Upheld, recommendations

Summary

C made a complaint about their late parent (A)'s discharge from University Hospital Hairmyres. C believed that A was not fit to be discharged and that this resulted in A having a fall, and sustaining an injury which then contributed to A's death.

We took independent advice from a physiotherapy adviser and a consultant physician and geriatrician (a speciality focussing on the health care of elderly people). We found that a comprehensive geriatric assessment was not carried out during A's admission. Given that this is a requirement outlined in the Healthcare Improvement Scotland (HIS) Care of older people in hospital standards, we considered it was unreasonable that no assessment appears to have been carried out. This may have provided a more comprehensive view of the issues affecting A.

We also found that A's case was not discussed at a Multidisciplinary team (MDT) meeting prior to A's discharge. If this meeting had taken place, the MDT could have considered whether A would have benefited from further rehabilitation (either in hospital or in the community).

Given that an MDT meeting did not take place prior to A's discharge, and given the lack of a comprehensive geriatric assessment in line with HIS standards, on balance, we considered the decision to discharge A was unreasonable. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not carrying out a comprehensive geriatric assessment during A's admission and for not discussing A's case at a Multidisciplinary team (MDT) meeting prior to their 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:

• Clinicians should have access to MDT meetings including all appropriate specialties to discuss patients on geriatric units who have MDT input.
• Older people presenting with frailty syndromes should have prompt access to a comprehensive geriatric assessment in line with Healthcare Improvement Scotland standards.

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 their late parent (A) was allowed to discharge themselves against medical advice. C considered that A was not fit to make this decision and that A's mental capacity had not been appropriately assessed.

We took independent advice from a consultant geriatrician (a specialty that focuses on the health care of elderly people). We found that no formal assessment of A's capacity was carried out when they were noted to be agitated, confused or not-orientated during their admission. We found that a senior doctor did not review A's decision-making capacity at the time that A expressed the wish to discharge themselves.

Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a formal assessment of A's capacity when they were noted to be agitated, confused or not-orientated during their admission and for failing to ensure a senior doctor reviewed A's decision-making capacity at the time that they expressed the wish to discharge themselves. 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:

• Patient decision-making capacity should be kept under review and if their clinical condition changes (such as agitation, confusion, disorientation) this should prompt further review in line with the Adults with Incapacity (Scotland) Act 2000.
• Where there is evidence that the patient has experienced confusion and agitation during their admission, as in this case, senior doctors should take steps to assess the patient's decision-making capacity at the time they express the wish to discharge themselves.

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 treatment provided by the board to their spouse (A) who was initially admitted to University Hospital Monklands with a fractured leg before being transferred to Wishaw General Hospital for further management. A's condition subsequently deteriorated, in response to which they received a full dose of Tinzaparin (anticoagulant). As A showed no improvement, they underwent an exploratory laparotomy (a surgical incision into the abdominal cavity, for diagnosis or in preparation for major surgery). A few hours later, due to further deterioration, A underwent a further laparotomy. During this procedure, significant bleeding and an injury to A's spleen was identified. A splenectomy (a surgical operation involving removal of the spleen) was then performed. A's condition did not improve and they died shortly after.

We firstly obtained advice from a consultant orthopaedic (conditions involving the musculoskeletal system) surgeon. We found no failings in relation to the orthopaedic care provided to A. We then obtained advice from a consultant general surgeon. We found that while it could not be definitively said how the tear to the spleen identified at the second laparotomy had been caused, it was possible that this may have been caused some time between commencing closure of the abdomen at first laparotomy and the second laparotomy. However, we also noted that A should not have received a full dose of Tinzaparin before it was established whether they would need surgery, as this was irreversible and greatly increased the risk of bleeding during surgery. The surgical adviser told us that the dose of Tinzaparin administered prior to surgery intensified the bleeding caused by the injury to A's spleen and contributed to A's death, although they may still have died from the underlying cause of their acute illness that could not be identified during post mortem examination. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably administering a full dose of injectable Tinzaparin to A before establishing whether they would require a laparotomy to explore the cause of their abdominal pain and deterioration. 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:

• Clinical staff should be aware that full-dose injectable anticoagulation should be withheld until it is clear that the patient does not require an operation due to the bleeding risk. In the event, a pulmonary embolism or deep vein thrombosis is identified.

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 a failure to diagnose their late partner (A)'s spinal cord cancer when they attended Wishaw General Hospital. They attended the Accident & Emergency Department and were referred on to the medical team for an urgent MRI scan for a suspected malignant spinal cord compression (MSSC, MSCC can happen when cancer grows in the bones of the spine or in the tissues around the spinal cord). However, this was subsequently changed to a CT scan, the result of which was normal, and A was discharged. A attended a private neurology (the science of the nerves and the nervoussystem, especially of the diseases affecting them) appointment the following week, where arrangements were made for an urgent hospital admission and a tumour in the spinal cord was diagnosed. A was left confined to a wheelchair following surgery and died around ten months later. C complained that, in not carrying out an MRI scan, the board failed to adhere to national guidance on MSCC management.

