Health

Summary

C complained on behalf of their sibling (A) who is a Type 1 diabetic. A was admitted to hospital twice following hypoglycaemic (low blood sugar) episodes. The second admission took place via A&E. The discharge letter for A's second admission described A as being 'anorexic' (an eating disorder where individuals feel a need to keep their weight as low as possible) and having 'learning difficulties'. A, and A's family, complained about the decisions taken to discharge A, about the treatment A received at A&E, that the board did not perform tests or investigate A's condition during A's second admission and about the descriptions of A included in the discharge letter.

We took independent advice from an appropriately qualified adviser. We found that that the decisions to discharge A had been reasonable, that A had been provided reasonable treatment within A&E, that A's management during the second admission had been reasonable and that the board's inclusion of the descriptions A took issue with in the second discharge letter were reasonable. We did not uphold the complaints.

Summary

Ms C complained that the total knee replacement surgery she had undergone had not been carried out appropriately. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). The board were unable to locate the operation note for the surgery. However, we found that the evidence that was available indicated that it was likely there had been a technical error in the operation in that too much bone was resected (removed). However, without the operation note, it was not possible to state this categorically.

We also found that Ms C had been poorly consented for the operation. There was little evidence that she had been informed of the risks of surgery. The risks of ongoing pain, dissatisfaction and the fact that revision might be necessary were not specifically recorded. It was also unreasonable that the operation note was not available. Given this, we upheld this aspect of Ms C's complaint.

Ms C also complained that the board's response to her complaint was unreasonable. We found that the board's response had been inaccurate about who carried out the operation. There was also a delay in responding to the complaint and no evidence that the board agreed revised time limits with Ms C for responding. Therefore, we also upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings we have 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:

• Important documents such as operation notes should be securely retained by the board.
• Patients who are being offered total knee replacements should be given adequate information about the risks and possible complications.

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.
• Responses to complaints should be accurate.

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 she received at A&E at Royal Infirmary of Edinburgh (RIE) and when she attended for an MRI scan. She also complained about the clinical and nursing care and treatment provided during a number of admissions to the RIE.

We took independent advice from a consultant in emergency medicine in relation to Miss C's attendance at A&E. We found that the care and treatment was reasonable, in particular, that Miss C was seen by an emergency medicine doctor who obtained a thorough history and conducted a comprehensive examination; that the possibility of a pituitary (a small gland in the brain that makes hormones) tumour was considered and the most appropriate radiological imaging plan was discussed with a radiologist; that arrangements were made for an emergency out-patient MRI scan which was carried out within the timeframe for an urgent MRI scan.

We took independent advice from a consultant radiologist in relation to the care and treatment given to Miss C when she attended for an MRI scan. We found no evidence that the care and treatment was unreasonable and, therefore, we did not uphold the complaint.

In relation to the clinical care and treatment given to Miss C when she was admitted to the RIE on three occasions, we took independent advice from a consultant surgeon. We found that the clinical care and treatment given to Miss C during these admissions was reasonable and we did not uphold these complaints.

Finally, we took independent advice from a nursing adviser in relation to the nursing aspects of the care given to Miss C during two of her admissions to the RIE. We found failings in relation to Miss C's discharge medication on one occasion and we upheld this aspect of her complaint. The board accepted these failings and had taken action which we considered was reasonable.

Therefore, we made no further recommendations. We found no failings in relation to the nursing care and treatment given to Miss C during the second admission to the RIE and we did not uphold this complaint.

Summary

Mr C complained about the clinical care and treatment provided to his late mother (Mrs A). Mr C complained that Mrs A had been incorrectly diagnosed with dementia and that the care and treatment Mrs A received during her admission to the Western General Hospital (WGH) and by the community mental health team (CMHT) prior to her death was unreasonable.

We took independent advice from a consultant psychiatrist and a consultant geriatrician (a specialist in medicine of the elderly). We were concerned that the board had failed to follow their retention and destruction policy and that some of Mrs A's medical records had not been retained in line with that policy and were therefore not available during the investigation of the complaint. However, from the available evidence, we found that the diagnosis of dementia was questionable and that there had been a failure to review this diagnosis as new information emerged. Therefore, we upheld this complaint.

