Health

Summary

C complained on behalf of their parent (A) about the care and treatment provided by the practice. C considered that there was a failure to carry out reasonable physical examinations and appropriate tests based on the symptoms A presented with, prior to A receiving a diagnosis of untreatable Signet Ring Cell Carcinoma (a type of cancer).

We took independent advice from a GP. We found that there was a failure to refer A for an urgent investigation or for an urgent ultrasound due to their weight loss, new diabetic diagnosis and age. We upheld this aspect of the complaint. We found there was a failure to carry out a physical examination of A on two occasions and also a failure to ensure that an urgent referral letter was sent to the colorectal (conditions in the colon, rectum or anus) service within a reasonable timeframe. Therefore, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for a failure to refer A for an urgent investigation or an urgent ultrasound; a failure to carry out a physical examination of A; and a failure to ensure an urgent referral letter was sent within a reasonable timescale.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 clinical staff are aware of colorectal referral guidelines relating to the need for a physical examination of a patient prior to referral.
• Ensure relevant clinical staff are aware of referral guidelines for newly diagnosed diabetes and weight loss.

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 parent (A) about the care they received by the practice. A had been unwell and required a home visit from the practice. C believed that A had not been adequately examined during this visit, which had placed A's life at risk. C said that within days of the home visit, another GP had reviewed A, which resulted in A's admission to hospital. During this admission a significant amount of fluid was removed from A's legs and A was found to have a damaged heart valve. C felt that the practice had failed to honestly admit their failings or to offer a sincere apology.

We took independent advice from a GP. We found that A had been reviewed thoroughly and appropriately. There was no evidence that clear symptoms of heart failure had been overlooked. There was also no evidence that A had an acute condition at the time of the home visit, and the symptoms reported and recorded were consistent with A's pre-existing medical conditions.

We found that the care provided to A was of a reasonable standard and did not uphold the complaint

Summary

C complained about the care and treatment the board provided to their late spouse (A) at University Hospital Crosshouse (UHC). A suffered a heart attack and was taken by ambulance to a hospital in another health board area. Following treatment, A was transferred to UHC, but then suffered what was thought to be a stroke event and died a week later.

C complained about several aspects of A's care, including that staff did not tell them what was happening with A and failed to advise them that A was in a coma. C also said that A's health had improved at the other hospital and they understood that A was being moved to UHC to recuperate before being sent home, but A died shortly after their arrival at UHC.

We took independent advice on the case from two advisers - a consultant cardiologist (a doctor that specialises in diseases and abnormalities of the heart) and from a nurse. We found that the medical records showed staff gave C regular updates about A's condition and tried to be realistic about the likely outcome, while being supportive of C. We considered that there was evidence that staff kept C reasonably updated about A's condition during the admission. However, we welcomed the board's apology that the communication did not meet C's needs; this showed a sensitivity to the responsibility for ongoing learning and improvement to ensure communication is tailored to the needs of individuals and their families. We found that there was a lack of clarity from the other hospital about A's prognosis and future treatment plan at the time of their transfer to UHC, which may have contributed to C's confusion and distress at this time. We included some feedback to the board about this. However, we noted that this did not influence A's care at UHC, following the sudden stroke that they suffered soon after transfer, which was ultimately fatal. We considered that, overall, A's care and treatment at UHC was reasonable and we did not uphold the complaint.

Summary

C complained to us about the board, as they held a number of concerns regarding the board's management of their medication for ADHD, pain (they suffer from fibromyalgia), and insomnia. C also considered that the board had failed to take reasonable account of their needs in the way they had communicated with them.

We took independent advice from a consultant psychiatrist. We found that C's medication was appropriate for the management of their diagnosed conditions. We did not consider that there was any evidence of unreasonable communication which failed to take account of C's needs. Therefore, we did not uphold C's complaints.

Summary

C complained that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an ambulance from their late relative (A). C also complained about the way their complaint to SAS about the matter was handled.

Through its own investigation, SAS found that the second call from A was not handled appropriately because medical priority despatch system was not utilised to assess A's symptoms and the level of response required. In addition, the first crew to attend A's home did not follow clinical practice guidelines and policy in relation to consent. The crew felt A did not want any help. SAS also found that information on the patient report form was limited and did not meet the expected standards of clinical reporting.

We took independent advice from a paramedic. We found that SAS took reasonable corrective action in response to failings highlighted through its investigation. However, we noted that there was a missed opportunity for interaction between the ambulance control centre (ACC) clinical advisor, who had spoken with A, and the clinician who attended A's home. This may have afforded the attending clinician the necessary information to prompt a more comprehensive clinical assessment of A. There was also an opportunity for the attending clinician to seek clarifying information and question the ACC on the requirement to send a frontline ambulance to A. This would have stimulated discussion and provided an opportunity to share both information and the decision-making responsibility prior to ending the engagement with A. Finally, having listened to the recordings available, a call made from the ACC to A was not ended properly. We upheld this complaint.

In relation to complaints handling, we found that C was not kept reasonably informed about what was happening with the complaint and the investigation itself took a long time. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to handle their complaint reasonably and for for the failure to handle contact with A appropriately. 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:

• SAS should take steps to ensure the process for ending calls is improved; review/implement a process for passing complex background information to the attending clinician to assist clinical judgement and decision-making; and introduce procedures as preventative measures to ensure that a paramedic would seek clarification from the ACC when a patient denies calling for an ambulance or the patient cannot be located.

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 the decision to move them to another ward and the manner in which they were discharged while they were a patient at Royal Edinburgh Hospital. The board explained that beds are allocated according to clinical need and, due to extreme pressures on hospitals at that particular time, it was felt appropriate to move C to another ward as they were clinically stable. The board said appropriate referrals were made following C's discharge, however, as C did not return to the ward following an overnight pass, they were unable to complete their assessment for home treatment.