We took independent medical advice from a consultant radiologist (a specialist in the analysis of images of the body), who advised that it is normal practice to initially investigate any patient with a history of prior malignancy and suspected MSCC with an MRI of the whole spine. We, therefore, considered that it was unreasonable in A's case for the board to have carried out a CT rather than an MRI scan. It was noted that there was limited MRI scanner availability the day A presented, however, guidance allows for an MRI scan to take place within 24 hours. We found that an MRI scan should have been undertaken the following day and this omission was unreasonable. Had the MRI scan taken place, the spinal tumour would have been detected earlier. We were unable to say whether this would have had an impact on A's overall prognosis. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to conduct an MRI scan prior to discharging 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:

• NHS Lanarkshire's guidance on the management of MSCC should be reviewed to ensure that it is in line with NICE guidance. The findings of this investigation should be shared to ensure relevant learning for staff.

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 us about the care and treatment that they and their two children had received from a dentist. They said that they were told by the dentist that they and the children did not have any cavities, but when they attended another dentist, they were told that they had cavities and needed fillings. One of the children also needed crowns and experienced an abscess.

We took independent advice from a dentist. We found that the dentist complained about had failed to take bitewing X-rays (detect decay between teeth and changes in the thickness of bone caused by gum disease) for C and their children, which was unreasonable. There were also failings in relation to documentation. Whilst it was reasonable that one of the children was told that they had no cavities, we found that based on the evidence available, C and the other child had cavities that needed treatment when they attended the dentist.

We also found that the abscess experienced by one of the children was not avoidable, however, the dentist did not follow the relevant guidance on treating the abscess and gave the child antibiotics with no justification for their prescription. There was also no evidence available to demonstrate that the dentist discussed and explained treatment plans to C on all occasions. Given these failings, we found that the dentist's practice fell below the expected standard and upheld complaints about the care and treatment provided to all three patients.

C also complained to us about the way in which their complaint had been handled. We found that the dentist had not responded to C's concerns regarding their own care and treatment, or that of one of the children. Consequently, we found that the dentist had not handled C's complaint in line with the NHS Complaint Handing Procedure and we also upheld this complaint.

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:

• Bitewing x-rays should be taken in line with the relevant guidance. (Selection Criteria for Dental Radiography, FGDP).
• Clinical notes should be recorded in line with the relevant standards (4.1, Standards for the Dental Team, GDC & Clniical and Examination & Record Keeping Standards (FGDP)).
• Communication with patients and/or their guardians, and conversations regarding consent, should be carried out and documented in line with the relevant standards (Principles 2 and 3, Standards for the Dental Team, GDC).
• Diagnosing and treating abscesses should be in line with the relevant guidance (Management of Acute Dental Problems Guidance, SDCEP).
• Radiography reporting should comply with the relevant regulations.

In relation to complaints handling, we recommended:

• Complaints should be responded to in line with the NHS 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 on behalf of their parent (A) who had stage one oesophageal cancer at the time of the complaint. A was admitted to hospital via the A&E and later diagnosed with pulmonary embolism (PE, a blockage of an artery in the lungs).

C complained that the board delayed in diagnosing the PE and that the care and treatment they provided to A was subject to delays and unreasonable. C was concerned that A had been incorrectly treated as a palliative patient when their cancer was not advanced and that should not have impacted the care A received.

The board apologised for the delay in diagnosing PE and for the delays to A's care that happened whilst they were an in-patient e.g. delay to x-ray being carried out. The board considered various aspects of A's care, such as, when they decided to use a nasogastric (reaching or supplying the stomach via the nose) feeding tube and the action they took to manage A's sepsis, to be appropriate at the time.

We took independent clinical advice from advisers with relevant experience. We concluded that the board failed to diagnose the PE when they should have, that they failed to carry out the x-ray when it should have been done, and that they delayed starting antibiotics to treat suspected pneumonia. We considered that if these delays did not happen, it is likely that A would not have needed to be admitted to a high dependency unit for care. We noted that the decision to use a nasogastric feeding tube was taken reasonably and in line with relevant guidelines.

In light of this, we found that there was an unreasonable delay in diagnosing PE and that there was a delay in starting antibiotics for suspected pneumonia. These delays likely led to A's condition worsening and contributed towards the requirement for A to be admitted to a high dependency unit. There were also communication failings that led to a delay in an x-ray being carried out.

We identified failings in the way in which the board handled the complaint. We found that the board's response to C's complaint did not address the matters raised in a structured format, which made it difficult to follow.

As such, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and 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:

• A suitable handover tool should be used consistently to ensure instructions have been carried out as prescribed, e.g (SBAR) Handover Tool.
• Patients presenting with symptoms of pulmonary embolism should be diagnosed and treated in line with the relevant guidelines. Clinicians should be aware of confirmation/cognitive bias in differential diagnosis of patients with pre-existing conditions.
• Patients should be treated appropriately for their presenting symptoms and where appropriate antibiotic treatment commenced.

