Health

Summary

C had a number of concerns about their child (A)’s behaviour, development, and educational attainment. A was referred to Child and Adolescent Mental Health Services (CAMHS) in the board. An assessment was carried out, the result of which was that A was not diagnosed with a neurodevelopmental condition.

C complained that the board had unreasonably discharged A from the CAMHS service after having determined that they did not have attention deficit hyperactivity disorder (ADHD), without sufficient consideration being given to other potential diagnoses, and that the board failed to provide reasonable support following the lack of a diagnosis.

We took independent advice from a psychologist specialising in CAMHS. We found that the while the board had ruled out ADHD, their assessment had also considered other neurodevelopmental conditions such as autism spectrum disorder (ASD) and intellectual disability (ID), as well as a broader consideration of A’s circumstances and early life experiences. It was evident that A did not meet the criteria for ongoing treatment via CAMHS and that that the board had carried out a sufficiently thorough and comprehensive assessment prior to discharging A. We also found that appropriate thought and consideration had been given to ensuring that A and C were engaged with the relevant agencies with respect to ongoing support being available, in particular through A’s schooling.

For these reasons, we found that the care and treatment provided to C and A had been reasonable and we did not uphold C’s complaints.

Summary

C complained on behalf of their spouse (A) about the standard of care and treatment received in the months before A died. The board partially upheld the complaint, including failings in communication and a lack of privacy and dignity shown to A.

We took independent advice from a registered nurse. We found that while the board had acknowledged some failings, they had not identified other issues with person-centred care planning, care delivery and documentation. We therefore upheld this part of the complaint.

C complained that the board had failed to communicate with A and their family to a reasonable standard. The board acknowledged that despite C being A’s carer, and it having been agreed to utilise email communication, information was not always shared with the wider team, which may have contributed to C’s perception that communication was lacking. We found that the board’s position that there was no record of any upset between A and individual staff members was factually incorrect. We thereby upheld this part of the complaint.

C complained that there was no record of a care plan, and that the package of care was not adequate for A’s needs. The board acknowledged the lack of a suitable care package had an impact on discharge planning, and that they had failed to establish a more detailed person-centred care plan once A was discharged. We found that there was detailed planning and discussion around discharge involving C and A. We did not uphold this element of the complaint because, on balance, while the delivery of care did not match C and A’s expectations, this did not make the plan unreasonable in the circumstances.

C also complained that the board’s response to their complaint was unreasonable and delayed. We found that C’s complaint was complex and multi-faceted accounting to some extent for the delay. However, the response had inaccuracies and failed to identify all the failings in care. For that reason, on balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures in this case. 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 that person centred care planning is person specific and staff are knowledgeable on how to create a person-centred care plan; that care rounding is completed appropriately, that pain is assessed to the appropriate level and using the correct tools, that privacy and dignity is maintained by all staff for all patients and that staff are aware of how to promote continence and are competent in the use of products used to promote continence.
• Communication with patients and families should be person-centred, full, and accurate.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and identify all failings.

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 Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, C was admitted to the Orthopaedics department of Board 2’s hospital and an MRI was carried out the following day. The MRI scan results were discussed with the Board 1's neurosurgery team, following which C was discharged. C later required emergency surgery and considers the outcome would have been better if they had undergone surgery when they originally attended hospital.

When C complained to Board 2, they confirmed that they had relied on the Board 1’s specialist advice but Board 1 had failed to keep a record of the referral. C complained that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. C also complained about the neurosurgery advice provided by Board 1 to Board 2.

We took independent advice from a consultant orthopaedic surgeon in relation to the complaint about maintaining accurate records. We found that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. We upheld the complaint.

We took independent advice from a consultant neurosurgeon in relation to the complaint about neurosurgery advice. We found that C had been appropriately assessed with a thorough examination. As such, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing 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:

• A system is in place which ensures when advice is provided by the board for tertiary patients there is a record of this as a permanent part of that patient’s electronic record.

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’s elderly parent (A) spent two months in hospital due to extensive bruising on their arms and legs with no obvious cause. A suffered acute hip pain while in hospital and became dependent on oxygen. C complained about concerns that they had regarding many aspects of A’s experiences, including A’s discharge after a few weeks and readmission just over a week later. On the day of readmission, A had been visited by district nurses who had administered morphine to A. A died on readmission.

We took independent advice from an adviser specialising in medicine for the elderly. C complained that A was unreasonably discharged. We found that steps had not been taken to ensure that A and C had been provided with reasonable information about the medication that A had been prescribed. Therefore we upheld this aspect of the complaint. Additionally, C complained that district nurses unreasonably failed to administer an appropriate amount of morphine to A. We found that the district nurses’ should have administered an additional dose after the initial dose of morphine did not take effect. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failures in this case. 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 reflective reviews undertaken to reduce the risk of similar issues emerging in future should have included specific discussion of information about medication being provided to patients and, where appropriate, their carers/families or other support.

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 received by their young child (A). A had a complex congenital (from birth) heart condition. C complained to the board after A received heart surgery, which had been part of the treatment planned for A. C complained that the board did not reasonably respond to C’s concerns prior to A’s operation. C also complained about the timing of A’s admission to hospital and the timing of the operation.

We took independent advice from a consultant paediatric cardiologist (specialist in children’s heart problems). We found that, overall, the board provided excellent care to A and a successful outcome was achieved through A’s surgery. We found that the timing of A’s operation was reasonable considering A’s age. However, we also found that A was not provided with appropriate follow-up plans in relation to care provided before A’s surgery and that A should have been admitted to hospital three days earlier. On balance, 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 case. 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 timely admission to hospital and follow-up appointments, based on their clinical needs and presentation.

