Health

Summary

C attended the board in relation to concerns about swelling to their neck area. C was eventually diagnosed with differentiated carcinoma (type of cancer) of the left parotid (salivary gland situated just in front of the ear) with extension to regional nodes and infiltration of the skin.

C said that the board, in particular the ear, nose and throat (ENT) department, failed to provide them with reasonable care and treatment in that the board failed to take their concerns seriously and there was a delay in their diagnosis.

The board’s position was that as soon as the ENT department were presented with symptoms which raised concern, these were acted upon immediately and appropriately to ensure that C was diagnosed quickly and that a plan for further treatment could be developed with C.

We took independent advice from an ENT adviser. We found that there had been failures in the care and treatment C received which led to a delay in diagnosis and treatment, including: a delay between having an ultrasound scan and C being seen in clinic; interpretation of that ultrasound scan and a failure to appreciate the relevance of the time delay to the scan appearances; the classification of C’s referral which should have been classed as urgent; and C’s discharge from clinic and lack of follow-up appointment. We found that the board did not provide reasonable care and treatment to C and upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable care and treatment. 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:

• Consideration should be given to providing follow-up appointments for scan results if concerns are raised by the findings. If ENT patients are discharged prior to investigation results being available, there should be an audit trail to show what action has been taken.
• Patients should be diagnosed in a timely manner. In doing so, clinicians should take into consideration relevant guidance, paying particular attention to any symptoms which would be considered ‘red flag’, and triage referrals as urgent where required.
• When considering investigation findings, clinicians should ensure that they take into consideration all relevant factors. This should include the time elapsed from initial presentation/presentation at time of referral and any delays.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained to the board about the circumstances whereby their late parent (A) was a patient at Forth Valley Royal Hospital. A had been admitted after suffering a stroke (a serious medical condition that happens when the blood supply to part of the brain is cut off). A also had delirium and a background of dementia. Whilst an in-patient, A suffered a fall. Staff were aware that A had to be supervised and to be accompanied at all times when they were out of bed. However, despite being under close observation, a contracted nurse allowed A to remain in the toilet unsupervised and they sustained a fall which resulted in a severe head injury and subsequently A’s death. C believes that A should not have been left unattended and that, had that been the case, the fall may have been prevented.

We took independent advice from an appropriately qualified adviser. We found that staff at the hospital had carried out a comprehensive falls risk assessment in regards to A and that A was not to be left unsupervised. It was felt that A had no awareness regarding the use of the call bell system (a button or cord found in hospitals that patients can use to alert hospital staff of their need for help). However, a nurse had stepped out of the toilet to afford A some privacy and A attempted to rise from the toilet unaided and suffered a fall. Although the record-keeping regarding the falls risk was completed to a good standard, there was a breakdown in communication between permanent staff and the contracted nurse about the specific level of observation required for A. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure in communication. 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 when passing information to others that full details of the levels of observation required are understood.

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 developed severe left arm pain and 'pins and needles' in the fingers of their left hand. Around a year later, C began to experience the same problems with their right side. Their GP was concerned their symptoms were bilateral and they urgently referred C to the board's neurosurgery service (specialists in surgery on the nervous system, especially the brain and spinal cord).

C complained that the board failed to respond to their GP referral in a reasonable manner. In particular, that the board unreasonably downgraded the urgency of the referral. During our investigation, we took independent advice from a specialist in orthopaedic medicine (the treatment of diseases and injuries of the musculoskeletal system).

We found that C did not have any red flags or signs of a serious underlying condition so they did not require to be seen urgently. We also found that C's referral was appropriately redirected to orthopaedics. However, we noted that there was an unreasonable delay (over five weeks) in telling C's GP that their referral had been vetted and redirected. In light of this delay, we upheld the complaint. We also found that the board did not adequately respond to C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in responding to C's GP about their urgent referral and for not adequately addressing their complaint. 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:

• If an urgent referral has been redirected, there should be timely communication with the GP so patients can be updated.

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 relative (A). A was admitted to hospital with an ongoing Clostridium difficile infection (bacteria that can infect the bowel and cause diarrhoea). A remained in hospital until their death.

C raised concerns with the board about the level of clinical and nursing care provided to A. The family were particularly concerned that staff took the decision to implement the nil by mouth protocol, meaning A would not be given any foods or fluids. The board acknowledged failings and agreed to review relevant practice.

