Health

Summary

C complained that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an ambulance from their late relative (A). C also complained about the way their complaint to SAS about the matter was handled.

Through its own investigation, SAS found that the second call from A was not handled appropriately because medical priority despatch system was not utilised to assess A's symptoms and the level of response required. In addition, the first crew to attend A's home did not follow clinical practice guidelines and policy in relation to consent. The crew felt A did not want any help. SAS also found that information on the patient report form was limited and did not meet the expected standards of clinical reporting.

We took independent advice from a paramedic. We found that SAS took reasonable corrective action in response to failings highlighted through its investigation. However, we noted that there was a missed opportunity for interaction between the ambulance control centre (ACC) clinical advisor, who had spoken with A, and the clinician who attended A's home. This may have afforded the attending clinician the necessary information to prompt a more comprehensive clinical assessment of A. There was also an opportunity for the attending clinician to seek clarifying information and question the ACC on the requirement to send a frontline ambulance to A. This would have stimulated discussion and provided an opportunity to share both information and the decision-making responsibility prior to ending the engagement with A. Finally, having listened to the recordings available, a call made from the ACC to A was not ended properly. We upheld this complaint.

In relation to complaints handling, we found that C was not kept reasonably informed about what was happening with the complaint and the investigation itself took a long time. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to handle their complaint reasonably and for for the failure to handle contact with A appropriately. 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:

• SAS should take steps to ensure the process for ending calls is improved; review/implement a process for passing complex background information to the attending clinician to assist clinical judgement and decision-making; and introduce procedures as preventative measures to ensure that a paramedic would seek clarification from the ACC when a patient denies calling for an ambulance or the patient cannot be located.

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 decision to move them to another ward and the manner in which they were discharged while they were a patient at Royal Edinburgh Hospital. The board explained that beds are allocated according to clinical need and, due to extreme pressures on hospitals at that particular time, it was felt appropriate to move C to another ward as they were clinically stable. The board said appropriate referrals were made following C's discharge, however, as C did not return to the ward following an overnight pass, they were unable to complete their assessment for home treatment.

We took independent advice from a mental health nurse. We found that it was unavoidable that a patient had to be transferred to another ward due to the pressures on the wards at the time, and that the board followed a reasonable process in selecting C as a suitable candidate. We did not uphold this aspect of the complaint.

However, we found that while appropriate assessment was carried out, the board failed to appropriately manage C's discharge as they did not ensure that Intensive Home Treatment Team supports commenced when C left the hospital. 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 ensure that the planned post-discharge inputs by the Intensive Home Treatment Team commenced at the point of discharge. 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 that planned post-discharge inputs by community-based services are followed through at the point of discharge and that said community-based services are timeously notified that discharge has taken place. This is especially important in circumstances where discharge has occurred in irregular circumstances which elevate the risk of the person becoming lost to follow-up.

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 (B) whose adult child (A) had developed deep vein thrombosis (a blood clot in a vein) and pulmonary embolism (a blocked blood vessel in the lungs) requiring treatment in hospital. Despite receiving blood thinning medication, A developed further pulmonary embolism. A's medication was revised and arrangements were made for A to be seen as an out-patient. A died after returning home following a later review appointment. B questioned the quality of care A had received from the board.

We took independent advice from a consultant respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs). We found that A received a good standard of care both as an in-patient and as an out-patient in line with the relevant guidance and good practice. There was no evidence that A's outcome could have been changed had the board acted differently. We did not, therefore, uphold C's complaint

Summary

C complained that the board failed to provide them with reasonable care and treatment regarding their Lyme disease (LD – a disease caused by bacteria).

We took independent advice from a consultant in general internal medicine.

C raised concerns that they were refused intravenous antibiotics when they understood this was an available treatment option. The evidence in C's medical records suggested a treatment approach was discussed and agreed about this. We took account of the advice we received that it did not appear from the evidence that any of the relevant medical complications of LD, which applied for starting a patient on intravenous antibiotics, had been established in C's case. We, therefore, did not find evidence that the clinical judgement of C's doctor was exercised in an unreasonable manner. Furthermore, the board's actions were consistent with the relevant guidelines when applicable.

C also raised concerns about the manner and approach of a doctor. Our investigation did not identify the supporting evidence needed to conclude that unreasonable communication had occurred.

However, we found that the time C waited for diagnosis of LD was unreasonable. We also found that there was an unreasonable delay before a referral for a second clinical opinion was actioned and a significant delay before nerve conduction studies were carried out, in particular, given that in C's case, the test results may have altered their clinical management.

