Health

Summary

Ms C complained to us about the care and treatment provided to her late partner (Mr A) by Raigmore Hospital during an admission. Mr A was assessed and a crisis plan was agreed; Mr A was then discharged home, but soon after he died. Ms C complained that the board unreasonably discharged her partner home. She also raised concerns about the significant adverse event review (SAER) carried out by the board into Mr A's care and treatment.

We took independent advice from a mental health nurse and from a consultant psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the board carried out an appropriate and systemic risk assessment. We found that a coherent short-term crisis plan was agreed with Mr A, until he could engage with his local mental health services. We found that the decision to discharge Mr A home was reasonable. We did not uphold this aspect of Ms C's complaint.

We found that the board's SAER process and report was reasonable; and it identified appropriate learning. However, we noted that when Ms C complained to the board, they said that they would address her concerns through the SAER. In the circumstances and given the time it took to complete the SAER, we considered that the board should have kept Ms C updated more regularly on its progress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to keep her appropriately updated. 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:

• If the board decides to address a complaint through their SAER, they should then keep the complainant appropriately and regularly updated on its progress.

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

Miss C complained about the care and treatment her late mother (Mrs A) received at Raigmore Hospital after she was admitted with symptoms of bleeding from her stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea). Mrs A died around three weeks later following surgery to revise the stoma (resected ileostomy). Miss C raised concerns that the surgery was unnecessary and Mrs A had not properly consented to it; that the nursing care was poor (in terms of wound management, personal care, repositioning Mrs A and cables that had tied down her hands); and that the board did not handle Miss C's concerns through the NHS Model Complaints Handling Procedure (MCHP) appropriately.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We considered that the decision to operate was reasonable on the basis that Mrs A had multiple admissions in the period immediately prior to this admission and required blood transfusion. In addition, Mrs A had undergone appropriate investigation to identify the source of gastrointestinal blood loss and that the pathology report of the resected ileostomy had confirmed that it was the source of bleeding. In addition, we were of the view that although Mrs A had experienced a rare complication of the surgery, there was no evidence that it had fallen below a reasonable standard. However, we found that there was insufficient evidence to show that any of the recognised risks of the surgery had been discussed with Mrs A. We considered this unreasonable and not in accordance with guidance. Therefore, we upheld this aspect of Miss C's complaint. We noted that the board's investigation had accepted that the documentation regarding communication was of an unreasonable standard and that the staff involved had reflected on their practice for learning and improvement. The board also took steps to amend the surgery consent form to ensure that the recognised risks of surgery are clearly captured.

In terms of nursing care, we found this to be reasonable and appropriate. We did not uphold this aspect of Miss C's complaint.

In relation to complaint handling, we found that the board should have summarised the issues for investigation and checked whether Miss C wanted to provide any further information before they issued their response to the complaint. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings identified in terms of the documentation of communication; the surgery consent process; and the handling of her complaint. 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 surgical staff understand their responsibilities in ensuring important events and communications with the patient or supporter is recorded; and involving patient supporters in decisions about treatment in accordance with the Good Surgical Practice guidance.
• Ensure the current standards of consent are followed as outlined by the Royal College of Surgeons.

In relation to complaints handling, we recommended:

• Ensure complaints are handled in line with the NHS MCHP: www.spso.org.uk/the-model-complaints-handling-procedures

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 client (A) who was admitted to the Royal Alexandra Hospital after fainting at home. A CT scan showed that A had suffered a fractured bone in their neck. A was initially fitted with a collar but C complained that this did not fit well and caused A severe pain and discomfort, to the extent that A's neck injury became worse. Due to A's ongoing pain, a further CT scan was carried out which confirmed that the fracture had displaced (not lined up) slightly. A was referred to the spinal unit at another hospital and was fitted with an alternative form of brace. C complained that A should have been referred to the spinal unit from the outset.

We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We considered that the initial investigations and treatment were reasonable. We found evidence that the fitting of the collar was checked by staff. We also considered that the subsequent change to an alternative brace was reasonable, and there was no indication for an earlier referral to the spinal unit. However, we were critical of a delay in reporting the second CT scan. This was an urgent scan which should have been reported within days, but it was not reported for three weeks. This delay did not cause A harm, but it did prolong their pain and discomfort. The treatment of A's injury was otherwise of a good standard and, on balance, we did not uphold this complaint.

Summary

C complained that the care and treatment they received from the board when they were admitted to Inverclyde Royal Hospital with severe abdominal pain was not reasonable. C raised issues regarding lack of a laparoscopy (a type of surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis without having to make large incisions in the skin being performed), and delays in receiving a CT scan and antibiotic therapy. C had concerns that these issues contributed to the major surgery they ultimately underwent for suspected appendicitis (a painful swelling of the appendix).

We took independent advice from a general surgeon. We found that while a laparoscopy would have been helpful in diagnosing C's condition, it was not unreasonable that the board did not perform one in C's case. However, we found that a CT scan should have been performed earlier in C's admission, particularly when the decision was made not to perform a laparoscopy. We further found that it was unreasonable not to provide antibiotic therapy earlier in C's admission, given their presentation with features of infection. We found it was likely that, had the board performed a CT scan earlier, C would have undergone surgery earlier or received antibiotic therapy sooner, and this would have altered the clinical course with earlier and more minor surgery. As a result, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in their care and 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:

• Patients should be managed so that they receive treatment and scanning based on their clinical presentation at the appropriate time.

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 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.