Not upheld, no recommendations

Summary

C underwent a hysterectomy (surgery to remove the womb) and although the procedure was considered successful, C began to bleed from scar tissue soon after the operation. An ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) showed blood clots in C's pelvis and C was kept in hospital in case further surgery was required. C was given blood thickeners and a blood transfusion. C developed a chest infection and suffered from further complications.

C raised complaints about their care and treatment following their initial surgery with Greater Glasgow and Clyde NHS Board. C raised a number of specific concerns about their post-operative complications and their management. C was also concerned about the surgery, or that the post-operative complications had caused the nodule on their lung, which was subsequently identified as lung cancer.

We took independent advice from a gynaecology (medicine of the female genital tract and its disorders) adviser. We found that C's care and treatment was reasonable and that C had experienced significant post-operative complications, but that these were appropriately managed. We noted that there was no evidence that C received inadequate consultant input post-surgery, or that C's complications were as a result of the surgery being performed poorly or inappropriately. We found that the board were correct to say that there was no relation between C's surgery and the subsequent health issues that they faced. We also found no fault with the level of physiotherapy support offered to C.

We concluded that C's medical records showed that they were regularly reviewed by a physiotherapist and that the exercises that were provided to C were also reasonable and appropriate. As such, we did not uphold C's complaint.

Summary

C complained about the care and treatment provided to their late child (A) by their GP practice. A had attended the practice on several occasions over a five month period with persisting chest symptoms. C complained that the practice failed to recognise the severity of A's symptoms or recognise that symptoms were indicative of a serious cardiac condition until A's health had significantly deteriorated. A subsequently suffered a cardiac arrest resulting in them being transferred to another health board for surgery, where they later died.

We took independent advice from a GP adviser. Although we noted that there had been a delay of a few days in responding to A's x-ray report, we found that the practice's care of A was reasonable, with referrals and tests being timeously arranged and in keeping with A's presenting symptoms at the time. Therefore, we did not uphold the complaint.

Summary

C complained about a financial assessment carried out in respect of their parent (A)'s, care costs. C complained that the council wrongly determined that in transferring the title to A's property to C three years previously, A had intentionally deprived themselves of capital to avoid paying residential care costs. C disagreed with the council’s decision to treat the value of the property as notional capital when calculating the costs that A owed.

There followed extensive communication between the council, C and C's solicitor. According to C, A had no expectation of going into care when they transferred the property, or at any point in the future. C said that A was a very active, intelligent and healthy individual who had every intention of remaining in the same home for the rest of their life. Nor, as far as C was aware, had A had any thoughts of disposing of some of their assets to avoid paying for care in the future.

Summary

C complained about the mental health care and treatment their late sibling (A) received at Gartnavel General Hospital. C complained that A was misdiagnosed and received inappropriate treatment. C complained that A was insufficiently supervised, as they were able to leave the hospital on a number of occasions. C also complained that A was discharged when they were still unwell. C believed there had been a focus on discharging A rather than ensuring their condition improved.

We took independent advice from a consultant psychiatrist. We found that during each admission, A's care and treatment was reasonable and appropriate given their presenting symptoms. We found that the changes in A's diagnosis reflected a better understanding of their symptoms and presentation over time. We did not uphold this aspect of the complaint.

With regard to the complaint about supervision, we found that the level of supervision was appropriate andthat there was no clinical justification for any enhanced observation. We did not uphold this aspect of the complaint.

In relation to the complaint about A's discharge from hospital, we noted that difficult circumstances to do with A remaining in the ward was contributing to an escalation in their presentation. We found that the decisions to discharge A after the first and second admissions were reasonable. There was evidence of discharge planning with appropriate follow-ups being put in place. The decision to discharge after the third admission was more complicated, as A was discharged into police custody after their behaviour escalated. We found that under the circumstances this was reasonable, noting that follow-up arrangements were made with support agencies. We therefore did not uphold this complaint.

Summary

C complained about the care and treatment their late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, the patient in the bay beside A was confirmed positive for COVID-19. A received a test for COVID-19 and was discharged home. A was then made aware that they had COVID-19. A's condition deteriorated and they died.

C complained about the placement of A within an amber zone, rather than a green zone at the hospital. C was also concerned that A was placed in a bay beside the other patient, who subsequently tested positive for COVID-19.

We sought independent advice from a consultant oncologist (a specialist in the diagnosis and treatment of cancer). We noted that the COVID-19 guidance in place at the time required NHS Boards to have COVID/Non-COVID areas and provided examples of pathways for how NHS Boards might separate patients. The guidance was not prescriptive and each NHS Board had to decide how to apply the guidance to the different hospital environments within their area. We found that the board’s internal pathways were consistent with the pathways set out in the guidance. Given that A did not meet the criteria for a low risk/green zone within the hospital, we found it was reasonable to place A in an amber zone based on the information known at the time. We therefore did not uphold this aspect of the complaint.

We recognised how distressing it must have been for C to learn that their parent had contracted COVID-19 while in hospital. To assess this aspect of C's complaint we obtained the relevant clinical records for the other patient and shared these with the independent adviser. We found that the symptoms the other patient was exhibiting were not thought to be due to COVID-19 and we did not identify any failure regarding the placement of A beside this patient. We therefore did not uphold this aspect of the complaint.