C also reported difficulties contacting the medical team to obtain the results of their investigations. We noted that the board had acknowledged this and apologised to C. For the reasons outlined above, we found there were elements of C's care and treatment that were unreasonable and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonably delay in diagnosing them with Lyme disease, the delay in the referral for a second clinical opinion, and the time taken to receive a nerve conductivity appointment. 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:

• Tests and investigations should be carried out in an appropriately timely manner. Patients should be provided with clear information in relation to waiting times for testing and referrals.

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

Mr C complained that he was unreasonably removed from the boards waiting list when he did not attend an appointment. We took independent advice from a dental adviser. We found that it was reasonable to remove Mr C from the waiting list without offering him another appointment in the clinical circumstances. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the board did not communicate reasonably with him. We found that the board's letter to Mr C did not inform him that, if he contacted the service within four weeks, he may be offered another appointment. This was contrary to the NHS Lothian Standard Operating Procedures for Waiting Times Management. We also found that there was no written record of Mr C's call to the board. We upheld this aspect of Mr C's complaint.

Lastly, Mr C complained about the way the board handled his complaint. We did not find evidence that the board had handled Mr C's complaint unreasonably. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to inform him that if he contacted the service within four weeks he may have been offered another appointment and for failing to record Mr C's call to the board. 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

Mrs C complained about the care she received at St John's Hospital. In particular, Mrs C was unhappy with delays in the identification, monitoring and diagnosis of an abnormality in her pancreas. Mrs C had a number of hospital admissions and underwent four scans. The scans showed that the abnormality had increased in size. By the time of the final scan, it was identified that the abnormality was likely to be cancer. Mrs C was subsequently diagnosed with cancer and had surgery to have part of her pancreas removed as well as chemotherapy.

We took independent advice from a radiologist (a specialist in the analysis of images of the body) and a general surgeon. We found that the management of the abnormality was reasonable until the point of the third scan. The report of this scan identified a definite increase in size of the abnormality, although inconsistently referred to it as unchanged. We considered that a referral should have been made to the surgical team to follow up the abnormality and concluded that the failure to do this was unreasonable. We upheld the complaint. However, we concluded that if follow-up had been appropriately planned, it was unlikely that the course of events would have been different in this case. This is because Mrs C received a scan to investigate abdominal pain around the same time that a scan would have been planned in line with the recommended timescales for follow-up of abnormalities.

Mrs C also had concerns about the way the board handled her complaint. We noted that the board had acknowledged and apologised to Mrs C that there had been a significant delay in responding to the complaint. We were critical that the board did not seem to have identified the cause of the delay. We also found that the board had failed to provide updates to Mrs C about the delay. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to make a pancreatic surgical referral after a CT scan identified a definite change in the size of a pancreatic lesion. 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:

• A definite increase in size of a pancreatic lesion should prompt a pancreatic surgical referral.

In relation to complaints handling, we recommended:

• Where there has been a significant failure follow the Complaints Handling Procedure, the board should consider whether they need to take any actions as a result of learning from this case.

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 admitted to University Hospital Monklands with abdominal pain, vomiting and an inability to pass urine. C was diagnosed with possible appendicitis (inflammation of the appendix) and was operated on the next day. C was discharged after surgery but was later readmitted and underwent further surgery. C complained they should have had their first operation sooner, given the pain they were in.

We took independent advice from a consultant in general and colorectal surgery (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C's first operation was carried out within an acceptable timeframe. We did not uphold this aspect of the complaint.

C complained their first operation was not carried out in a reasonable manner, as they experienced problems afterwards. C had suffered a recognised complication of the operation and we did not find failings in how C's first operation was carried out. We did not uphold this aspect of the complaint.

C also complained that they should not have been discharged home after their first operation, as they were still unwell. We found it was unreasonable that C was discharged home, as they had a raised temperature and inflammatory marker. We upheld this aspect of the complaint.

When C was readmitted to hospital for a further operation, C said that there was an unreasonable delay in carrying it out. We found there was an unreasonable delay giving C a scan, which caused a delay in carrying out their second operation. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable discharge and the delay in carrying out the CT scan. 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:

• A CT scan should be carried out to aid diagnosis in patients with similar symptoms.
• Continuing post-operative symptoms of infection should be investigated before discharge in patients at higher risk of infective complications.

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 time taken by the practice to refer them to the breast clinic. C initially attended at the practice with pain in their breast, which was diagnosed as musculoskeletal pain. C later returned to the practice with ongoing pain and a new lump in their breast. The practice referred them urgently to the breast clinic and a scan found a large breast cancer.

