Upheld, recommendations

Summary

C complained that the board failed to provide their adult child (A) with adequate care and treatment by discharging them from hospital when they were not medically fit to be discharged, highlighting A’s ongoing incapacity at that time.

A was admitted to hospital following an insulin overdose. Following treatment in an intensive care unit, they were transferred to a general ward. A was discharged after an in-patient stay of several days. A was readmitted to hospital by ambulance transfer the day after their discharge.

We took independent advice from an emergency medicine consultant adviser. We found that it was unreasonable for the board to have discharged A. We found that there were failings in the discharge process which had led to A being discharged with an unaddressed medical condition. Therefore, we upheld the complaint.

We also found that there had been delay in undertaking a psychiatric review. We provided feedback to the board about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A, C, and their family for discharging A from hospital with an unaddressed medical condition leading to their readmission and for the delay in carrying out a psychiatric review. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• In similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and the assessment recorded in the patient’s clinical 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 presented at A&E with a painful left foot. The diagnosis recorded in the medical records was a foot sprain. A few months later, C was diagnosed with a rare degenerative condition and a possible healing fracture in their foot was also noted.

C complained that the doctor at A&E had not physically examined the foot, had not carried out an x-ray and had not taken a medical history. As such, a possible fracture may have been missed and a diagnosis of the degenerative condition was not considered. As a result, C felt that the correct treatment was not offered.

We took independent advice from an emergency medicine adviser. We found that the condition in question is rare and unlikely to be diagnosed in an A&E setting. It was also not clear whether the possible healing fracture had been present at the time. However, it would have been appropriate to carry out a physical examination, to take a medical history and to carry out an x-ray. Overall, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not carrying out a physical examination and not taking a medical history, such that an x-ray was not considered. 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:

• Clinicians should be reminded of the importance of carrying out a thorough physical examination and recording the patient’s medical history.

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 service provided by the council's social work service in connection with their child (A), who resided with their other parent. C was unhappy with the way the council facilitated contact between them and A, as well as C's other children and A.

We took independent advice from a social worker. For the period of time we considered, we found that the social work service should have engaged with C more proactively in relation to contact with A. We did not find any issues with the way the council managed contact between A and their siblings. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to engage with them more proactively in relation to contact with A. 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 social work service should engage and communicate with families effectively and in the best interests of the child.

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.

Please note the events this complaint refers to may have occurred some time ago due to a delay in publication. We publish our findings to share learning and inform improvement.

Summary

C complained about medical treatment provided to their late spouse (A) following their transfer to a community hospital from a regional hospital, where A had been treated for a heart attack. C raised concern about several aspects of the care provided, including the frequency of medical reviews and communication with A’s family about their condition.

We took independent advice from a consultant in care of the elderly. We found that A had been suffering from hypernatraemia (high sodium levels in the blood) at the time of their hospital transfer and that this condition required careful monitoring of A’s fluid balance, planned daily medical reviews and frequent blood tests. Despite this, we noted that A had not been medically reviewed daily at the community hospital. Weekend medical cover was provided by an out-of-hours GP service, which would only attend if required. Given this, we found that the decision to transfer A to this hospital had been unreasonable.

We also found that the frequency of blood tests carried out was insufficient and that no medical review was carried out despite rising sodium levels in A’s blood. We noted that A had not received intravenous fluids over a period of three days despite their oral intake documented as poor and that, when intravenous fluids had been administered, the particular type of fluids given had been inappropriate to treat hypernatraemia and may have worsened A’s condition. However, it was not possible to say how this might have affected A's outcome given the generally poor prognosis associated with the condition and A’s significant comorbidities. For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A’s treatment. 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:

• Robust handover procedures should be in place so that staff taking over responsibility for patient care following transfer to community hospitals are clear about ongoing treatment and review requirements.
• Patients should only be transferred to community hospitals when it is clear that the required level of care can safely be provided following transfer.
• In patients presenting with conditions causing electrolyte imbalances, such as hypernatraemia, medical and nursing staff should be clear on (i) the frequency and the means by which such patients require to be reviewed including the frequency of blood tests and; (ii) the appropriate intravenous fluids to be used to manage such conditions.

