Upheld, recommendations

Summary

C complained about the practice on behalf of their spouse (A). A is paraplegic (affected by or relating to paralysis of the legs and lower body) and was receiving district nursing treatment for various wounds, including one on the large toe of their left foot. The condition of A’s left foot deteriorated and they were showing signs of infection. A was seen by a district nurse who took photographs of A's foot and showed them to the duty GP at the practice. The GP made an urgent referral to vascular surgery, which was sent the next day, but did not assess A themselves or communicate the management plan to them. A’s condition worsened and a few days later they required immediate admission to hospital and urgent surgery. A subsequently required amputation of some of their toes. C complained that A’s outcome may have been better had they been assessed by the duty GP and/or admitted to hospital the same day.

We took independent GP advice. We were not critical of the fact the duty GP did not carry out a face to face assessment of A. We found that the GP followed the relevant guidelines by making an urgent referral to vascular surgery, which was a reasonable assessment. However, we found that the GP should also have made direct contact with the vascular surgery team for advice as to whether A required to be seen the same day. We found that the GP also should have communicated their management plan to A and to C, as they acknowledged in their complaint response. This would have allowed the opportunity to raise any concerns with the GP directly. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the communication 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:

• When making an urgent referral to vascular surgery for a patient with critical limb ischaemia, GPs should contact the vascular team directly for advice as to whether same day assessment is required. GPs should discuss the management plan with the patient.

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, an advocate, submitted a complaint on behalf of the family of A. A was a resident of a care home and attended hospital with low potassium levels. A later sustained a leg fracture around the time of the first discharge and was re-admitted to hospital. A later died. C complained that the nursing and medical care provided by the board was unreasonable.

We took independent advice from a nurse, consultant orthopaedic surgeon and consultant geriatrician. We found that there were failings in the nursing and medical care provided and that the board failed to carry out a reasonable investigation into the concerns raised. We also found that A did not receive appropriate care and treatment after they sustained a leg fracture. Specifically, there was a lack of recorded consultant input, delays in having a second cast fitted and delays with A being discharged afterward.

In addition, the concerns raised regarding how the leg fracture occurred weren’t appropriately investigated across multiple agencies and it took a number of contacts by both C and the SPSO before a full response was provided. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the failings identified in relation to the investigation and treatment of A’s fracture and their 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:

• Consultant ward rounds, particularly at the weekend, should review all patients and should be documented.
• Frail elderly patients with fractures should receive appropriate orthogeriatric support.
• Patients should be discharged as soon as clinically appropriate following treatment.
• When harm comes to a patient and there are multiple organisations involved as to where the injury may have occurred, a multi-agency review is carried out in a timeous manner.

In relation to complaints handling, we recommended:

• Evidence that the learning from this complaint has been shared at an Acute Sector Clinical Governance Group.
• Evidence that the learning from this complaint has been shared via the Acute Sector Clinical Risk Management Group.
• Evidence that the learning from this complaint has been shared via the Board’s Clinical Governance structures.

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, an advocate to A, complained on behalf of A that their colonoscopy was performed without sedation or anaesthetic. A was advised at pre-assessment that they could not have pain relief during the procedure, due to having taken methadone prior to the colonoscopy. C also complained about the lack of information on the patient leaflet for methadone users, the attitude of staff, and that the procedure was performed by a trainee endoscopist.

The board considered that the care and treatment provided to A was reasonable as A consented to the colonoscopy being carried out without pain relief and understood that a trainee would undertake the procedure. The board apologised for the comments made by staff.

We took independent advice from a colorectal surgeon. We found it unnecessary to contain methadone specific information on the patient leaflet as all medication should be considered when administering sedation for all patients. We found that the advice given at pre-assessment was incorrect. There is no contraindication (a specific situation in which a medicine, procedure, or surgery should not be used because it may be harmful to the person) for use of sedation with methadone and being on methadone does not preclude either sedative or opioid pain control. Therefore, we found that A should have been given pain relief during the colonoscopy. We also found that it is the endoscopist's responsibility to understand drug interaction in prescribing medication for pain and sedation and that was not the case in this instance and a second opinion should have been sought. Due to the absence of pain relief, we found that this procedure should have been performed by an experienced endoscopist, to ensure correct technique and minimise the discomfort experienced by A. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings 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:

• All staff are familiar with the relevant BNF and AOMRC guidance.
• All staff are reminded of the importance of seeking specialist advice in complex or unusual cases.
• Endoscopists to be aware of the importance of technique when minimising discomfort for the patient.

