Health

Summary

When C became a patient of the practice their 'as required' medication was reduced and stopped. Within a couple of years C moved to another GP practice. They complained to the practice that the decision to reduce and stop their medication had been unreasonable, that they had not been reasonably monitored following the ending of these prescriptions and that the practice had failed to provide their notes to the new practice within a reasonable timescale. The practice responded that they felt the decision to stop medication had been reasonable and that C had received good and safe clinical care. They also stated that, while one specific summary part of C's notes had not been provided to the new practice initially, this had been corrected as soon as they had been made aware of it, and they had apologised for it.

We took independent advice from a GP adviser. We found that the decision to stop the medication was reasonable in principle given C's circumstances and the possible long-term effects of their use; that the withdrawal was carried out in line with applicable guidance; that a reasonable level of follow-up was provided; and that the practice's explanation that the failure to provide part of C's medical record to the new practice had been reasonable. We did not uphold C's complaints.

Summary

Mr C complained about the care and treatment his late brother (Mr A) received at Queen Elizabeth University Hospital (QEUH). Mr A had a number of complex medical conditions; he had previously undergone liver transplantation and suffered a brain aneurysm. Mr A was admitted to QEUH for treatment associated with an unusual resistant form of cytomegalovirus (CMV, a virus). Mr A's health deteriorated during his admission and he died in hospital.

Mr C complained that the board failed to provide Mr A with reasonable clinical care and treatment. Mr C also raised concerns that there was a lack of reasonable communication with him and his family about Mr A's care and treatment.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines); a consultant in critical care and anaesthesia with experience in transplant services and a senior nurse.

We found that there were aspects of Mr A's care and treatment that were reasonable. In particular, in relation to the management of Mr A's blood pressure and the fall in his platelets. When Mr A's condition deteriorated, there was no unreasonable delay in escalating him to the intensive care unit (ICU). In relation to the staff caring for Mr A, there was clear evidence of regular reviews and consultation and liaison between a large number of different specialists at QEUH and the transplant unit.

However, we identified the following failings in Mr A's clinical care and treatment:

For a period of time it was not noticed that there was an unintentional co-adminstration of two medications. While, on balance, any impact was limited and was not a significant contribution to Mr A's eventual outcome, this should not have occurred and was an omission in care. This was acknowledged by the board and appropriate action was taken.

We found that there was a lack of recording of Mr A's titres (level of virus). In addition, insufficient consideration was given to carrying out further investigations in order to confirm a diagnosis of Mr A having posterior reversible encephalopathy syndrome (PRES, a rare condition in which parts of the brain are affected by swelling) rather than CMV encephalitis as a possible alternative diagnosis.

Mr A had infected CMV that was known to be resistant to valganciclovir (antiviral medication) and the decision to restart Mr A on this medication was unreasonable. As this treatment was ineffectual, an alternative treatment should have been considered. Whilst it was wrong to use valganciclovir, on balance, taking account of the evidence any impact was limited and was not a significant contribution to Mr A's eventual outcome.

We found that communication with Mr A's family was reasonable while he was in ICU. However, prior to this communication with Mr A's family could have been better and their concerns about aspects of his care and treatment did not appear to have been reasonably addressed.

Mr C further complained that the board's investigation of and response to his complaint was inadequate. The board acknowledged that their complaint response letter was not issued within 20 working days in terms of the relevant guidance. Given the complexity of the complaint, we considered that the delay in providing a response was reasonable in the circumstances. However, we identified an error in the board's calculation of when the 20 day working period for providing a response to Mr C's complaint started. Following the issue of the board's response to the complaint, Mr C had contacted the board making further comment. We considered that the board should have informed Mr C when he could reasonably have expected to receive a response to his further correspondence and if there was going to be a delay in providing this. However, this had not happened.

We upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family that insufficient consideration was given to carrying out further investigations in order to confirm a diagnosis of PRES; about the decision to restart valganciclovir and not to have considered an alternative treatment for resistant CMV; for the failure to record Mr A's titres; for the lack of reasonable communication with Mr C and his family about Mr A's care and treatment; and for the failings identified in complaint handling. 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 appropriate investigation prior to confirming a diagnosis of PRES. Decisions about medication should be reached after careful consideration of the effectiveness of the medication and potential side effects. There should be appropriate recording and monitoring of a patient's condition and this should be documented.
• Communicating significant news, especially bad news, to a patient and/or their family should be carried out in a clear and sensitive manner and without any unreasonable delay.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and in accordance with the board's Complaints Handling Procedure. The board should aim, whenever possible, to inform a complainant about when they should expect to receive a response to their communication and if there is going to be a delay in providing this.