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.

Please note the events this complaint refers to may have occurred some time ago due to a delay in publication. We publish our findings to share learning and inform improvement.

Summary

C, a support and advocacy worker, complained on behalf of their client (A) that the board failed to ensure clinicians provided a surgical assessment and procedure to A within a reasonable time frame. A had been referred to the board’s neurosurgical department (specialists in surgery on the nervous system, especially the brain and spinal cord) following an injury to their back but decided to undergo a surgical procedure privately following delays from the board. A continued to experience pain and felt that the board's delay had led to an adverse outcome from the surgery.

We took independent advice from a consultant neurosurgeon. We found that the board unreasonably delayed the clinical assessment and treatment of A. We also found that there was an unreasonable delay to A being given a clinic appointment and that communication around the treatment time guarantee process could have been better. However, we could not say with any certainty that the delay led directly to an adverse outcome for A. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to progress their treatment 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:

• Consideration as to how to better manage patients’ expectations in terms of their treatment time guarantee calculation and how the treatment booking process works.
• Make improvements to the clinic booking process to ensure patients are seen within national waiting time targets.

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.

Please note the events this complaint refers to may have occurred some time ago due to a delay in publication. We publish our findings to share learning and inform improvement.

Summary

C complained on behalf of their partner (A). A had a telephone consultation with the practice and reported haemoptysis (coughing up blood) and a fever. A also reported that they had taken a lateral flow test for COVID-19 which was negative. A did not take a PCR test for COVID-19 prior to contacting the practice. The practice considered it was likely that A had COVID-19 and advised that they self-isolate for ten days after symptoms started. A's condition deteriorated and several weeks later they were admitted to hospital and diagnosed with bacterial pneumonia.

C complained that the practice did not offer A a face to face appointment and subsequently failed to correctly diagnose their condition of bacterial pneumonia, instead focussing on COVID-19 as being the cause of A's illness.

The practice considered that they had been following the guidelines in place at the time and had correctly signposted A to the COVID-19 Hub for further assessment. We took independent advice from a GP. We found that there was no evidence in the clinical record that A had been signposted to the COVID-19 Hub and that haemoptysis was never listed as one of the common symptoms of COVID-19 infection. We found there was a failure to offer A a face to face appointment, particularly given they had reported haemoptysis.

We welcomed that during our investigation the practice reflected further and accepted that A's complaint of haemoptysis merited further clinical consideration and assessment. Given that the practice have taken appropriate and sufficient action to learn and improve from this complaint, we did not recommended that they take any further action. However, we recommended that they apologise to C and A for not offering A a face to face appointment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for not offering a face to face appointment which may have led to bacterial pneumonia being considered. 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

C had a history of multiple facial trauma and had undergone various procedures over the last decade in relation to their nose and face. C then received further injury which caused damage to their nose.

C complained that the board refused to perform any further investigations or the reconstructive surgery they considered was required. This was despite numerous GP referrals to the ear, nose and throat (ENT) department. C stated that they continued to suffer ongoing pain and symptoms associated with their facial injuries. C complained that the board were acting on the basis of a psychological assessment from a number of years ago, which suggested investigation and treatment could be damaging to C. C strongly objected to the content of this assessment.

We took independent advice from an ENT surgeon. We found that it was reasonable for the board to take into consideration the psychiatric assessment that warned against unnecessary investigations and treatment unless indicated on objective grounds. However, we considered that given the passage of time since that document was produced, and because C had recently been assaulted potentially causing new injury, it was reasonable for C to be reassessed. Therefore, we upheld C's complaint.

We also noted failings in relation to complaint handling and made a recommendation to address this.

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:

• Where a significant period of time has elapsed since a patient was clinically assessed and there is evidence that the patient’s clinical situation has changed, the patient should be offered a clinical reassessment.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement. The board should comply with their complaint handling guidance when investigating and responding 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.