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 parent (A). A had presented with foot pain and initially had been thought to have Plantar Fasciitis (an inflammation of the tissue along the bottom of the foot). A later returned to the practice with an infected toe, which failed to respond to antibiotics. A was referred to vascular medicine and later underwent surgery in hospital, but died a few months later. C believed that A should have been referred to vascular medicine sooner, as A was at high risk and displayed symptoms of vascular disease. C was also unhappy with the language used in the complaint response that the family received.

We took independent advice from a general practitioner. We found that A was given a reasonable standard of treatment and care. There was no evidence that symptoms of vascular disease were dismissed or overlooked. We did not uphold this aspect of the complaint. In relation to the language used in the complaint response, we found that the complaint response was inappropriately informal and contained some errors, which added to the family’s distress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the inappropriate language and incorrect dates in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" 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

C complained that the board failed to reasonably respond to their complaint about the way a form was completed by the GP at their GP Practice.

We found that while the board provided regular updates, apologised for the delay and reasonably managed C’s contact, the length of time responding to the complaint and the inaccuracies of the updates provided to C, were unreasonable. The response to the complaint was unclear and did not answer all of the points raised by C. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failures in this case. 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:

• Complaint responses are issued as soon as possible, with the response responding to the main points raised and agreed with the complainant, and any required updates accurately reflect the reasons for the 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 complained about the care and treatment provided to their friend (A) when they were admitted to hospital. A was in hospital for around three and a half months after being admitted with weakness and reduced mobility, with a short history of dysuria (pain or discomfort when urinating) and urinary urgency. A died during their stay in hospital.

C complained about several aspects of the nursing care provided to A. In addition to this, they complained about the physiotherapy input provided to A. Finally, C complained about what they considered to be insufficient detail in A’s death certificate.

In respect of the nursing care provided to A, the board acknowledged that there was learning or areas for improvement. We took independent nursing advice. We found that the board provided A with a reasonable standard of care. We recognised that there was learning to take from A’s experience, however, we did not consider that the care provided unreasonable. Therefore, we did not uphold this complaint.

In respect of the physiotherapy provided to A, we took independent physiotherapy advice. We found that the physiotherapy input provided to A was reasonable, given the circumstances at the time. Therefore, we did not uphold this complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the board. A, who had a history of breast cancer, was admitted to hospital with pain and vomiting. Tests were carried out and A underwent a liver biopsy. Following the biopsy, their condition deteriorated and they died a few days later. C felt that A’s death was premature and was hastened by the actions of the board.

The board said that CT scans showed that A had an abnormal liver and an MRI was requested. This wasn’t completed until eight days later due to high demand. The liver biopsy was undertaken the same day. When A began to deteriorate, an urgent CT scan showed that A was bleeding from an injury to the branch of the cystic artery from the biopsy site. The board said that this is a known complication of a liver biopsy. The bleed was successfully treated but A deteriorated further and died. A had shown signs of potential infection and was commenced on antibiotics. The post-mortem stated that the cause of death was ‘complications of liver biopsy and metastatic breast cancer in liver’, and could not conclude to what extent the infection contributed to A’s death.

We took independent advice from a consultant general and colorectal surgeon. We found that the MRI did not appear to have been reviewed prior to proceeding to biopsy and the breast team were not notified of the CT scan results. We also noted that A was not referred to the breast cancer multidisciplinary team (MDT). We found that antibiotics should ideally have been administered within one hour of deterioration and sepsis considered as a main cause of A’s deterioration. A was also given a cystic artery embolization (a minimally invasive procedure that blocks or closes the blood vessel) and two units of blood despite having a normal blood count and no evidence of significant bleeding. Therefore, we upheld this part of C’s complaint.

C complained about communication with A and A’s family, stating that A was not given sufficient information about their condition or results from tests. A’s family were unaware of test results until after A’s death. We found that communication with A and A’s family was unreasonable and that there had also been an absence of communication with the breast team and MDT, which was a missed opportunity. We upheld this part of C’s complaint.

C complained that the board unreasonably failed to undertake a Significant Adverse Event Review. We found it was unreasonable for the board not to have undertaken a Significant Adverse Event Review. This was a missed opportunity to reflect on A’s care and treatment, and identify learning from these events. We upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment to A, the failure to communicate to a reasonable standard and the failure to undertake a Significant Adverse Event Review. 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:

• Plans for investigations, especially of an invasive nature, should be adequately discussed with the patient, including where there is a suspicion of malignancy.
• Relevant clinical teams should be involved, especially where investigations were initiated prior to admission. Sepsis should be appropriately considered as a reason for deterioration, and wherever possible, antibiotics be administered within an hour of deterioration. Appropriate treatment should be given based on clinical signs and symptoms.
• Significant Adverse Event Review’s should be completed in line with the national framework and the board’s own protocols.

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 post-operative care and treatment that they received from the board after they suffered a leg and ankle fracture. C said that unreasonable post-operative care led to a poor recovery and the requirement for an additional operation.

We took independent advice from a consultant orthopaedic surgeon (specialists in the treatment of diseases and injuries of the musculoskeletal system). We found that the board failed to report some x-rays and to reasonably explain why further x-rays were taken and who had reviewed them. We also found that there had been an unreasonable delay in carrying out a CT scan and in discussing C’s case at a Morbidity and Mortality meeting. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board handled C’s complaint reasonably and did not uphold 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:

• A patient’s medical records should document the reasons why a scan(s) has been taken and who has reviewed them. The results should be recorded on the hospital’s clinical portal system.
• There should be processes and guidance in place to ensure when it is appropriate to carry out a CT scan.
• Where a patient’s case is appropriate for discussion at a Morbidity and Mortality meeting, this should take place as soon as possible.

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.