Health

Summary

Miss C complained about the care and treatment the board provided to her late father (Mr A). Her concerns related to the board's out-of-hours service and care provided at Dumfries and Galloway Royal Infirmary.

Mr A had been unwell and the board's out-of-hours service was contacted. Mr A was subsequently admitted to hospital with signs of infection but later discharged himself. He was then readmitted after it had been identified that he had staph aureus bacteraemia (SAB, an infection). Subsequently, Mr A suffered a gastrointestinal bleed (bleeding on the digestive tract, and a symptom of a disorder), and developed kidney failure. Mr A then also developed severe heart failure. He was discharged for palliative care and died shortly thereafter.

We took independent advice from a GP, a consultant in acute medicine and a nurse. In relation to the treatment provided by the board's out-of-hours service, we found that it was reasonable that a GP did not visit Mr A at home, based on the situation and what was known at the time. We did not uphold this complaint.

In relation to Mr A's admissions to Dumfries and Galloway Royal Infirmary, we found that during Mr A's first admission staff had provided reasonable reviews, tests and treatment for Mr A, and the level of clinical care and his treatment was reasonable. However, it had been identified after Mr A left hospital that he had SAB and we found that there was a failure to recognise or act on the seriousness of the SAB result and start proceedings to bring Mr A back to hospital and obtain treatment. In relation to Mr A's second admission, we found that Mr A was given intravenous potassium too quickly and that there was a delay in receiving a transoesophageal echocardiogram (an ultrasound test that uses sound waves to produce moving, real-time pictures of the heart) though it would not have changed his treatment. As such, we found that there were unreasonable failings in the clinical care and treatment provided to Mr A. We upheld this complaint.

In relation to the nursing care provided to Mr A, we found that there was a lack of evidence of day-to-day nursing care, significant failures in record-keeping by nursing staff and a scarcity of relevant nursing records. There were some areas of concern in relation to Mr A's fluid balance and shortcomings in the pressure care provided to Mr A. We also found failings in communication between nursing staff. Therefore, we found that there were unreasonable failings in the nursing care provided to Mr A. We upheld this complaint.

Miss C further complained that the board failed to communicate reasonably with her about Mr A's care and treatment. We found that medical staff had communicated reasonably with Miss C. However, we found there were shortcomings in how nursing staff communicated. In particular, there were limited references to communication, and where they existed, they were prompted by Mr A's family, not by staff. We therefore found there was a failure by nursing staff to communicate reasonably with Mr A's family. As such, we upheld this aspect of Miss C's complaint.

Miss C also complained that the board had failed to respond reasonably to her complaint. We found that there were a number of failures by the board in their handling of Miss C's complaint. We found that there was an unreasonable delay in acknowledging Miss C's complaint, a repeated failure by the board to meet their own timescales to finalise the complaint response letter or request a further extension and a lack of clear communication with Miss C. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings this investigation has 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 SAB result should prompt staff to review the patient, repeat blood cultures, give consideration to the investigations needed to find the source, and provide treatment. Relevant staff should be aware of the correct rate for administering intravenous potassium. Where a transoesophageal echocardiogram is planned, this should be carried out as soon as possible.
• The board should have systems in place to ensure the quality of day-to-day nursing care and record-keeping.
• Ward nursing staff should communicate with a patient and their relatives and ensure that any communications are appropriately recorded in the nursing notes.

In relation to complaints handling, we recommended:

• Complaint investigations and responses, including acknowledgement of receipt, should be in accordance with board's complaints handling procedure. The board should, whenever possible, 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 agreed to specialist reconstructive surgery, underwent their treatment, but experienced urinary incontinence thereafter. C said that they had believed the surgery would be of a routine nature and felt that they had not been not provided with adequate information about it; in particular, that a possible side effect was incontinence.

The board said that they could not comment on the information provided about the procedure as it was care provided by another board. We found that, while the procedure itself was carried out in another health board area, it was clear from the board's records that the procedure in question was discussed with C at a consultation within Borders NHS board and their agreement to proceed with the procedure was obtained.

We took independent advice from a urology (specialists in the male and female urinary tract, and the male reproductive organs) adviser. We found that the board failed to provide adequate information to C about the planned procedure prior to obtaining their consent. Therefore, we upheld this complaint.

C also complained that the board failed to provide them with reasonable aftercare in that they had to arrange follow-up care independently and had to undergo a further unnecessary test. The board said that C's discharge letter, outlining need for aftercare, was not copied to them by the board who carried out the procedure and acknowledged that C had to arrange follow-up care independently. We found that the board did not receive information about required aftercare from the other board and that the further test was necessary. Therefore, we did not uphold this complaint.

C also complained that the board failed to handle their complaint reasonably. We found that the board did not respond to a specific concern raised in C's complaint and as such we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with adequate information about the procedure and its recognised complications prior to obtaining their consent and for failing to handle their complaint reasonably. 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 consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery. As part of the consent process, there should be a clear discussion of the risks and benefits (of having the surgery and not having the surgery) and of any alternative options; and those discussions should be clearly documented.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes responding to all aspects of complaints.