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 attended the practice with a growth on their face. When after initially being prescribed antibiotics the growth remained, the practice referred C to the local NHS board's plastic surgery department as a routine referral. C contacted the practice some months later as the growth had enlarged and C was experiencing other symptoms. The referral was upgraded to urgent and C was seen by the plastic surgery department shortly after. C was subsequently diagnosed with a malignant tumour and underwent further treatment by the board after the diagnosis.

C complained to the practice about the treatment that they received. C said that if the malignant tumour had been diagnosed sooner, then the treatment to remove the tumour would have been less invasive and impactful on their appearance. The practice responded via the local NHS board. Dissatisfied with the response, C brought the complaint to our office.

We took independent advice from a GP. We found that the practice's working diagnosis of a sebaceous cyst (a common non-cancerous cyst of the skin) was reasonable, with appropriate treatment provided, initially with antibiotics and, when the cyst remained, with a referral to the local NHS board's plastic surgery department. We considered that the skin cancer had presented atypically, and it was therefore reasonable that the practice initially considered the lesion to be a benign lesion, rather than an atypically presenting cancerous lesion. When it was reported that the lesion had grown and C was experiencing other symptoms, the practice reasonably escalated C's referral to urgent. We did not uphold the complaint.

Summary

Mrs C, an advice worker, complained on behalf of her client (Ms A) about the treatment which Ms A received following admission to Aberdeen Royal Infirmary with symptoms of right upper quadrant pain and inflammation. Investigations led to a diagnosis of chronic cholecystitis (inflamed gallbladder). Treatment options were considered and it was decided to insert a drain, rather than perform surgery at that time, with a referral to a hepatobiliary surgeon (surgeon specialising in the treatment of the liver, bile duct and pancreas) for ongoing treatment. Ms A was discharged home but was readmitted to hospital as an emergency due to further right upper quadrant pain and required surgery. By the time of readmission, Ms A had not received any correspondence from the surgeon. Ms A said that surgery should have been performed during the initial admission and that the delay in treatment caused her additional health problems.

We took independent advice from a consultant in general surgery. We found that Ms A had multiple medical problems and that upon admission to attempt keyhole surgery would be impossible and open surgery would be challenging. It was appropriate to discharge Ms A with a drain in situation for follow-up by specialists at a later date. Although there were gaps in communication with Ms A, this did not impact on her clinical treatment. We did not uphold the complaint.

Summary

C was referred to the board's plastic surgery department with a suspected sebaceous cyst (a common non-cancerous cyst of the skin) as a routine referral. It was found that C had a squamous cell carcinoma (a type of skin cancer). After diagnosis of the cancer C subsequently underwent treatment to remove it. After surgery the board's district and community nurses managed C's wound in the community. C complained about the treatment provided by the board and subsequent wound care.

We took independent advice from a consultant plastic surgeon. We found that the board's investigation, diagnosis and treatment of C was reasonable and met the waiting times specified by the Scottish Government in 'Better Cancer Care, An Action Plan'. While there had been some communication failings, the treatment provided was reasonable. We did not uphold this aspect of C's complaint.

We took independent advice from a nurse regarding C's wound care. We found that the wound care provided by the board was unreasonable. It was not evidenced that C's wound had been seen and assessed by an appropriate clinician before agreeing how the wound would be cared for. The board accepted there was a lack of documentation relating to C's wound care. 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 provide reasonable wound care to them. 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:

• Wounds should be assessed by an appropriate clinician before determining the best course of treatment.

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 that the board delayed in arranging the surgery she needed. She was entered onto the list for surgery at a gynaecology (medicine of the female genital tract and its disorders) out-patient clinic, but said that she was told months later that they were only carrying out surgery for patients entered onto the list in the previous year. She decided that she could not wait for the surgery and had it privately.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We found that there had been a delay in arranging the surgery and we upheld the complaint. However, we also considered that the action the board were taking to reduce waiting times was reasonable. This included addressing their referral pathways and seeking to increase their consultant capacity. In addition, the board had apologised to Ms C that they had failed to meet the treatment time guarantee. When the board had received contact from Ms C's GP about the delay, they had acted on this quickly and a plan for escalation was commenced. We did not, therefore, recommend that Ms C was reimbursed for the costs of the operation, as we were unable to conclude that Ms C had no option but to arrange treatment privately. We did not make any recommendations to the board in relation to Ms C's complaint.

Summary

C complained about the care provided by the board during their admission to Woodend Hospital. C said that the board unreasonably administered an overdose of an opioid drug. We took independent advice from an appropriately qualified adviser. We found that the board failed to follow local protocol and unreasonably administered an opioid drug to C. We upheld this part of C's complaint.