In relation to the clinical care and treatment given to Mrs A during her admissions to the WGH, while we found that aspects of the care and treatment given to Mrs A was reasonable, there had been a number of failings and we upheld the complaint. However, we noted that the board had carried out a significant adverse review event and had made a number of recommendations.

In relation to the community mental health care given to Mrs A, we were unable to address all the issues raised by Mr C due to the absence of relevant medical records. However, based on the available evidence we found that there had been a lack of coordination and communication between the various mental health teams and as a result, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and the family for the failings identified in this case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.

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

• Medical records should be retained in line with the retention and destruction policy.
• The board should ensure that in psychiatry of old age the diagnosis of dementia is reviewed as new information emerges.

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, brought a complaint on behalf of their client (A). A was concerned that the Child and Adolescent Mental Health Service (CAMHS) did not follow the correct process regarding a childhood autism assessment and about the communication from CAMHS about the process for getting an autism assessment.

We took independent advice from a registered mental health nurse. We found that it was reasonable for CAMHS to conclude that A would have to access an autism assessment through their GP because A was over 16 years of age at the time. We also found that the board had communicated reasonably with A and A's parent about the process of getting an autism assessment. We did not uphold these aspects of C's complaint.

C also complained about the way the board handled the complaint. We found that there was a delay in responding to C's complaint and that they were not kept updated on the progress of their complaint or provided with a revised timescale for the response. We upheld C's complaint that the board had failed to handle the complaint reasonably. The board have already apologised for this failing but we have made a further recommendation for learning and improvement.

Recommendations

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Model Complaints Handling Procedure (MCHP). The MCHP and guidance can be found here: https://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

Ms C had cataract surgery (a procedure that involves replacing a cloudy eye lens with a clear artificial one) at Hairmyres Hospital. Ms C stopped using the eye drops she had been prescribed and she began to have a feeling of discomfort in her eye. Ms C visited her optician who said there seemed to be a scratch on its surface. Ms C complained that something went wrong during her cataract surgery.

We took independent advice from an ophthalmologist (a specialist in eye disorders). We found that Ms C's cataract surgery was technically successful. We considered it was most likely that Ms C had suffered a small accidental scratch to the lens of her eye during the cataract surgery, which is a recognised complication. However, we found that there were no failings in how her cataract surgery was carried out. We also found that Ms C was given appropriate treatment for the discomfort she experienced. We did not uphold Ms C's complaint.

Summary

Ms C complained that the board failed to take reasonable steps to prevent her father (Mr A) from falling in hospital. We took independent advice from a nursing adviser. We found that staff had completed the required risk assessments prior to Mr A's fall and that the fall would have been hard to predict. However, updates to the care plan in place for Mr A lacked detail and the plan itself was not updated to address the changes in Mr A's functional ability. Although there was an indication on the falls risk assessment that Mr A was attempting to walk alone, there was nothing recorded in the nursing records or care plan to support or address this.

Staff also failed to follow the board's policy in relation to the assessment and use of the bedrails. In addition, there was no evidence of nursing staff updating Mr A's falls risk assessment or his care plan immediately after the fall, nor was there a record of a delirium screening at that time. In view of these failings, we upheld this aspect of the complaint.

Ms C also complained that staff failed to contact the family to inform them of the fall until the following morning. We found that, as Mr A had sustained a significant injury, staff should have called the family at the time of the fall, when the harm was confirmed, or earlier in the morning before the shift changed. Given this, on balance, we also upheld this aspect of the complaint.

Finally, Ms C complained that staff had attempted to use inappropriate equipment on Mr A after his second operation. Staff had to use a commode to transfer Mr A to the toilet because the stand aid had been condemned and the hoist had no battery. We found that when the decision was taken to use a commode in this way, a risk assessment should have been completed and recorded and an agreed approach noted in Mr A's care plan. Given the failure to do this, we upheld this aspect of the complaint.

