed antibiotics and given advice on what to do if their condition worsened. C’s condition deteriorated and they attended the practice again. C was referred for a chest x-ray and diagnosed with empyema (pockets of pus that have collected inside a body cavity). C’s condition was life-threatening and they remain impacted by it.

In their response to the complaint, the practice arranged an independent review of C's treatment by a respiratory consultant. They noted that C had a significant tachycardia (heart rate exceeding 100 beats per minute at rest). The practice said that this could have been discussed with the Acute Medical Unit at the time. However, it was likely that they would have advised to treat C at home rather than to admit them.

We took independent advice from a GP. We found that C’s presentation and clinical examination findings were suggestive of pneumonia at least, and indicated that they were at high risk of sepsis. We found that C should have been admitted to hospital rather than sent home with antibiotics. Therefore, we upheld C's complaint.

During the course of our investigation the practice confirmed further reflection and learning. We were satisfied that in doing so they had appropriately addressed the failings in C’s care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in our investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

Summary

C complained that the board failed to consider their request for bariatric surgery reasonably. C also complained that the board failed to handle their complaint reasonably. C suffers from complex physical and mental health issues. They were referred for bariatric surgery by the clinicians treating their medical conditions. C attended a number of assessment appointments to determine their suitability for surgery. C was concerned by the assessment process and asked to see the report being submitted to the Multi-Disciplinary Team (MDT) meeting but this request was refused. C was not accepted for surgery.

C received a copy of the assessment report through a subject access request. C was told by the board that they would accept a complaint from C if their complaint was made within 12 months. C complained a few months later. The board delayed in acknowledging and responding to the complaint but met with C to agree how the complaint would be handled. The following month, the board wrote to C stating that they would not investigate the complaint, because it had been submitted outwith the time limit for investigation.

We took independent advice from a consultant psychologist. We found that C should have been allowed the opportunity to provide feedback on the assessment process before it was discussed at an MDT. C had been promised an appointment to do this, but the appointment was not made. However, we considered that the assessment itself had been reasonable. Therefore, we did not uphold this part of C's complaint.

In relation to complaints handling, we found that C was not properly informed about the process that the board intended to follow and was repeatedly given the impression that the case would be investigated. The board did not demonstrate how it had determined C’s complaint was out of time. Therefore, we upheld this part of 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:

• The board should have robust administrative systems in place to ensure appointments are arranged as intended and that patients are effectively communicated with.
• In relation to complaints handling, we recommended
• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when they make a complaint.
• The board should ensure timebar decisions reference the relevant board guidance.

Summary

C complained on behalf of their partner (A) about the care and treatment provided to A by the board when they presented to the obstetric triage department 25 weeks’ gestation with pain and abdominal tightening. A was assessed as having Braxton Hicks (when the womb contracts and relaxes during pregnancy, also known as ‘false labour’) given advice on what to do if their condition worsened, and discharged. Four weeks’ later A suffered preterm prelabour rupture of the membranes (PPROM) and their child was delivered prematurely.

C complained about the care and treatment provided to A as they considered the assessment at 25 weeks’ gestation was a missed opportunity for further investigation or follow-up.

The board’s complaint investigation identified that according to local guidelines, A should have been reviewed by a more senior doctor. However, they were of the view that it was unlikely that this would have led to a different outcome.

We took independent advice from a medical adviser. We found that while there were some areas for potential improvement, overall the care and treatment provided to A was reasonable. We therefore did not uphold C's complaint, though we did provide feedback to the board according to the adviser’s comments.

Summary

C complained about the care and treatment given to their late sibling (A) by the board. A, who had a history of addiction issues and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties), was admitted to A&E after overdosing on non-prescription drugs. A was treated for the overdose and was discharged to C’s care. A died the following day. C complained that the board inappropriately discharged A and that the treating doctor had failed to communicate adequately with them.

The board did not identify any failings in A’s care, but did apologise that A was discharged with a cannula in place. The board also apologised for communication failures with C. C remained unhappy and brought their complaint to us.

We took independent advice from a consultant in emergency medicine. We found that A was monitored for approximately 12 hours before discharge. This is the minimum period recommended by Toxbase (the primary clinical toxicology database of the National Poisons Information Service). However, we found that A would have required observation over and above this minimum period. This was because of A’s history of acute seizures, intoxication with opiate drugs and their complex medical history. In the circumstances, we found that it would have been reasonable for A to have remained as an in-patient to enable a greater period of medical observation. Therefore, we considered that the decision to discharge A was unreasonable. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Internal reviews should include a thorough consideration of all of the relevant evidence including clinical records and there should be reflection on these in an open and transparent manner in order that lessons can be learned.
• Overdoses complicated with seizure activity and aspiration lower respiratory tract infection may require observation over and above the advice provided by Toxbase. Patients admitted with overdoses and who present with a history of seizure activity should be admitted for a minimum of 24 hours observation. Concerns raised by relative(s) of patients should be listened to by staff.