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 by the ear nose and throat (ENT) clinic. C had been referred to the ENT clinic to have a nasal polyp (a painless soft growth in the nose) removed as they had been suffering sinus congestion. Prior to the procedure, C contacted the ENT clinic to advise they were suffering with severe tinnitus (ringing or buzzing in the ears) and cluster headaches. C complained that their concerns regarding tinnitus were not taken seriously and that there was a lack of follow-up once treatment had been provided.

We took independent advice from an ENT consultant. We found that appropriate referrals to neurology (the area of medicine that deals with disorders of the nervous system) and audiology (the area of medicine that treats those with hearing problems balance and related disorders) had been made and that there were no significant failings in the care and treatment provided to C in respect of their concerns. We did not uphold the complaint.

Summary

Miss C attended the Maternity Assessment Unit (MAU) at Crosshouse Hospital after suffering a bleed at home. Miss C had had a caesarean section at the same hospital a few weeks earlier. Miss C was reviewed by staff and an ultrasound scan was taken. Staff concluded the bleeding was likely related to Miss C's period starting and she was discharged home. Miss C was readmitted to the same hospital days later after she collapsed at home and was transferred to the Maternity High Dependency Unit where a further scan revealed a blood clot in the uterus. Miss C complained that she had received poor care at the MAU and that it was wrong to send her home only to be readmitted at a later date.

We took independent advice from a consultant. We found that staff performed appropriate investigations when Miss C attended the MAU, that it appeared her symptoms were improving and that there was no clinical reason for a hospital admission at that time. We did not uphold the complaint.

Summary

C complained to us that the board had unreasonably given their child (A) an overdose of morphine. We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that A had received an overdose of morphine as a result of a doctor failing to discard excess morphine from a syringe and giving them the full syringe. We upheld this aspect of the complaint.

C also complained that the board then failed to carry out observations on A appropriately after the error was identified. We found that staff had recognised the need for close observation, but the observations were not clearly documented in A's clinical records and we were unable to say definitively whether or not the observations were carried out appropriately. Therefore, we upheld this aspect of the complaint.

Finally, C complained that the board had failed to provide a reasonable response to their complaint. We found that there had been an unreasonable delay in responding to the complaint. Also, there was no evidence that the board had kept C updated during this time. We upheld this aspect of the complaint.

We noted that the board had already apologised for these failings but we made further recommendations for learning and improvement.

Recommendations

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

• The board should review their guidelines for administration of intravenous medication in light of the findings of this investigation and ensure there are explicit instructions on how to deal with situations where only part of the prepared dose is to be administered.
• Patient monitoring and observations should be appropriately recorded in the medical records.

In relation to complaints handling, we recommended:

• Where an investigation takes longer than 20 working days, the board should inform the complainant, agree revised time limits, and keep them updated on 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

A GP practice contacted the Scottish Ambulance Service (SAS) to request that C's grandchild (A) be transferred from a local hospital to a hospital with a paediatric unit after A became unwell with suspected meningitis. The practice prioritised the request as urgent, therefore requiring a response within an hour. SAS contacted the practice to request approval for a delay in responding to the request. The practice agreed to the extension based on the information provided by SAS.

C complained that the time taken for A to be transferred to the main hospital was unreasonable for A's suspected ailment. C considered that an air ambulance should have been sent to transfer A to the main hospital.

We took independent advice from a consultant paramedic. We found that the SAS failed to provide the practice with accurate clinical information about A on which the practice could base their decision to agree or refuse the extension to the transfer time. As SAS failed to obtain confirmation from the local hospital that A's condition was unchanged, and therefore the practice's decision to agree to the delay was based on incomplete information, we upheld this aspect of the complaint.

C also complained that SAS's response to their complaint was unreasonable. We found that the investigation of the complaint did not identify SAS's failure to provide accurate information regarding A's condition to the practice. As a consequence, the complaint response failed to provide an accurate account of how the decision was made to delay the transfer. For this reason we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C, and A's mother, for SAS staff failing to share accurate clinical information on A's clinical condition with the GP.
• Apologise to C for failing to provide a reasonable response to their complaint. The apologies 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:

• SAS staff should provide accurate clinical information on a patient's clinical condition with relevant healthcare professionals.
• SAS staff should seek relevant information where necessary from the healthcare professionals in direct care of a patient.

In relation to complaints handling, we recommended:

• SAS should provide accurate responses to complaints.

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's brother (Mr A) collapsed at home and an ambulance was called. It took around 45 minutes to arrive and, upon arrival, the crew found Mr A to be in cardiac arrest. He was pronounced dead shortly after. Ms C complained about the failure to send assistance to Mr A sooner, including that a community first responder (CFR) was not used. She also complained that the crew did not carry out cardiopulmonary resuscitation (CPR).

