Health

Summary

Mr C complained that the board had not made reasonable decisions around whether to provide plasma exchanges (a procedure which separates your blood into its different parts: red cells, white cells, platelets and plasma. The plasma is removed from the blood and replaced by a plasma substitute) to his wife (Mrs A) and whether to further explore the possibility of thrombectomy (procedure of removing a blood clot from a blood vessel), or reasonably monitor her levels of consciousness during an admission to hospital following a stroke. We found that the board's decisions around plasma exchanges and the possibility of thrombectomy had been reasonable, but that the board had not reasonably monitored Mrs A's levels of consciousness for a period. This meant that there was a delay to the board providing her with specific treatment. Although this treatment had only a small chance of success, we decided that the board's actions had been unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained about how the board had responded to his complaint. We found that the board's responses had been reasonable and did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A's family for their unreasonable failure to monitor Mrs A's consciousness levels hourly, which caused a delay in providing reasonable treatment to her. 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 reasonably monitor patients' consciousness levels.

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, an advocate, complained on behalf of their client (A) about the care and treatment A received at St John's Hospital when they attended after becoming unwell with vomiting. A had also been suffering from migraines over the previous few days. C complained that there was inaccurate reporting of the CT angiogram (a specialised scan using x-rays to look at the heart) which resulted in a delay in diagnosing a stroke; there was a delay in performing a lumbar puncture; and there had been a lack of consistent communication with the family. C also complained that A was not treated fairly due to comments made by staff about their previous medical history and that they did not receive assistance with personal care.

The board accepted that there was a failing in relation to the provisional report of the CT scan and this would have initiated treatment for A's stroke at that time. The board apologised and said that they would highlight the case at their local learning meeting. The board accepted that there was no documented evidence to support that A was receiving help with personal care, for which they apologised. However, they noted that there were regular attempts to keep A and their family updated on care.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), from a consultant in general medicine and from a registered nurse. We found that, while many aspects of the medical care provided were reasonable (including the timing of the lumbar puncture), there was an unreasonable error regarding the provisional CT scan. This meant that there was a delay between the scan being performed and it being correctly reported. We upheld this aspect of the complaint.

We considered that A would have received medication, such as aspirin, to thin their blood earlier, but the effect of this is to prevent future strokes rather than improve the one that has currently occurred. While this would have added to the distress of A's family, we were of the opinion that the impact on A's clinical outcome would not likely have been significant.

We found evidence of reasonable communication and did not consider that inappropriate comments were made about A's previous medical history. However, we were unable to establish that A received a reasonable level of assistance with personal care because the nursing documentation fell below the record-keeping standards set out in the Nursing and Midwifery Code. Therefore, we upheld this aspect of the complaint.

Recommendations

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

• Patients should receive personal nursing care where appropriate; and this should be clearly and accurately recorded in accordance with the Nursing and Midwifery Code.
• The board should minimise the contribution of any system deficiencies to radiological errors.

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 about the way the practice removed his Duloxetine medication when he reported that it was not giving him adequate pain relief. When the medication was removed Mr C suffered from withdrawal symptoms and had to be admitted to hospital.

We took independent advice from a GP. We found that the practice had reduced Mr C's medication in line with accepted medical practice, while at the same time introducing an alternative painkilling medication. Unfortunately, Mr C then developed some signs of withdrawal, but this was not as a result of inappropriate medical treatment. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment he received at University Hospital Monklands in relation to hip pain. In particular, Mr C was concerned that the board mismanaged his condition and did not identify that he required a hip replacement following scans and x-rays.

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 the care and treatment provided to Mr C was reasonable. We noted that, based on the findings of the x-rays and the scan, there was no indication that Mr C should have been offered surgery at that time. We did not uphold Mr C's complaint.

Summary

C's spouse (A) suffered from chronic pancreatitis (inflammation of the pancreas) and was receiving care and treatment from the board. A attended hospital multiple times over several months. A was discharged home but the following day they were admitted again with significant pain and died.

C complained to the board, raising a number of specific questions about the treatment provided to A and was of the view that more could have been done to help A.

We took independent advice from a consultant general surgeon. We found that while during the majority of A's admissions, the treatment provided by the board was reasonable, there was a significant failing in relation to A's discharge the day before their death. At the time A was discharged, their observations were still abnormal, A's pain score remained high and there was no evidence that the blood test results had been reviewed prior to discharge. We concluded that to discharge A at that time was unreasonable. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable 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:

• Ensure there is a clear policy in place on discharging patients with abnormal observations from A&E.

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 their discharge from hospital. The discharge letter to C's GP said that C would be followed up by a consultant psychiatrist in an out-patient clinic and by C's community psychiatric nurse (CPN). C attended the consultant psychiatrist's out-patient clinic. Based on their assessment of C on that day, the consultant psychiatrist discharged C from the clinic. Later, C became concerned about a related matter. When pursuing this further, C spoke to their GP who told C that they had been discharged from the consultant psychiatrist's clinic. C complained to the board that they had not been advised of being discharged. The board told C that the consultant psychiatrist recalled that the discharging had been discussed. C disputed this and also complained that a promised referral for CPN follow-up had not taken place. The board reiterated their response regarding the discharge and explained that a referral to a CPN was not felt to be required following an occupational therapy assessment in the days following their discharge from hospital. The board apologised that this had not been communicated to C appropriately. C was dissatisfied and raised their complaints with this office.

We took independent advice from a suitably qualified adviser. We concluded that the failure to action the promised referral for CPN follow-up had been reasonable in the circumstances and that the available evidence indicates that C was advised that they would be discharged by the consultant psychiatrist. We did not uphold C's complaint.