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 was diagnosed with severe heart valve stenosis (when a heart valve narrows and blood cannot flow normally) and was informed that they required heart valve replacement surgery. A referral was made to a specialist unit within another health board. However, A died whilst awaiting surgery, during the early months of the COVID-19 pandemic.

C complained that there was a delay in providing A with treatment, and that when A’s condition appeared to deteriorate, they were prescribed only water tablets. C also felt that there was a lack of communication from the Cardiology Department. Additionally, C pointed to a Significant Adverse Event Review (SAER) carried out by the hospital to whom A had been referred, which had concluded that the referral had been, in their view, wrongly categorised as “routine” as opposed to “urgent”. C felt that the care provided to A had been unreasonable.

We took independent advice from a consultant cardiologist. We found that it was unreasonable that A was not referred more urgently for surgical consideration, noting that even before the COVID-19 pandemic a routine referral could take up to 18 weeks. We were also critical of the lack of formal arrangements made to keep A under regular review. A was diagnosed with severe chronic obstructive pulmonary disease (COPD) and we found that this was a missed opportunity for A’s management plan to be reviewed. Additionally, we found that we were unable to establish whether the risks of surgery were ever explained to A or whether they were given the choice of treating their symptoms with drug therapy alone. Given the importance of this, we would have expected to see evidence of this in A’s case notes. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. 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 with congestive heart failure should be appropriately assessed with consideration given to having an urgent echocardiography (a scan used to look at the heart and nearby blood vessels) and an in-patient cardiological review. Patients being referred for more specialist investigation or treatment should be appropriately categorised in terms of urgency in relation to their condition. Patients diagnosed with severe aortic and mitral stenosis should be kept under regular clinical review. The risks of surgery and choices of available treatment should be explained to a patient and any discussions about this should be recorded in the patient’s records.

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 was a carer for their parent (A). A carer's assessment self-referral form was submitted on C's behalf to the partnership's Carers Team. C was contacted by the Carers Team and advised that, in the circumstances, the requested assessment would be carried out by A's social worker. Within 24 hours the social worker had discussed and clarified the situation with the Carers Team. The Carers Team had also emailed C to advise that they had been under a mistaken impression the previous day and to request that C contact them to progress C's request. Relations between C and the Carers Team broke down during further email correspondence involving C, the Carers Team and the social worker the same day. Within this correspondence the Carers Team had made clear that they required further information from C to progress C's request and that they would end consideration of C's request if they had not received a response from C.

The partnership responded to a complaint from C, and accepted that there had been short comings in the Carers Team's communication with C and stated that the social worker would contact C to discuss carer support further. Some time later, a further referral for carer support was submitted to the Carers Team. Relations between the Carers Team and C again broke down and C submitted a complaint about the Carers Team's actions and the partnership's failure to provide carer support.

The partnership's response outlined their view of events regarding C's requests for carer support over a period. The partnership gave their view that C had not received carer support during this period because it had been unclear what supports C wished to access. The partnership accepted that there appeared to have been some confusion on the part of their staff as to who was ultimately responsible for moving forward with the matter and that this may have caused some delay. Given this, the partnership partially upheld C's specific complaint about this. The partnership noted that matters were now being progressed via the social worker and considered that, in those circumstances, there was no further resolution that they could offer.