We took independent advice from appropriately qualified advisers. In relation to the clinical care provided, we found that clinical staff took detailed consideration of A’s health and were aware how frail they were when admitted to hospital. The records indicated that a good level of investigation took place along with frequent blood tests and x-rays, when appropriate. We considered that the clinical care A received was reasonable. We did not uphold this aspect of C's complaint.

In relation to the nursing care, we found that important information from A’s family with regards to the requirement to provide thickened fluids was handled poorly by nursing staff. We found that it was unreasonable to carry out the appropriate swallow test with A using water instead of thickened fluid. In addition to this, risk assessments and person-centred documentation were never completed throughout A’s time in hospital. Had this documentation been completed, then failings might have been avoided in A’s case, meaning medications and fluids would have been provided. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for failing to provide a reasonable level of nursing 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:

• National guidance and standards of care for older people in hospital should be implemented appropriately by the board by demonstrating that appropriate guidance is available for staff when undertaking compromised swallow tests; measures are in place to maximise patients receive their medications; and important documentation is completed on admission and from that, an appropriate person-centred plan of care will be devised.

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

Ms C was referred to the ophthalmology department (the branch of medicine concerned with disorders and diseases of the eye) by her optician after she became concerned about the vision in her eye. She attended several appointments with a consultant ophthalmologist but was unhappy with the care and treatment provided. In particular, Ms C felt that the consultant did not take her seriously at her initial appointment. She was also unhappy that the treatments given and tests carried out did not give her a definitive diagnosis or improve the vision in her eye.

We took independent advice from a consultant ophthalmologist. We found that the consultant's assessment, management and onward referral for tests were reasonable. Therefore, we did not uphold Ms C's complaint.

Summary

C complained about a consultation with a consultant psychiatrist. During the consultation, C discussed a previous incident where their GP prescribed medication without carrying out a review of C's medical records. Following the consultation, the consultant psychiatrist recommended C be prescribed Mirtazapine (antidepressant medicine). C experienced side effects from the medication and subsequently discovered that their GP's records showed they had been prescribed this medication a number of years previously and had experienced adverse side effects. In light of this, C complained as they did not feel the consultant psychiatrist carried out an appropriate check of C's medication history before recommending that Mirtazapine was prescribed. C also complained about the time taken by the board to investigate their complaint and the thoroughness of their investigation.

In respect of C's first complaint, we took advice from an appropriately qualified independent adviser with a background as a consultant psychiatrist. We found that the course of action taken by the consultant psychiatrist was appropriate and reasonable. We recognised that the decision to recommend Mirtazapine ultimately had a negative outcome for C, but we concluded that the decision-making and process leading to this recommendation was reasonable. We considered the consultant psychiatrist took appropriate action to ensure they had enough information to make an informed decision. In light of this, we did not uphold this complaint.

In respect of the C's second complaint, we concluded that the board had carried out an appropriately thorough investigation, but their responses could have been clearer and more detailed. We also considered the time taken for the board to provide both a stage 1 and stage 2 response was unreasonable. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not handling their complaint in a reasonable or appropriate manner. 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 should reflect on how the complaint was handled from when it was received to when the stage 2 response was issued. Consider what failings took place during the process and what learning and improvement can be put in place.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C attended Dumfries and Galloway Royal Infirmary (DGRI) for a colonoscopy (a procedure where a camera on the end of a flexible tube is inserted into the rectum). During this procedure, polyps (tissue growths) were found and biopsies (a sample of tissue) were taken. C was told that a polyp showed possible signs of cancer. A second colonoscopy was carried out and the doctor attempted to remove the polyp, however the procedure was painful and was stopped. C was discharged home the next day.

Soon after, C had a bloody bowel movement and went to Galloway Community Hospital where they were then transferred to DGRI. C collapsed and was resuscitated, given a blood transfusion and moved to critical care.

C complained that the colonoscopy was not carried out properly, that it was painful and asked whether it should have been done in the first place. C also complained about the decision to transfer them from Galloway Community Hospital to DGRI and about the care they received on arrival at hospital.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We considered that the colonoscopy procedure was required as there was evidence C might have cancer. We noted that pain is subjective and the amount of pain relief given to C may not have been sufficient, although it was the recommended dosage. We found that the procedure appeared to have been carried out appropriately.