Summary

C, an advocate for A, complained about the way A was treated by the board for their chronic psychotic illness. A experienced a relapse when administration of their medication was changed from a depot injection (a slow release method) to an oral route. A subsequently required two in-patient admissions. C complained the second admission only occurred due to a failure by the board to manage A's medication properly, and to being discharged from their first admission when they were still experiencing psychotic symptoms.

We took independent clinical advice from a consultant psychiatrist on the board’s management of A's medication and the circumstances of their discharge from hospital during their first in-patient admission. In reference to the board managing A's transition back onto their medication by depot injection, we found that this had been managed appropriately, and in agreement with A. However, we noted that the documentation of this could have been better. While we did not uphold this aspect of the complaint, we gave feedback to the board in respect of record-keeping.

Regarding the timing of A's discharge from hospital, we found that this had been reasonable and person-centred in approach, noting there was no reference in the medical records to A experiencing psychotic symptoms at the time of their discharge. As such, we did not uphold this aspect of the complaint.

Summary

C, an advocate for A, complained about the actions of the board's paediatrics department in relation to child protection concerns raised about A's child (B). C complained that the board did not reasonably communicate with A about the concerns raised and that they took an unreasonable length of time to arrange a child protection conference. C also complained that the board failed to fully involve the family GP in the child protection process and to explain the rationale for proposing to reassess B's autism spectrum disorder (ASD) diagnosis.

To investigate C's concerns, we reviewed the relevant clinical records and sought independent advice from a consultant community paediatrician. Our investigation found that the steps taken to invite A to a meeting to discuss the concerns about B and to share a summary of the professionals meeting held were reasonable. We also concluded that from the time the concerns were noted to holding a child protection conference, it was reasonable to consult with other professionals, gather information and attempt to speak with A. As such, we did not consider there was an unreasonable delay in holding the child protection case conference.

We also found evidence that the family GP was invited to a professionals meeting by email, however, due to administrative errors outwith the board’s control, the email was not received by the GP. With regards to the reassessment of B's ASD diagnosis, we concluded this was explained both in writing and at a meeting. We therefore did not uphold C's complaints.

Summary

C complained about the treatment they received at the Queen Elizabeth University Hospital. C said that they had been admitted with problems concerning a foot ulcer and that on both occasions they were discharged home after one night in hospital. C felt that they should have been admitted for a longer period to ensure that their condition improved and that they were able to take any medication which was required. The board felt that C was fit for discharge on both occasions and that there was no clinical requirement that C should remain in hospital and it was appropriate to discharge C home with support from the district nurses.

We took independent advice from an adviser and found that staff at the hospital had carried out appropriate investigations and that it was appropriate to discharge C home with support from the district nurses to change the foot dressings. We did not uphold the complaint.

Summary

C attended Queen Elizabeth University Hospital (QEUH) on a number of occasions prior to being diagnosed with cauda equina syndrome (CES, a narrowing of the spinal column where all of the nerves in the lower back suddenly become severely compressed). C required two emergency surgical procedures and has been significantly impacted by the condition. C complained that there were missed opportunities to diagnose CES, and about the clinical assessments carried out at QEUH.

C's complaint concerned assessments in A&E and in gynaecology (specialists in the female reproductive system). We took independent advice from a consultant in emergency medicine and a consultant gynaecologist. We found that C was assessed appropriately during each admission to A&E. We found that C was displaying no red flag symptoms and that appropriate follow-ups were arranged. We also found that C was not exhibiting symptoms which would indicate CES, nor was C displaying symptoms which would have triggered immediate imaging. We were satisfied that C was assessed appropriately and that it was reasonable to arrange follow-up gynaecology assessment later that day. We did not uphold these aspects of the complaint.

We also found that C was appropriately assessed when they attended the emergency gynaecology appointment. There was no clinical evidence to suggest C needed emergent care. The doctor noted no symptoms of CES and consulted with the consultant on call before discharging C with appropriate advice. We found this was reasonable. We did not uphold this aspect of C's complaint.

Summary

Ccomplained that their late parent (A) called the practice and was given a prescription without being seen in person. C also complained that an appointment or home visit wasn’t arranged when C called three days later and reported that A's condition had worsened.

We obtained independent advice from a general practitioner adviser. We found that the actions taken by the practice at the time of the initial call were reasonable and considered it reasonable for A not to have been seen in person at that time. We also considered that reasonable action was taken when C called three days later, based on what was documented in the records. However, it was acknowledged that there were differing accounts of what had been discussed, and that the symptoms C said they communicated would reasonably have prompted A to be seen in person. Based on the evidence available and the advice obtained, which we accepted, we concluded that A received reasonable medical care and we did not uphold this complaint.

However, we noted that the level of documentation could have been improved. This includes recording when safety netting advice is given (when patients are advised to return if their symptoms don’t improve, advice which the practice said was given to A during the first call but was not documented); reasons why a patient is not spoken to directly (as was the case when C called); and reasons to see or not to see a patient in person, particularly for a repeat caller. We fed this back to the practice for their reflection and learning, along with feedback on their handling of the complaint.