C raised their complaint with SPSO shortly after receiving the partnership's response. We took independent advice from a social work adviser. We found that there had been confusion between the social worker and the Carers Team about who would provide C with support and that this led to a delay. On balance, we upheld the complaint on this basis. The partnership had already acknowledged this delay but had not provided a direct and clear apology to C for this or taken steps to ensure that the situation could not recur. We made recommendations to address these matters and provided feedback to the partnership.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the confusion on the part of partnership staff that caused some of the delay in the provision of carer support to C. 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 partnership review and update their internal protocols, process flows and triage systems for carers assessments to ensure clarity, for staff and the public, regarding what staff are ultimately responsible for moving forward requests for carers support in a given circumstance.

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 board's decision not to fund the travel and accommodation costs they and their spouse had incurred as a result of travelling to visit their child (A) who was receiving treatment under a compulsory treatment order (CTO) in a different part of the country. C complained that the board's decision had failed to take into account the provisions of section 278 of the Mental Health (Care and Treatment) (Scotland) Act 2003 (the 2003 Act), which they considered placed a duty on the board to continue funding travel costs until A became 18, in addition to other legislation they considered to be applicable. C also complained about the board's failure to respond to correspondence in relation to this issue.

The board's position was that C was an adult once they turned 16 and that their patient travel policy did not allow for the funding of visits to adult patients. The board stated that it would have nevertheless considered funding C's visits to A had it been deemed critical by the consultant in charge of A's care but that no request for C's attendance had been made by clinicians.

We found that the board's patient travel policy did not allow for visits to patients over the age of 16 years to be funded by the board. However, we found that the board had failed to demonstrate that they had meaningfully considered the provisions of section 278 of the 2003 Act and had not adequately explained why they considered it did not apply to C and A's circumstances. We also found that the board had unreasonably failed to respond to C and their spouse's correspondence.

Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should reflect upon the findings of this investigation and reconsider their position in relation to the award of travel expenses to C under their policy and in particular consider whether section 278 of the 2003 Act applied to C and A's circumstances between the relevant period. Having done so, the board should consider whether C's travel and accommodation costs should be met. If the board does not consider section 278 to be applicable, the board should provide sufficient reasons for its position to C.

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

• The board should acknowledge and/or respond to correspondence which requests specific information.

In relation to complaints handling, we recommended:

• The board should ensure that complaints are identified and processed in accordance with their complaints handling procedure.

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 to their parent (A) who had been admitted to hospital with an infection of the gallbladder. A Magnetic Resonance Cholangiopancreatography (MRCP, an MRI scan of the gall bladder) was ordered and gallstones were found to be present. However, A did not hear from the hospital for several months following the scan until they proactively chased up a response. The board later confirmed that the MRCP report had not been provided to the consultant who had ordered the test causing the delay.

A was subsequently admitted for an Endoscopic Retrograde Cholangiopancreatography (ERCP, a procedure combining an endoscopy and X-rays to examine and treat conditions of the bile and pancreatic ducts) and discharged the following day. A was admitted again a few weeks later suffering from a complication of pancreatitis and a drain was inserted. A was discharged to be seen again as an out-patient. However, a few days later A was readmitted as an emergency patient suffering from a significant infection and died shortly after. C complained about the delay between the MRCP and ERCP procedure and questioned whether this had led to A's death. C also complained about the general standard of care provided to A.

We took independent advice from a consultant general surgeon with a specialist interest in upper gastrointestinal problems. We found that there had been a failing in both the board's paper and electronic reporting systems. Despite these failings, we were of the view that the delay did not, on this occasion, lead to a worse outcome for A clinically.

However, we were critical of the care provided to A following the ERCP procedure. We also found that A was discharged too soon, despite having developed pancreatitis, against both local policies and clinical best practice. We considered that A should have been admitted for longer, under the care of the original consultant, and that better initial care for A may have facilitated earlier intervention to possibly allow for their ultimate recovery. Therefore, we upheld C's complaint.

We also commented on complaints handling noting that the complaint had not been handled in line with the board's complaints handling procedure with respect to timescales, and that the initial complaints investigation had not identified issues with post-ERCP care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings 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 receiving scans should have their scans reported to the relevant and appropriate clinicians; reviewed, and followed up without delay.
• Patients should be under the care of the appropriate medical team during their admission. Any decision in relation to discharge should be taken by the appropriate medical team with appropriate account taken of local protocols and management pathways.
• There should be appropriate learning from serious events that ensure failings are identified and addressed and appropriate learning and practice improvements are made.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures. They should fully investigate and address the issues raised and identify and action learning.

