Health

Summary

C complained about the care and treatment provided by the board’s Children and Adolescent Mental Health Service (CAMHS) in respect of their child (A). After a number of referrals, A attended an initial appointment with CAMHS. This was due to A’s challenging behaviour. The outcome of this assessment was that A would be further assessed before a conclusion was reached on how to progress.

Between this initial assessment and the point C made their complaint, CAMHS engaged with C and A in a variety of ways. A left the family home and moved in with their grandparent. C felt that CAMHS did not provide the help that they and A needed during this time. In C's view, they had been involved with CAMHS for years but nothing productive had been done. Overall, C felt CAMHS failed to provide appropriate care and treatment for A.

We took independent advice from a consultant child and adolescent psychiatrist. We found that overall care and treatment provided by CAMHS was reasonable and in line with relevant guidance for this area. We concluded that the actions taken by CAMHS was reasonable and based on an appropriate consideration of the evidence and A’s presentation. We identified that there were some areas where greater clarity in relation to specialist terms may have been helpful and that there was uncertainty around whether the contents of a risk assessment should have been shared with C. However, we did not consider this to mean that the overall care and treatment provided to A was unreasonable. We did not uphold C’s complaint.

Summary

C complained about the care and treatment they received from the board. C said that a ruptured Achilles tendon (the band of tissue that connects calf muscles at the back of the lower leg to the heel bone) was not identified in a timely way.

We took independent advice from an advanced nurse practitioner and from a consultant physiotherapist. We found that the care and treatment provided to C was consistent with the National Institute for Health and Care Excellence (NICE) guidance on when to suspect an Achilles tendon rupture, and with the board’s own pathway. We did not uphold this aspect of the complaint.

C also complained about the way the board handled their complaint. We did not find any failings regarding the way the board handled C’s complaint. Therefore, we did not uphold this aspect of C's complaint.

Summary

Ms C was admitted as an in-patient under the Mental Health (Care & Treatment) (Scotland) Act 2003. At this time, Ms C was prescribed an anti-psychotic medication. Following discharge, Ms C continued to take the medication until she stopped the following year. Ms C complained to the board about the dose of the medication and reported that she experienced multiple significant side effects. Ms C also had concerns about the way the board had handled her complaint about her previous Community Psychiatric Nurse (CPN).

We took independent advice from a consultant psychiatrist. We found that treatment had been provided to Ms C in accordance with the relevant clinical guidelines. We did not identify failings in relation to the management of Ms C’s medication. For this reason, we did not uphold this complaint.

We also considered the board’s handling of Ms C’s complaint about a previous CPN. By the time Ms C complained to the board, the CPN had retired, whilst the complaint was also complicated by the fact that it related to a third party. We found that there was a lack of clarity in the reasons the board provided for not investigating Ms C’s complaint. We noted that it appeared that the board could have investigated the complaint, even if only to a limited extent. We upheld the complaint and asked the board to provide a further response to Ms C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not appropriately handling her complaint about her previous CPN having a conflict of interest . 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:

• In line with the NHS Scotland Complaints Handling Procedure, complaint handing staff should support people to decide whether a matter is a complaint or not and explain how complaints are handled. Clear and consistent reasons should be provided where it is considered that an investigation is not possible under the procedure.
• Investigate Ms C’s complaint about her previous CPN having a conflict of interest in line with the NHS Scotland Complaints Handling Procedure and provide Ms C with a response to the extent possible in accordance with data protection legislation.

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 on behalf of his mother-in-law (Ms B) about the care and treatment Ms B's late husband (Mr A) received during his admission to University Hospital Ayr with suspected renal colic (a type of pain experienced when urinary stones block part of the urinary tract). After Mr A collapsed in the hospital he was assessed by a consultant vascular surgeon (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) who suspected a ruptured abdominal aortic aneurysm (a bulge or swelling in the main blood vessel from the heart that has burst). This was confirmed on an urgent CT scan. Mr A was taken to theatre where he died.