Summary

C complained about the ophthalmology (eye) care and treatment provided by the board when they had surgery for cataracts (when the lens, a small transparent disc inside the eye, develops cloudy patches). There had been a complication during the procedure which meant that C had to undergo further surgery at a later date. C was concerned that the procedure was not carried out appropriately and that the follow-up was not reasonable.

We took independent advice from an ophthalmologist. We found that all aspects of care, from the decision to carry out cataract surgery and do this under local anaesthetic, to the management and follow-up of the complication, was appropriate. We therefore did not uphold C's complaint.

Summary

C complained on behalf of A, who has a history of complex congenital heart disease (a problem with the structure of the heart). A was admitted to Hairmyres Hospital, treated for paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate) and a possible chest infection, and discharged a few days later. A was readmitted to hospital three weeks later and diagnosed with endocarditis (an infection of the heart valves). A said that they had asked a doctor specifically about endocarditis during the first admission, but the doctor told them they had been tested for endocarditis and did not have it. C complained that A should have had blood cultures (a test used to detect bacteria or fungi in a person's blood) taken to test for endocarditis during this first admission.

The board did not uphold C's complaint. They said that doctors considered whether A had endocarditis, but ruled this out because A did not have symptoms of endocarditis at the time. The doctor said they told A that tests showed they did not have a significant underlying infection, but not that they had been tested specifically for endocarditis.

We took independent medical advice from an appropriately qualified adviser. We found that endocarditis was considered, but it was reasonable for doctors to rule this out based on the evidence at the time. We also found that it was reasonable for doctors not to take blood cultures during this admission, based on A's symptoms. The medical records stated A was told that they did not have a 'significant infection' (rather than endocarditis specifically), and we did not consider A was given incorrect information about being tested specifically for endocarditis. We did not uphold this complaint.

Summary

Mrs C, an MSP, complained on behalf of her constituent (Ms A). The complaint related to the care and treatment provided by the board to Ms A's late partner (Mr B) who died by suicide.

Mrs C complained that the board had failed to provide appropriate care and treatment in respect of Mr B's mental health. We took independent advice from a consultant psychiatrist. We found that the care and treatment the board provided was reasonable and appropriate. We acknowledged that we could not know for certain what was discussed between clinicians and Mr B or Ms A. However, we concluded that the records made by different clinicians were consistent with each other and the board provided appropriate care and treatment to Mr B, based on the information known at the time. The board had acknowledged some failings in respect of providing information about self-referral to addiction services. However, we considered that this related to communication rather than care and treatment. As such, we did not uphold this complaint.

Mrs C's second complaint was that Mr B's medical records repeatedly state he was using cannabis in the days before his death. However, the post-mortem and toxicology report indicated that there were no drugs in his system when he died. Mrs C complained that the board had not provided a satisfactory explanation for this. The board said that they could not establish why the post-mortem and toxicology report did not find drugs in Mr B's system or explain the apparent contradiction between this and the medical records. We were not able to confirm exactly what was discussed during the consultations before Mr B's death. However, given the consistency of the medical records, it was reasonable to conclude that the understanding of the clinical staff who reviewed Mr B was that he was using cannabis on an ongoing basis at that time. Therefore, we did not uphold this complaint.

Mrs C also complained that the board's out-of-hours service failed to respond to Ms A's request to provide medication for Mr B in a reasonable or appropriate manner. Ms A stated she was told that urgent medication to calm Mr B down could not be issued and that she felt her concerns were dismissed. We took independent advice from a GP. We found that the care and treatment provided by the out-of-hours service was reasonable and appropriate. We found that the decision not to provide or prescribe medication was appropriate and in line with relevant guidance. The out-of-hours service appropriately arranged an appointment with the Community Mental Health Team and advised Mr B to attend the emergency department if necessary. We did not uphold this complaint.

Finally, Mrs C complained about how the board handled Ms A's complaint and the standard of their communication during the complaint process and related reviews. In particular, Mrs C highlighted what they considered to be miscommunication over the scope and process of the review, delays in the board issuing their stage two complaint response, and questioned the investigating officers impartiality.

We found that it was appropriate for the board to carry out a Suicide Review before issuing a stage two complaint response. Although it took longer than the standard 20 working day timescale for the board to provide a stage two response, we did not consider their handling of the complaint to be unreasonable. We did not consider there to be any evidence that the investigating officer failed to investigate the complaint impartially. We also noted that comments provided by other senior staff during the course of the complaint investigation were reflected accurately in the stage two response. We considered the handling of the complaint to be reasonable and did not uphold this complaint. However, we acknowledged there was some confusion caused by the board referring to both a Significant Adverse Event Review and a Suicide Review and fed this back to them.

Summary

C's parent-in-law (A) suffered from symptoms that they later learned were caused by having a stroke, and was taken by emergency ambulance to University Hospital Monklands. A CT scan carried out that day was reported as normal, but A's condition continued to deteriorate and they were admitted to the intensive care unit and put on life support. The following day, a repeat CT scan was performed which showed evidence of A having had a severe stroke and, following discussions with family, their life support was switched off and they died. C was concerned about the time it took staff to diagnose A with a stroke.

We took independent advice from a medical adviser. We found that the management of A including investigations and treatment decisions were appropriate and carried out within a reasonable time. Clinicians considered the possibility that A had a stroke and took appropriate action by arranging a CT scan, and then a further CT scan the following day. We did not uphold the complaint.