We took independent advice from a mental health nurse. We found that it was unavoidable that a patient had to be transferred to another ward due to the pressures on the wards at the time, and that the board followed a reasonable process in selecting C as a suitable candidate. We did not uphold this aspect of the complaint.

However, we found that while appropriate assessment was carried out, the board failed to appropriately manage C's discharge as they did not ensure that Intensive Home Treatment Team supports commenced when C left the hospital. 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 ensure that the planned post-discharge inputs by the Intensive Home Treatment Team commenced at the point of discharge. 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 take steps to ensure that planned post-discharge inputs by community-based services are followed through at the point of discharge and that said community-based services are timeously notified that discharge has taken place. This is especially important in circumstances where discharge has occurred in irregular circumstances which elevate the risk of the person becoming lost to follow-up.

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, a support and advocacy worker, complained on behalf of their client (B) whose adult child (A) had developed deep vein thrombosis (a blood clot in a vein) and pulmonary embolism (a blocked blood vessel in the lungs) requiring treatment in hospital. Despite receiving blood thinning medication, A developed further pulmonary embolism. A's medication was revised and arrangements were made for A to be seen as an out-patient. A died after returning home following a later review appointment. B questioned the quality of care A had received from the board.

We took independent advice from a consultant respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs). We found that A received a good standard of care both as an in-patient and as an out-patient in line with the relevant guidance and good practice. There was no evidence that A's outcome could have been changed had the board acted differently. We did not, therefore, uphold C's complaint

Summary

C complained that the board failed to provide them with reasonable care and treatment regarding their Lyme disease (LD – a disease caused by bacteria).

We took independent advice from a consultant in general internal medicine.

C raised concerns that they were refused intravenous antibiotics when they understood this was an available treatment option. The evidence in C's medical records suggested a treatment approach was discussed and agreed about this. We took account of the advice we received that it did not appear from the evidence that any of the relevant medical complications of LD, which applied for starting a patient on intravenous antibiotics, had been established in C's case. We, therefore, did not find evidence that the clinical judgement of C's doctor was exercised in an unreasonable manner. Furthermore, the board's actions were consistent with the relevant guidelines when applicable.

C also raised concerns about the manner and approach of a doctor. Our investigation did not identify the supporting evidence needed to conclude that unreasonable communication had occurred.

However, we found that the time C waited for diagnosis of LD was unreasonable. We also found that there was an unreasonable delay before a referral for a second clinical opinion was actioned and a significant delay before nerve conduction studies were carried out, in particular, given that in C's case, the test results may have altered their clinical management.

C also reported difficulties contacting the medical team to obtain the results of their investigations. We noted that the board had acknowledged this and apologised to C. For the reasons outlined above, we found there were elements of C's care and treatment that were unreasonable and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonably delay in diagnosing them with Lyme disease, the delay in the referral for a second clinical opinion, and the time taken to receive a nerve conductivity appointment. 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:

• Tests and investigations should be carried out in an appropriately timely manner. Patients should be provided with clear information in relation to waiting times for testing and referrals.

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 that he was unreasonably removed from the boards waiting list when he did not attend an appointment. We took independent advice from a dental adviser. We found that it was reasonable to remove Mr C from the waiting list without offering him another appointment in the clinical circumstances. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the board did not communicate reasonably with him. We found that the board's letter to Mr C did not inform him that, if he contacted the service within four weeks, he may be offered another appointment. This was contrary to the NHS Lothian Standard Operating Procedures for Waiting Times Management. We also found that there was no written record of Mr C's call to the board. We upheld this aspect of Mr C's complaint.

Lastly, Mr C complained about the way the board handled his complaint. We did not find evidence that the board had handled Mr C's complaint unreasonably. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to inform him that if he contacted the service within four weeks he may have been offered another appointment and for failing to record Mr C's call to the board. The apology 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

Mrs C complained about the care she received at St John's Hospital. In particular, Mrs C was unhappy with delays in the identification, monitoring and diagnosis of an abnormality in her pancreas. Mrs C had a number of hospital admissions and underwent four scans. The scans showed that the abnormality had increased in size. By the time of the final scan, it was identified that the abnormality was likely to be cancer. Mrs C was subsequently diagnosed with cancer and had surgery to have part of her pancreas removed as well as chemotherapy.

We took independent advice from a radiologist (a specialist in the analysis of images of the body) and a general surgeon. We found that the management of the abnormality was reasonable until the point of the third scan. The report of this scan identified a definite increase in size of the abnormality, although inconsistently referred to it as unchanged. We considered that a referral should have been made to the surgical team to follow up the abnormality and concluded that the failure to do this was unreasonable. We upheld the complaint. However, we concluded that if follow-up had been appropriately planned, it was unlikely that the course of events would have been different in this case. This is because Mrs C received a scan to investigate abdominal pain around the same time that a scan would have been planned in line with the recommended timescales for follow-up of abnormalities.

Mrs C also had concerns about the way the board handled her complaint. We noted that the board had acknowledged and apologised to Mrs C that there had been a significant delay in responding to the complaint. We were critical that the board did not seem to have identified the cause of the delay. We also found that the board had failed to provide updates to Mrs C about the delay. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to make a pancreatic surgical referral after a CT scan identified a definite change in the size of a pancreatic lesion. 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 definite increase in size of a pancreatic lesion should prompt a pancreatic surgical referral.

In relation to complaints handling, we recommended:

• Where there has been a significant failure follow the Complaints Handling Procedure, the board should consider whether they need to take any actions as a result of learning from this case.

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.