Mr C told us that he considered the care and treatment Mr A received was unreasonable because the aneurysm was misdiagnosed for the vast majority of Mr A’s time in the hospital; that no urine test was ever performed and as a result nitrites (nitrites can be a sign of infection) in Mr A’s urine could not have pointed towards the diagnosis of renal colic; no effort was made to investigate or test for an aneurysm prior to Mr A’s collapse; no ultrasound or CT scan was performed prior to Mr A’s collapse; and there was delay in starting the operation once the suspected ruptured abdominal aortic aneurysm was identified.

We took independent advice from a consultant vascular and general surgeon. We found that aspects of Mr A’s care and treatment were reasonable. In particular, that the initial diagnosis of renal colic was reasonable. We noted that once the diagnosis of an aneurysm was made there was no delay in getting Mr A to theatre. However, we found that there was an unreasonable delay in carrying out a CT scan which would have identified the presence of an aneurysm. As such, there was an unreasonable delay in making the diagnosis of a ruptured aneurysm. The board have accepted that the diagnosis should have been considered earlier than it was and have taken action to prevent a similar incident happening again.

We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and the family for the unreasonable delay in carrying out a CT scan and as a result, an unreasonable delay in making the diagnosis of a ruptured aneurysm. 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 presenting with apparent renal colic should have differential diagnosis considered and also be considered for urgent CT scanning.

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, an advocate, complained on behalf of his client (Mr A) about the care and treatment Mr A received from the board when he attended hospital after his GP sent for an ambulance for him. The GP sent for an ambulance after a phone consultation with Mr A's wife, as they suspected that Mr A was having a stroke.

When Mr A was admitted to A&E, he was treated for fast atrial fibrillation (an irregular heart beat) and possible alcohol related issues. Mr A was discharged from the hospital on the day after he was admitted. However, he was admitted to hospital again the following day. A CT scan was carried out and this confirmed that Mr A had suffered a stroke.

Mr C said that medical staff within A&E did not act appropriately when Mr A was originally admitted to hospital and that medical staff unreasonably failed to investigate the possibility that Mr A had suffered a stroke, despite symptoms being identified in his admittance notes.

We took independent advice from an appropriately qualified adviser. We found that there was nothing contained in Mr A records when he was originally admitted that indicated he had suffered a stroke. Based on the evidence and Mr A's presentation, we concluded that it was reasonable for medical professionals to exclude a stroke at that time. However, we noted that Mr A symptoms were suggestive of a transient ischaemic attack (TIA; a stroke lasting for a shorter period, less than 24 hours). The records suggested appropriate consideration was not given to the possibility and symptoms of a TIA. If a TIA had been diagnosed, then the management of Mr A's atrial fibrillation may have been different. This may not have prevented Mr A's readmission or stroke, but could have changed the overall clinical management.

We concluded that medical professionals did not unreasonably fail to identify a stroke when Mr A was originally admitted. However, we concluded that the board did not give appropriate consideration to whether Mr A had suffered a TIA. In light of this, our view was that the board unreasonably failed to provide appropriate care and treatment to Mr A when he was originally admitted to hospital. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to give appropriate consideration to the possibility he had suffered a TIA and as a result, did not include this as part of their atrial fibrillation workup and decision-making with respect to out-patient follow-up and anticoagulation. 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&E staff should be aware of the signs of a TIA and the links between TIAs and arterial fibrillation.

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 mental health care and treatment provided by the board. They also complained about the board's communication in relation to their care and treatment.

C had been referred to psychiatry by their GP because of difficulties with anxiety and depression. C was seen by a psychiatrist who referred them for cognitive behavioural therapy (CBT) and discharged them from their clinic. C was re-referred to psychiatry urgently by their GP a few months later, following a deterioration in their mental health. C saw a psychiatrist three times and was referred for community psychiatric nurse (CPN) support because of the CBT waiting list and C's deteriorating mood state.

C saw a locum psychiatrist four times over a two-month period when C was experiencing a continued deterioration in their mental health. C then saw their original psychiatrist on another two occasions. C's mental health deteriorated further and they were admitted to a psychiatric unit.

We took independent advice from a mental health adviser, who noted from C's records that their clinical presentation was complex and multifaceted. We found that there had been a significant interruption in C's psychiatric out-patient care, with a period of 17 weeks elapsing between appointments. There was a further unplanned and unexplained gap of seven weeks between out-patient appointments. We considered these interruptions to be unreasonable, although we could not conclude with certainty that the interruption to continuity of out-patient care led to the deterioration in C's mental state and subsequent hospitalisation. Although we found that the care planning was reasonable, the significant unscheduled gaps between out-patient appointments were not reasonable, causing continuity of C's care to be disrupted. We therefore upheld this aspect of the complaint.