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) who had been admitted to hospital with pneumonia. C complained that they found medication on the floor and in A's bedside cabinet. C complained that A's personal care needs had not been met, as they had not been washed and they had sore gums and an ulcer in their mouth. C also complained that A had red, sore skin in the groin area.

The board apologised for the fallen medication and advised that they were undertaking a project to reduce medication errors. They advised that A had not wanted to shower and that both personal and oral care had been undertaken regularly. They also said that the skin in the groin area had been checked and had only become red on the day that C visited.

We took independent advice from a nurse. We found that there appeared to be a design fault with the lockers, such that medication could fall out of the medication pod. We also found that A should have had a personal care plan and had not been offered sufficient personal care or oral care. We found that red skin had been noted 11 days prior to C's visit but had been recorded as healthy in the interim period. This would suggest that the skin was not properly checked. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for providing unreasonable personal care and unreasonable skin care. 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:

• Person centred care plan to be put in place for patients within 24 hours, as per board policy and skin care guidance to be followed correctly.

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 to their late spouse (A). A was diagnosed with pancreatic cancer. C was unhappy with the delays with A's treatment and said that these prevented A from receiving any treatment before their death.

The board said that their intention was to treat the cancer and that A was required to meet with a consultant to assess their fitness for surgery. The board said that the delay in meeting with a consultant was to allow the health board to carry out two multidisciplinary meetings, for some of A's symptoms (such as jaundice) to improve, and for other investigations and procedures to be carried out (such as, imaging scans and the fitting of stents). The board acknowledged that there was a delay in a PET-CT scan (where a drug is injected before the scan to help clinicians identify how certain body functions are working) being carried out due to failures in the drug production. The board said that when this fails, there is no back-up facility in Scotland to provide a replacement batch.

We took independent clinical advice from a consultant colorectal and general surgeon. We found that the timeframe for A's treatment could have been improved even with the allowable delays from the PET-CT scan. We considered that the investigations carried out were reasonable and the early scan and procedure to fit a stent were good points in the treatment pathway. However, the length of the pathway could have been improved and A's lengthy pathway to the offer of chemotherapy was unreasonable. The timing of the clinic appointment and PET-CT could also have been improved. Whilst we recognise some of the delays experienced could not be predicted or avoided, on balance, the timescale for A's pathway was unreasonable. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in assessing A's fitness for surgery and the impact this had on other investigations i.e. arranging a PET-CT scan, the delay in the PET-CT scan being carried out and A being identified as unsuitable for surgery. 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 who are considered suitable for surgery should have early assessment to establish fitness for surgery.

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 B about the care and treatment provided to B's spouse (A) by the practice. A attended the practice on a number of occasions over a few years with ongoing and worsening abdominal and lower back pain. C complained that the practice assumed A was suffering from a musculoskeletal problem and failed to consider other diagnoses sooner. A was later diagnosed with lymphoma and died at the time of diagnosis.

In responding to C's complaint, the practice undertook a Significant Adverse Event Review (SAER) and noted it was not clear when the lymphoma started. The practice also found that A had several normal or reassuring examinations and tests, and that several of A's presentations and tests pointed towards other diagnoses including liver disease and prostate disease. The SAER ultimately concluded that it seemed very unlikely that A had lymphoma for a long period of time given the very aggressive nature of their disease.

We took independent advice from a GP. We found that a number of tests and investigations were reported as normal and therefore there was no cause to refer A to specialists on suspicion of cancer. However, when concerns were raised about a possible missed renal cause for A's pain, we found that further investigations should have been undertaken at this time. These did not occur until almost a month later. A was suffering from an aggressive and difficult to diagnose cancer and, while the care and treatment provided by the practice was generally considered to be reasonable, the review should have triggered further tests at the time. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the issues identified in this decision. 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:

• That the practice share this decision notice with their GPs with a view to identifying any points of learning.

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.