When it was originally published on 22 March 2023, this case referred to a Medical Practice in the Ayrshire and Arran NHS Board area. This was incorrect, and should have read a Medical Practice in the Fife NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

C complained about the end of life care their late spouse (A) had received from the practice. A had Lewy body dementia (a progressive dementia that results from protein deposits in nerve cells of the brain which affects movement, thinking skills, mood, memory, and behaviour) and was cared for at home by C. When A’s condition deteriorated, C complained that the GP had not visited them at home to assess their decline. C also complained that there had been a delay in initiating their end of life care plan allowing access to appropriate pain relieving medication and to the community palliative care team for support.

In response, the practice said that although a GP had not visited A at home in their final weeks, a number of GPs had been in constant liaison with the district nursing team about their care and prescribing appropriate medications. They noted that their duty doctor had not been aware of, or could refer into, the palliative care team but following liaison with the district nursing team, this was progressed and A had received assistance thereafter.

We took independent advice from a GP. We found that the practice had not provided a reasonable standard of end of life care to A. We considered they should have carried out an earlier assessment of A’s palliative and end of life needs to inform better care planning, that there was an unreasonable delay in providing A with appropriate pain relieving medication, and noted that staff lacked awareness of the community palliative care team and the referral process. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of end of life 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:

• Patients experiencing a reported deterioration in their condition should be appropriately assessed in accordance with relevant national guidelines.
• Patients receiving end of life care should have their response to pain relieving medication appropriately assessed and any required changes promptly administered.

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 that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted and discharged from hospital on two separate occasions. A died shortly after their third admission to hospital.

We took independent advice from a consultant in geriatric medicine and general medicine (a specialist in care of the elderly).

We found that while some aspects of A’s care were reasonable, particularly in relation to cardiac (heart) care, given the complexity and combination of A’s conditions, age and frailty, A should not have been discharged the day after their first admission. A should have remained in hospital given that a deterioration in their condition was very likely to occur, and as they also required further detailed assessment of their mobility. It was determined that A’s combination of problems would have required inpatient care even for a previously healthy patient and the acute exacerbation of A’s conditions would have been profound and life threatening.

We also found that there was a lack of detailed assessment of A’s mobility difficulties prior to being discharged. We found that the board failed to take account of the evidence in A’s records that they had struggled with their mobility and had needed supervision and support. We noted that an assessment of A’s mobility had been part of the medical plan at the time of their first admission. Given the severity of A’s illness, age, and the difficulty with walking, there should have been a specific and detailed assessment of A’s mobility prior to their discharge. We also found that the board failed to provide a full response to C’s complaint.

Taking account of the evidence and the advice we received, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in discharging A from the hospital the day after their admission, for failing to carry out a full and detailed assessment of A’s mobility prior to their discharge and for the failure to provide C with a full and informed response in relation to their complaint. 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 similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and in line with recognised guidelines.

In relation to complaints handling, we recommended:

• Complaint responses should be informed and 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

C complained that the board failed to provide reasonable care and dental treatment to them over a period of several months. During clinical examinations, C raised concerns about experiencing pain from a particular tooth.

We took independent advice from a dentist. We found that while treatment provided by the dental practice was, in general, reasonable, there were some missed opportunities to further investigate the condition of the tooth in question. Further investigations would have been appropriate to help determine whether the tooth was the actual cause of the pain. We found that further information obtained at subsequent appointments would have helped confirm that C’s pain was the result of a localised infection. The board accepted that in retrospect, the pain was due to the tooth that was ultimately extracted. Given the missed opportunities to further investigate the condition of the tooth in question, develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the missed opportunities to further investigate the condition of the tooth in question, for the failure to develop a more appropriate diagnosis and potentially reduce prolonging C’s pain and discomfort. 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:

• Dentists should act in line with the Scottish Dental Clinical Effectiveness Programme's Management of Acute Dental 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.