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

Recommendations

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

• All staff should follow the board's bedrail policy.
• Patient care plans and risk assessments should be completed and updated appropriately.

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 they received from the urology (a speciality in medicine that deals with problems of the urinary system and the male reproductive system) service at Wishaw General Hospital. C was referred to the service with penile fracture symptoms. Following the referral, C was reviewed by two consultant urologists and investigations were performed over the following months. These investigations did not identify what the precise cause of C's symptoms were.

We took independent advice from appropriately qualified advisers. We identified a number of delays in the investigation of C's symptoms and concluded that there had been an unreasonable delay in making a diagnosis. We also found that there was an unreasonable delay in the board sending a discharge letter to C's GP after a surgical procedure was performed. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonable delays in the investigations of C's symptoms which resulted in an unreasonable delay in diagnosis. 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:

• In line with Scottish Government standards, no patient should wait longer than 12 weeks for a new out-patient appointment at a consultant-led clinic. Delays in arranging subsequent consultations and tests should be minimised to ensure patients do not experience significant delays.
• When an operative procedure is performed a discharge summary or letter outlining the procedure should be sent promptly to a patient's GP in case of any complications.

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 care and treatment his mother (Mrs A) received at University Hospital Monklands during her initial admission and subsequent readmission to hospital for treatment for supraglottis with parapharyngeal oedema (infections of the upper airways/throat).

We took independent advice from an ear, nose and throat consultant and from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques) with experience in interventional procedures (procedure used for diagnosis or treatment that involves incision; puncture; entry into a body cavity; or the use of ionising, electromagnetic or acoustic energy).

Mr C said that the board unreasonably discharged Mrs A from hospital following her initial admission. We found that, at the point Mrs A was discharged, there were no clinical indicators to suggest that this was the wrong decision and, based on what was recorded in the nursing and medical notes at that time, she appeared to be improving at that stage. We did not uphold this aspect of the complaint.

Mr C also said that the board failed to provide Mrs A with appropriate care and treatment following her readmission to hospital. We found that the decision to undertake a scan-guided drainage of Mrs A's abscess was reasonable in the circumstances in order to improve her condition, which was very serious at the time, and to avoid major surgery to her chest. The procedure was a technically difficult one, but it was clinically successful because it did lead to draining of the abscess. The catheter becoming dislodged during this is a common problem with any drainage procedure and it was not possible to conclude that the blood clot that developed was either a result of the procedure itself, or the dislodging of the catheter, rather than a result of Mrs A's condition at that time. We did not uphold this aspect of Mr C's complaint.

Lastly, Mr C complained that the board failed to respond appropriately to his letter of complaint about Mrs A's care and treatment. We recognised that Mr C did not agree with the response the board gave about why Mrs A was discharged. However, we considered that the board accurately identified Mr C's concern and provided a reasonable response, which was an accurate reflection of what was recorded in the medical records. We considered that the board provided a general response to a specific question Mr C asked about Mrs A's discharge, by acknowledging that there had been a difference in recollections and that this was something that the board would strive to improve. Therefore, we did not uphold this aspect of the complaint.

Summary

Mr C complained that there was an unreasonable delay in diagnosing his late mother (Mrs A) with cancer. Mrs A had a number of consultations in the respiratory clinic at University Hospital Monklands and had a background of chronic obstructive pulmonary disease (a type of lung condition that causes breathing difficulties) and bronchiectasis (a long-term condition where the airways of the lungs become abnormally widened). During the period of care under consideration, Mrs A experienced an increase in frequency of chest infections, and her chest x-ray results showed progressive changes.

We took independent advice from a consultant in respiratory medicine. We found that it was reasonable to consider that the progressive changes, and increase in symptoms, to be part of the progression of Mrs A's lung disease. In this context, we found that it was reasonable that investigations were not arranged earlier. We did not find that there had been a delay in diagnosing Mrs A's cancer and therefore we did not uphold Mr C's complaint.