Health

Summary

C complained on behalf of their family member (A). A had several admissions to hospital with complaints of abdominal and back pain. They underwent a laparoscopic cholecystectomy (removal of the gallbladder) but their symptoms did not improve. Following an MRI scan, a spinal infection was suspected and antibiotics were commenced, which resulted in a C.diff (a bacterium that can cause symptoms ranging from diarrhoea to life-threatening inflammation of the colon) infection. This type of infection most commonly affects people who have been treated with antibiotics. Further scans were then carried out which showed suspicious lesions on A's lung, and they were diagnosed with cancer.

C was concerned that, despite the tests and investigations arranged during A's time in hospital, it took around six months before cancer was diagnosed. In addition, C was unhappy with the board's handling of their complaints.

We took independent advice from an appropriately qualified adviser. We found that there were frequent and detailed reviews of A's care, and appropriate management plans were made and carried out. A's cancer could only reasonably have been expected in the last admission, and although there was an initial incorrect diagnosis of infection, this was a reasonable one to make at the time, and it was then corrected once A's symptoms changed and they failed to respond to the initial treatment. We did not uphold this aspect of the complaint.

In looking at the board's handling of C's complaint, the complexity of the issues that were raised meant that the level of investigation required impacted on the timescales. The responses issued to C demonstrated that the complaints were taken seriously by the board and the matters were investigated thoroughly. Overall, it was a lengthy process, with some significant delays, which was acknowledged by the board who apologised to C. We upheld the complaint but did not make any further recommendations.

Summary

C attended the minor injuries unit at Queen Margaret Hospital and was unhappy with the way they were dealt with by a member of staff in the reception area. C considered that the board's investigation of their subsequent complaint was incompetent and lacked professionalism.

We found that the board failed to take timely and robust action to investigate and respond to C's complaint. The complaint was initially dealt with as a concern at C's request, however, we considered it should have been dealt with as a formal complaint investigation from the outset, or at least immediately upon C expressing dissatisfaction with the response to their concern. It was not logged as a complaint until the board met with C a few weeks later. The timescale for responding to C's complaint was excessively beyond the 20 working day target timeframe.

There was ongoing confusion as to the identity of the individual C's complaint was about, which was never resolved. The board did not take robust steps to try to identify and obtain written statements from the individuals present. By the time they requested CCTV footage of the incident, it was no longer available. C continued to seek answers and had two post-complaint meetings. We found that there was a failure to adequately follow up on agreed actions points from the first of these meetings. Overall, we concluded that the board's handling of the complaint was unreasonable and we, therefore, upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to take timely and robust action to investigate their complaint, including the failure to treat the complaint as a complaint from the outset and quickly pursue relevant evidence; the failure to respond to the complaint within the required timescale; and the failure to adequately follow up on agreed action points from a post-complaint meeting. 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 ensure complaint investigations conform to the NHS Model Complaints Handling Procedure, particularly in terms of timeliness, thoroughness, and how to deal with complaints where a person states they do not wish to complain.

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

Summary

C underwent surgery at Victoria Hospital to repair a fracture in their left wrist. Following the surgery, infections developed and this led to several further procedures being required to clean the wound and address damage caused by the infections. C complained that the board failed to provide them with appropriate care and treatment. Their concerns included that the board did not detect and effectively treat the infections, and that blood tests were not carried out to check for infection after C was discharged from hospital.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that recognised complications (including infection) were discussed with C as part of the consent process and that there did not appear to have been undue delay in identifying C's first infection. We also found that blood tests to check for infection were carried out with reasonable frequency. However, the board should have ensured that blood test results were monitored and acted on timeously. Though we noted that there was a delay in responding to a blood test result, which suggested infection was present, this could not itself be said to have negatively affected the overall outcome for C.

We concluded that the overall care and treatment provided to C was reasonable. It was noted that the board had acknowledged the blood test result failing and taken appropriate remedial action. As such, we did not uphold the complaint.

Summary

C complained about the care and treatment provided to their spouse (A) when A was an in-patient at Dumfries and Galloway Royal Infirmary after being transferred from another hospital. A had been commenced on Sando K (a medication used to treat and prevent low potassium levels). Three days later, A's potassium levels were found to be high. A's condition deteriorated and they were transferred to the critical care unit. C complained about the board's management of A's potassium levels and kidney function.

We took independent advice from a consultant in acute medicine. We found that that there was a failure to note A's potassium levels were normal the day after being transferred and subsequent failures to check this on the following two days. Whilst we found that it was not A's potassium levels which resulted in their admission to the high dependency unit, we considered the failings to be unreasonable and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failure to provide reasonable care and treatment in relation to A's potassium levels and kidney function during their admission. 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:

• Sando K should only be administered when required, and patients on Sando K should have daily reviews to ensure it is still required.

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 complained about the care and treatment her mother (Mrs A) had received in Dumfries and Galloway Royal Infirmary and Castle Douglas Hospital. She was transferred to these hospitals after having surgery on her brain, which left her with quadriplegia (paralysis of all four limbs).

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. In relation to Ms C's complaint about the care provided to Mrs A, we did not uphold the complaint, as we found that:

staff had assessed Mrs A in detail after her transfer and there was no evidence of a negative or palliative approach to her care;

a detailed physiotherapy assessment was carried out promptly the day after her transfer and this was followed by regular sessions with physiotherapists;

Mrs A's care in relation to alerting staff and consuming meals had been reasonable;

it was reasonable that Mrs A did not receive counselling, as there was no clear indication for this in the observations of staff, or requests from Mrs A or her family; and

the level of care provided to Mrs A in relation to massage, physiotherapy and bodily movement was reasonable.