The Scottish Ambulance Service (SAS) responded to Ms C's complaint and then carried out their own internal clinical review with the ambulance crew to enable further reflection on the incident. SAS identified that the call had been inappropriately downgraded from a cardiac arrest to chest pain category. It was identified that a satellite navigation failure contributed to the delay in the ambulance arriving. It was also noted that a CFR was not showing as available due to software and systems issues, and was therefore not used.

We took independent clinical advice which agreed with some of SAS's findings. We noted that there were differing interpretations of the guidelines on when CPR should or should not be attempted. We found that the crew should have taken steps to establish all the available facts in order to fully inform their decision-making in this regard. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C that SAS were unable to utilise a CPR due to software/systems issues; that a satellite navigation system failure added to the ambulance response time; and that the ambulance crew failed to take steps to determine with more accuracy the facts of the cardiac arrest, in order to support the decision-making process prior to the cessation of resuscitation. 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:

• Steps should be taken to establish all available facts before taking the decision to terminate CPR, including asking relevant questions of family/friends. SAS should give consideration to ways in which aide memoire/checklists might be used to support clinical decision-making during resuscitation attempts.
• There should be confidence that control dispatchers are able to identify logged on CFR when checking for available resources.
• Call handlers should be familiar with Medical Priority Despatch System (MDPS) protocol and should ensure calls are accurately categorised.
• SAS should confirm they have a suitable organisational back-up system in place for directing crews to an incident in the event of a failure of satellite navigation systems.

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 to us about the practice after she was diagnosed with secondary breast cancer in her lymph nodes. She had been attending the practice with a number of separate symptoms including a drooping right eye, fatigue; pain in her right shoulder, a rasping voice, vomiting and fainting. She did not consider that these symptoms were ever properly considered as a whole, which may have prompted an earlier diagnosis. She was also concerned that there was a failure to appropriately ready her for the diagnosis, claiming she had been repeatedly reassured her symptoms did not point towards a serious diagnosis.

We took independent advice from a GP. We found that the symptoms were relatively common and were not suggestive of a cancer diagnosis. Given this, we considered that the practice's communication with Ms C had been reasonable. We did not uphold either of Ms C's complaints.

Summary

C underwent an operation to their eye at Ninewells Hospital. C considered that they were not provided with information about the medical reasons why an operation to their eye was necessary. There were complications following this surgery. C raised concerns about what happened and why there was a failure to involve them in discussions about subsequent treatment options. C was concerned that the operation was not necessary and put them in a worse position than they had been before the operation.

We took independent advice from an ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We considered that the operation was necessary. However we found that:

there was no evidence in the clinical notes that C was informed about the reasons for their options for treatment when they attended the hospital;

there was no evidence in the clinical notes that the risks of surgery were specifically discussed with C. There were the usual risks of bleeding and infection, but in this case there were also extra risks;

when C presented with severe pain after the initial eye surgery they should have been able to attend Ninewells Hospital within the same day to obtain advice from the surgical team who carried out the operation. We found that there was an unreasonable delay in C obtaining definitive treatment from the hospital after they suffered a complication from the original surgery; and

there was an unreasonable failure to include C in any subsequent discussions about treatment options after the first operation.

We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for an unreasonable failure to provide them with information about the medical reasons why an operation to their eye was necessary; an unreasonable failure to provide them with information about possible complications following surgery and alternatives to the planned operation; an unreasonable delay in them obtaining prompt advice from the surgical team at Ninewells Hospital when they developed severe pain following the eye surgery; and an unreasonable failure to include them in any subsequent discussions about treatment options after the first operation. 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:

• Information about reasons for treatment, possible complications, and alternative management of non-intervention should be provided to and discussed with the patient prior to consent for treatment being obtained.
• Patients undergoing eye surgery at Ninewells Hospital should have access to a reliable pathway where they can obtain advice urgently in the event of postoperative problems.

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 to us on behalf of his late father (Mr A) who was diagnosed with, and subsequently died as a result of, septic arthritis (a serious type of joint infection). Mr C complained that the board failed to provide reasonable care and treatment in relation to Mr A's shoulder pain at a minor injuries unit (MIU) consultation and at a physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) consultation. Mr C also complained that the board did not refer Mr A for x-ray or to orthopaedics (conditions involving the musculoskeletal system). Mr C considered that this had caused delays with Mr A being ultimately diagnosed with joint sepsis.

We took independent advice from an emergency nurse practitioner and from a consultant physiotherapist. We found that the board's consultations with Mr A were unreasonable in that Mr A should have been referred for an x-ray at the MIU consultation and that Mr A's presenting symptoms were not appropriately assessed at the physiotherapy consultation; it also had not been demonstrated that infection had been ruled out as a differential diagnosis. We found that Mr A should have been referred for further investigations/assessment at the physiotherapy consultation. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologiseto Mr C for the failures 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:

• Patients should be referred for x-ray as appropriate. Patients presenting for physiotherapy should be appropriately assessed in line with recommended clinical guidelines, taking in account their presenting symptoms, and this should be documented.

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.