Overall, we considered that C had been appropriately enabled to participate in decision-making related to their care, but some failings in communication were noted. C did not receive an explanation for the issues with consultant cover which appear to have contributed to the gaps in their psychiatric out-patient care. On balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to clarify precisely when their CBT referral was withdrawn; for the significant unscheduled interruptions to their out-patient psychiatric care; for failing to provide an explanation for the issues with consultant cover which contributed to the gaps in their psychiatric out-patient care; and for the instances of ineffective communication between the psychiatrist and CPN, including that which resulted in a delay in referring C to another service. 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:

• When there are unscheduled interruptions to patient care, the patient needs to be informed of this. There also needs to be clear communication between staff when decisions are made in relation to patient care, such as onward referrals or requests for intervention by other disciplines. The timescales for the action and the person responsible for the action should be made clear, and the request should be appropriately followed up to ensure the action is taken. The board should feed the above back to staff in a supportive manner.

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 is the parent of a teenaged adult (A). A was admitted to an acute admissions ward of a mental health unit as an informal patient. The following day, A contacted C from the ward. A told C that they were in possession of razor blades and intended to self-harm. C contacted the ward to advise them of this and ward staff obtained the razor blades from A. A day later, A contacted C and told C they had left the hospital. C contacted the ward and the police, and A was returned to the ward. A was transferred to another location shortly afterwards. C complained that A had not been properly searched or reasonably assessed on their first arrival at the ward. The board told C that the routine risk assessment at admission had shown no indication A was at risk of absconding, and that this had led to the decision not to lock the ward door. They also said that a check of A's belongings when they were admitted had led to razor blades being taken from A's possession. C was dissatisfied with the board's response and brought their complaint to us.

We took independent advice from a mental health nurse. We found that A had not been properly searched upon their arrival, that it was unreasonable that the board had not carried out a medical, nursing or joint assessment on the day of A's admission and that the standard of assessment and care-planning at the point of admission fell significantly below professional expectations. We upheld C's complaint.

C also complained that the board unreasonably failed to call C, as they had promised, following C reporting A was in possession of razor blades and intended to self-harm. We found that the available written evidence and staff recollection did not support C's recollection that they had been promised someone would call them back. Therefore, we did not uphold C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that they were not properly searched or reasonably assessed upon their arrival at the ward. The apology should meet the standards set out inthe SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Medical/nursing assessments should be carried out and clearly documented as part of the admission process, and each patient has a documented initial care plan based upon the information gathered during the admission assessment process.
• The belongings of patients assessed as being at imminent risk of harm to self or others are checked for the presence of harmful objects or substances.

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 sustained a serious pelvic injury with internal bleeding following a road traffic accident and was admitted to Ninewells Hospital where he underwent surgery to repair the internal bleed and his fractured pelvis. Mr C suffered a further internal bleed and complained that there was a delay in identifying this bleed. Mr C also complained that the physiotherapy input he received following his surgery was unreasonable and may have caused his fracture to move; and that he was provided with inappropriate pain relief and his respiratory rate was not monitored properly.

The board considered that Mr C was monitored appropriately and that any delay in identifying the internal bleed was due to the fact that the CT scan was occupied by another patient. The board also considered that the physiotherapy input and pain relief provided were reasonable.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system), a physiotherapist and a general physician . We found that Mr C was appropriately reviewed and monitored and that there was no unreasonable delay in identifying the internal bleed. We also considered that the pain relief provided was appropriate and Mr C's respiratory rate remained stable. We did not uphold these complaints. However, with regards to the physiotherapy input, we found the standard of record-keeping to be poor and there was a failure to establish a treatment plan with agreed goals. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain all relevant information about him prior to beginning treatment and failing to establish a treatment plan with agreed goals. 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:

• Physiotherapy records should meet the minimum documentation standards and the quality of records should be audited regularly.
• The physiotherapist should reflect on their handling of this case and discuss their learning from it in a supportive manner with their line manager.

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.