Ms C also complained that the board did not provide reasonable treatment to Mrs A following her admission. We found that there was evidence of a comprehensive assessment of Mrs A's needs and specific attempts to provide care and rehabilitation for her in both hospitals. The prescription of medication, based on the assessments carried out, was reasonable even if it did cause some sedation as a side-effect. We did not uphold this aspect of the complaint.

Finally, Ms C complained that the board unreasonably instructed staff not to talk to her. We found that it had been reasonable for staff to propose a contact time for Ms C every day. This meant that rather than deal with a number of calls from Ms C, staff could give a focussed update. We did not uphold this complaint.

Summary

C complained about the treatment the board provided to their spouse (A). After falling unwell, C had contacted NHS 24 on A's behalf as they were concerned that A's symptoms may have been due to a cardiac (heart and its blood vessels) issue. A then spoke to a medical professional from NHS 24 who signposted them towards Borders Emergency Care Service (BECS), an out-of-hours service, which they attended.

When A attended BECS, they were examined by a trainee advance nurse practitioner (ANP). After examining A and taking a history from them, the trainee ANP's view was that A's symptoms were due to a muscular strain rather than being cardiac in nature. A was discharged on this basis but died four days later as a result of coronary artery atheroma (fatty deposits that build up on the walls of arteries around the heart). C complained that A's death was preventable and that they were not examined appropriately when they attended BECS.

We took independent advice from a nurse. We found that the examination of A, and the trainee ANP's decision-making, were reasonable given the information provided to them. In addition to this, it was appropriate for a trainee ANP to examine A and reach conclusions on their treatment. We concluded that A received appropriate treatment when they attended BECS. Therefore, we did not uphold this complaint.

Summary

C complained on behalf of their parent (A) about the care and treatment provided by the practice. C considered that there was a failure to carry out reasonable physical examinations and appropriate tests based on the symptoms A presented with, prior to A receiving a diagnosis of untreatable Signet Ring Cell Carcinoma (a type of cancer).

We took independent advice from a GP. We found that there was a failure to refer A for an urgent investigation or for an urgent ultrasound due to their weight loss, new diabetic diagnosis and age. We upheld this aspect of the complaint. We found there was a failure to carry out a physical examination of A on two occasions and also a failure to ensure that an urgent referral letter was sent to the colorectal (conditions in the colon, rectum or anus) service within a reasonable timeframe. Therefore, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for a failure to refer A for an urgent investigation or an urgent ultrasound; a failure to carry out a physical examination of A; and a failure to ensure an urgent referral letter was sent within a reasonable timescale.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:

• Ensure clinical staff are aware of colorectal referral guidelines relating to the need for a physical examination of a patient prior to referral.
• Ensure relevant clinical staff are aware of referral guidelines for newly diagnosed diabetes and weight loss.

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 parent (A) about the care they received by the practice. A had been unwell and required a home visit from the practice. C believed that A had not been adequately examined during this visit, which had placed A's life at risk. C said that within days of the home visit, another GP had reviewed A, which resulted in A's admission to hospital. During this admission a significant amount of fluid was removed from A's legs and A was found to have a damaged heart valve. C felt that the practice had failed to honestly admit their failings or to offer a sincere apology.

We took independent advice from a GP. We found that A had been reviewed thoroughly and appropriately. There was no evidence that clear symptoms of heart failure had been overlooked. There was also no evidence that A had an acute condition at the time of the home visit, and the symptoms reported and recorded were consistent with A's pre-existing medical conditions.

We found that the care provided to A was of a reasonable standard and did not uphold the complaint

Summary

C complained about the care and treatment the board provided to their late spouse (A) at University Hospital Crosshouse (UHC). A suffered a heart attack and was taken by ambulance to a hospital in another health board area. Following treatment, A was transferred to UHC, but then suffered what was thought to be a stroke event and died a week later.

C complained about several aspects of A's care, including that staff did not tell them what was happening with A and failed to advise them that A was in a coma. C also said that A's health had improved at the other hospital and they understood that A was being moved to UHC to recuperate before being sent home, but A died shortly after their arrival at UHC.

We took independent advice on the case from two advisers - a consultant cardiologist (a doctor that specialises in diseases and abnormalities of the heart) and from a nurse. We found that the medical records showed staff gave C regular updates about A's condition and tried to be realistic about the likely outcome, while being supportive of C. We considered that there was evidence that staff kept C reasonably updated about A's condition during the admission. However, we welcomed the board's apology that the communication did not meet C's needs; this showed a sensitivity to the responsibility for ongoing learning and improvement to ensure communication is tailored to the needs of individuals and their families. We found that there was a lack of clarity from the other hospital about A's prognosis and future treatment plan at the time of their transfer to UHC, which may have contributed to C's confusion and distress at this time. We included some feedback to the board about this. However, we noted that this did not influence A's care at UHC, following the sudden stroke that they suffered soon after transfer, which was ultimately fatal. We considered that, overall, A's care and treatment at UHC was reasonable and we did not uphold the complaint.

Summary

C complained to us about the board, as they held a number of concerns regarding the board's management of their medication for ADHD, pain (they suffer from fibromyalgia), and insomnia. C also considered that the board had failed to take reasonable account of their needs in the way they had communicated with them.

We took independent advice from a consultant psychiatrist. We found that C's medication was appropriate for the management of their diagnosed conditions. We did not consider that there was any evidence of unreasonable communication which failed to take account of C's needs. Therefore, we did not uphold C's complaints.