We also considered that the decision to transfer C from Galloway Community Hospital to DGRI was reasonable. It was possible that C would need surgical intervention which was only available at DGRI. We found that C was promptly assessed and was treated appropriately following their collapse. We did not uphold C's complaints.

Summary

C complained about the care and treatment of their late partner (A) who died from a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs), secondary to a deep vein thrombosis (DVT, a blood clot in a vein). The complaint related to a GP practice run by the board, which A attended feeling unwell. A was given antibiotics for a suspected infection and a sick note for their employer. A phoned the practice the following week, still feeling unwell, and the antibiotic prescription and sick note were extended. A’s condition deteriorated and they died the following day.

C complained that the GP dismissed the recent history of A's long-haul travel and symptoms indicative of a DVT and misdiagnosed A with an infection. They considered that there was a failure to follow the National Institute for Health and Care Excellence (NICE) guidelines for assessing the possibility of a DVT. C also complained that arrangements were not made for A to be seen when they called the practice the following week. They considered A was denied appropriate follow-up care.

We took independent medical advice from a GP. We found that the recorded symptoms that A presented with were consistent with a diagnosis of infection and not DVT. We considered that the GP’s recorded examination, history and working diagnosis were reasonable at that time.

In terms of A’s follow-up phone call to the practice, we were unable to evidence what was said during the call and whether an appointment was requested. We noted that it is common practice for antibiotic prescriptions and sick notes to be extended without seeing the patient, and we considered that the practice’s actions were reasonable based upon the available evidence. We did not uphold C's complaints.

Summary

C complained about the care and treatment their late partner (A) received during two consecutive admissions to Dumfries and Galloway Royal Infirmary. A had a number of existing medical problems and spent around four weeks in hospital, including 18 days in critical care, before being discharged. C complained that A was inappropriately discharged with pneumonia, and required readmission 12 hours later. A spent almost a further three weeks in hospital before being discharged again, and died two months later. Whilst in hospital, A developed a severe pressure ulcer. C complained that nursing staff failed to take reasonable measures to prevent the pressure ulcer from developing.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that A’s suitability for the first discharge was assessed over a number of days and blood tests and basic observations did not indicate an underlying pneumonia at that time. We considered that it was reasonable for A to be discharged and we did not uphold this aspect of C's complaint.

We also took advice from a tissue viability nursing specialist (a nurse who provides advice and care to patients with, or at risk of, developing wounds). We found that, while the risk of pressure damage was identified and care prescribed to mitigate this, this was not adhered to. Risk assessment, skin inspections and repositioning were not carried out as often as required, and the pressure ulcer was initially graded incorrectly. Inappropriate dressings were also used and there was a delay in providing a pressure relieving mattress. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable pressure area care to A. 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 take steps to ensure staff are competent in pressure area care, with particular focus on the deficiencies identified in A’s care, and that they are aware of current best practice/adhere to the board’s own guidance (Active Care Prescribing Sheet & Wound Assessment Chart) as well as Healthcare Improvement Scotland’s Prevention and Management of Pressure Ulcer Standards (2016).
• The board should take steps to review why pressure relieving equipment was not readily available in this case and address any system failure which contributed to this 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 brought a complaint to us about the care and treatment given to their late parent (A) at Dumfries and Galloway Royal Infirmary. C complained that there was a lack of communication between staff and the family throughout A’s treatment. In particular, they said that the severity of A’s illness was not explained to A or the family. C stated that the family remained unclear about the specifics of the cancer A had, that there had been no reaction to A’s early symptoms and that A was advised about their diagnosis by phone with no offer of support provided. C also complained that the administration of A’s medication was unreasonable; in particular, that there was inadequate pain control and that no one took overall control of A’s care and treatment. During the board’s own investigation of the complaint, they accepted that A should not have been advised of their diagnosis by phone, and an apology had been given for that. The board had also indicated this was an area for reflection and learning.

We took independent advice from a consultant hepatologist and gastroenterologist (a doctor who cares for patients with benign or malignant disorders of the gastrointestinal tract, liver, pancreas and gallbladder). We found that while there was some learning for the board in relation to aspects of communication, the overall care and treatment given to A was reasonable. While we did not uphold the complaint, we asked the board to provide evidence of the action taken to ensure alternative methods of communicating a diagnosis to a patient had been considered.