We took independent advice from a GP and from a breast surgeon. We found that the treatment provided at the initial appointment was, for the most part, reasonable, and we did not find sufficient evidence to conclude that the practice missed the breast cancer in that appointment. However, we considered that the practice should have advised C, at their initial appointment, to return within three months (in keeping with guidelines). Ideally, the practice should also have sent the referral to the breast clinic as 'urgent – suspected cancer' rather than simply 'urgent', although we accepted that, on balance, this was not unreasonable. Based on the failings identified, we upheld C's complaint. We noted that the practice accepted both these points and considered the action taken was appropriate for reflection and learning .

Under section 16G of the SPSO Act, SPSO has a responsibility to monitor and promote good practice in complaint handling by organisations under our jurisdiction. We found that the practice failed to fully reflect on and learn from C's complaint until prompted by this office. We therefore made recommendations to address the failings we identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not advising them to return within three months, and for failing to fully reflect on their complaint until prompted by our 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:

• The practice should be willing to reflect on and learn from complaints (without being prompted by an investigation from this office).

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 medical and nursing care and treatment given to their late parent (A) during their admission to Wishaw General Hospital. They also complained about the way staff behaved and communicated with the family and the way the board responded to their complaints. A was admitted to hospital suffering from breathing difficulties, after a chest infection. A was registered blind and had poor hearing and limited mobility. C was concerned about A's level of confusion, as well as a lack of personal care from nursing staff. Although C had power of attorney for A and had provided this to the board, they were not informed for a number of days that staff considered A lacked the mental capacity to make decisions about their treatment. C said that on one occasion they had overheard staff making derogatory remarks about C and A. Although C had felt that A was improving during their last visit, A was found dead early the following morning.

C complained to the board about A's care and treatment and met with medical and complaints staff twice. C was unhappy with the board's records of these meetings, as they had taken their own notes and they felt there were significant and substantial differences between the two. C felt that the board's complaint response was inaccurate and the findings inadequate. C told us they felt they had let A down and it was clear from C's submissions that the experience had been distressing for them.

We took independent advice from a consultant geriatrician and a nurse. In relation to A's medical care and treatment, we found that treatment of A's infection and the management of A's medication was appropriate. There was, however, a failure to monitor or assess A's delirium appropriately, and for this reason we found the medical care and treatment they had received fell below a reasonable standard. We upheld this aspect of C's complaint.

In relation to nursing care, we found that aspects of A's care had fallen below a reasonable standard, particularly the assessment of A's mobility and communication needs, and the response to A's repeated falls. We upheld this aspect of C's complaint. We noted that the board had already accepted there had been serious failings in nursing care and had taken steps to address these with individual staff, as well as an organisation.

Without independent witnesses, it is not possible for this office to determine what happened in relation to the alleged remarks made by staff. However, we considered that C's complaint in relation to this point was escalated and investigated appropriately. We did not uphold this aspect of C's complaint.

In relation to communication, we found that although some aspects of medical staff's communication with C was reasonable, overall there had been a failure to communicate with them about decisions relating to A's lack of capacity. Nursing staff's communication with C had also fallen below a reasonable standard. We upheld this aspect of C's complaint. However, appropriate action had been taken by the board to address those failings.

Finally, we found that the handling of C's complaint to the board had also fallen below a reasonable standard. We found that the board had not explained their approach clearly to C and although it was not unreasonable to attempt to resolve C's concerns by meeting with them, the board should have been clear with C what the process would be and they should also have provided C with a clear indication of the conclusions of those meetings, as well as when the complaints process was at an end. We upheld this aspect 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 be assessed using current delirium screening tools.

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

Mr C was referred for orthotics and fitted with insoles. He attended a follow-up appointment with a private consultant as his symptoms were not improving and was diagnosed with anterior impingement syndrome (compression of the bone or soft tissue). After the consultation Mr C decided surgery was his preferred option. Mr C's GP subsequently referred him to the orthopaedics department (specialists in the treatment of diseases and injuries of the musculoskeletal system) at Hairmyres Hospital. His referral was refused as consultants considered that he was receiving appropriate first line care already. Mr C was unhappy with his treatment and told us that, had consultants acted on the report of the private consultant, he would have had surgery much earlier and his pain and suffering would not have gone on for so long.

We took independent medical advice from a clinical adviser who is experienced in orthopaedics. We found that Mr C was treated in accordance with guidelines and that conservative treatment was the appropriate response. It is not uncommon for medical professionals to have different views on treatment, but that the board's treatment following the GP's referral was appropriate. We did not uphold the complaint.