C also complained that the board failed to reasonably monitor them after they underwent an operation. C was being monitored using National Early Warning Score (NEWS). NEWS is a guide used by medical services to quickly determine the degree of illness of a patient. We found that when C triggered a NEWS score of one, they should have been observed every four hours, however C was next observed 11 hours later. This was unreasonable and we upheld this part of C's complaint.

C complained that their spouse (B) was unreasonably communicated with after their condition deteriorated. We found that while it was identified in the morning of that day that B should have been contacted, B was not made aware of C's condition until they entered the ward almost eight hours later. This was unreasonable and we upheld this part of C's complaint.

The board said that they had already taken action in response to these failings. We asked them to provide evidence of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for failing to communicate with them in a timely manner.
• Apologise to C for the failings as identified by the board and from our investigation. The apologies 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

C complained that their partner (A) was prematurely discharged from the Golden Jubilee National Hospital following cardiac surgery. The surgery was successfully performed with no reported complications. A was discharged home from hospital as staff deemed they were clinically fit for discharge. C was concerned that A had been discharged as they had severely swollen feet. A's health deteriorated, and days after discharge an ambulance was called as A had severe shortness of breath and a high temperature. A was then admitted to another hospital where they were an in-patient for several weeks.

We took independent advice from a cardiology consultant (doctor who deals with diseases and abnormalities of the heart). We found that insufficient action was taken to establish the extent of A's heart failure and possible wound infection prior to their discharge from the Golden Jubilee National Hospital, which amounted to a failing in the standard of care and treatment required. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failure to ensure their symptoms of severe fluid retention and possible infection were resolving prior to discharge from hospital. 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:

• Staff should ensure that, where a patient shows symptoms of severe fluid retention and possible infection, appropriate clinical investigations take place to ensure that the symptoms are resolving prior to hospital discharge.

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 on behalf of her husband (Mr A) about the treatment he received when he attended A&E of Forth Valley Royal Hospital due to experiencing pain that had started in his neck and had travelled to his hands. In particular, Mrs C was concerned that there was a delay in diagnosing Mr A with sepsis (blood infection).

Mr A had been examined and then discharged to the care of his GP on the same day. We found that there was no evidence that Mr A had sepsis at that time. A diagnosis of sepsis requires a source of infection and evidence of abnormal physiology; however, the urinalysis showed no signs of infection. Therefore, there was no failure to identify sepsis at this stage. The following morning Mr A was taken by ambulance to hospital and was admitted again. Mr A was diagnosed with a urinary tract infection and then developed sepsis. While we did not consider there to be a failure to diagnose sepsis, Mr A is a diabetic and we found that there was a failure to carry out a bedside blood glucose finger prick test during his first attendence at hospital given glucose was found in Mr A's urine following the urinalysis. On this basis, we considered that the board failed to provide Mr A with reasonable care and treatment. Therefore, we upheld this complaint.

Mrs C also complained about the response she received to her complaint regarding the content of the discharge letter to Mr A. The response to the complaint correctly stated what was in A&E notes (the GP was to consider referring Mr A to neurology (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system)), but the discharge letter to Mr A's GP did not mention this. We upheld the complaint on the basis that the discharge letter should have contained this information and the complaint response should have identified this discrepancy. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for (a) an unreasonable failure to carry out a bedside finger prick blood glucose test; (b) an unreasonable failure to include within the discharge letter to Mr A's GP information about a possible GP referral to neurology; and (c) a failure to ensure the response to the complaint correctly reflected what was in the discharge letter to the GP regarding a neurology referral. 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:

• To ensure clinical staff are aware of the circumstances in which a bedside fingerprick blood glucose test should be carried out.
• To ensure clinical staff include relevant information in discharge correspondence to GPs.

In relation to complaints handling, we recommended:

• To ensure the facts of an investigation are correctly reported to a complainant.

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 daughter (Ms A). Ms A was suspected to have gallstones (small stones that form in the gallbladder) and was referred for laparoscopic (keyhole) surgery. During the surgery Ms A's gallbladder could not be located and following further investigations, it was confirmed that Ms A had gallbladder agenesis (absent from birth). Mr C complained that Ms A's surgery could have been avoided had further investigations been performed when it was observed during the ultrasound that the gallbladder could not be definitively seen. Mr C also complained about the board's handling of his complaint. The board said that they considered the appropriate investigations were carried out and that further scans prior to surgery were not clinically indicated.

We took independent advice from a consultant surgeon. We found that the conclusion of Ms A's scan, which stated it was “suggestive of a contracted bladder” was reasonable on the basis that gallbladder agenesis is sufficiently rare. Further scans were not warranted in this case as Ms A did not meet the criteria. We also concluded that, while the board's final response to the complaint was somewhat delayed, the delay was reasonable in the circumstances. We did not uphold Mr C's complaints.