In relation to complaints handling, we recommended:

• Complaint responses should be clear and understandable, in line with the NHS 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 their family member (A) received from the board.

A had a complex medical history and received treatment in hospital on a number of occasions. C became aware that a wound that A had on their leg had deteriorated. C was very concerned about the condition of the wound.

C complained that, although A had been in and out of hospital on a number of occasions, the board had failed to take reasonable steps to treat A's leg wound. They complained that A was discharged from hospital on multiple occasions following treatment for infections, but that follow-up arrangements were inadequate and, as a result, the leg wound was left to deteriorate. C said that A had suffered both physically and mentally and that family members had been extremely distressed seeing A suffer.

We found that A's complex medical history meant that they had multiple hospital admissions and that they were seen regularly by community based district nurses and tissue viability nurses. A's wounds were quite severe and were complicated by the fact that their condition caused their leg muscles to contract, keeping the two skin surfaces together and difficult to access for pressure-relieving treatment. There was no suggestion that the wound on A's leg was caused, or made worse, by any shortfall in the care and treatment provided by the board.

We were satisfied that staff caring for A were aware of their wounds and made efforts to relieve the discomfort that they caused as well as working towards helping them to heal. Upon each admission to hospital, A's wounds were assessed and a referral was made to the tissue viability service for review. Whilst on some occasions A was discharged home before the review could occur, they continued to receive care at home from the community tissue viability nurses.

Whilst overall we were satisfied that A's wounds were taken seriously and a management plan was in place, we found that some discharge documentation was incomplete and that communication between the hospital and community based teams was lacking at times. As such, the most up-to-date review information from the acute tissue viability service may not have been communicated to the community nurses who provided the regular care that A required. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Consider holding a multi-disciplinary team meeting to discuss how to improve communication between teams and provide a holistic approach to care for individuals with multiple needs.
• Remind all appropriate staff of the importance of completing all discharge documentation and wound care charts.

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 of their late parent (A) who died in Glasgow Royal Infirmary (GRI) from respiratory failure and an undiagnosed progressive neurological condition. Potential Motor Neurone Disease (MND, a rare condition that progressively damages parts of the nervous system) had been noted by a neurology registrar five months earlier but this diagnosis was never confirmed. A was admitted to GRI four times over the following months, and C complained that their rapidly deteriorating condition was not acted upon and that palliative care was not initiated.

We took independent advice from a consultant neurologist (a specialist in nerves and the nervous system, especially of the diseases affecting them), who noted that investigations planned by the neurology registrar were not followed up, and that a referral to a specialist neuropathy clinic was not fulfilled, within national waiting time targets. We found that the medical teams caring for A during their hospital admissions failed to consider a neurological disorder as the cause of their deterioration and failed to seek specialist neurological input. We considered that neurological clinical standards should have been applied regardless of the absence of a confirmed diagnosis, and this would have included a timely assessment of communication, nutritional and respiratory needs. Notwithstanding this, we found that the palliative symptom treatment offered to A in the last months of their life was of a reasonable standard and, despite the absence of a diagnosis, we saw no evidence that A suffered from a lack of care or treatment. On balance, however, we upheld this complaint.

C also complained that the family were not informed that A's condition was terminal. We did not consider that staff were in a position to predict A would die when they did, given the lack of clear neurological diagnosis, and we were satisfied that there was communication with the family when death was appreciated to be imminent. However, the failure to seek specialist neurological input meant that there was a missed opportunity to clarify the diagnosis and enable clearer communication with the family regarding the prognosis. C also complained that the board failed to explain why a post mortem (PM) was not deemed necessary when A's deterioration and death was viewed as sudden. While we did not consider that a PM would have identified the underlying cause of A's neurological deterioration, we noted that it would have been best practice to discuss this with the family and seek their views before reaching a decision regarding a PM. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family that the failure to seek specialist neurological input meant there was a missed opportunity to clarify A's prognosis and enable clearer communication with them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for failing to ensure planned investigation was carried out within National Waiting Time Guidance; for the failure to seek a specialist neurological opinion during A's hospital admissions; and for the failure to apply the Neurological Standards regardless of the absence of a confirmed diagnosis.

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

• An effective handover of care should take place, and planned referrals should be followed up, when a clinician moves on to a different role / their role in providing a patient's care has ended.
• The board should consider their processes for ensuring maximum waiting times from diagnosis to treatment are adhered to, where possible, particularly in regard to patients who have progressive neuromuscular disease.
• The board should provide education to respiratory and emergency physicians to ensure they are aware of the potential contribution of neuromuscular weakness to respiratory failure in emergency situations, how to recognise this and how it can be managed effectively.
• The board should reflect on the view that the Neurological Standards would have been appropriate in this case, regardless of the absence of a confirmed MND diagnosis, and feed this back to relevant staff in a supportive manner to ensure that current standards are applied, where appropriate, in future.

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 brought a complaint about the care and treatment that their late spouse (A) received during three admissions to Aberdeen Royal Infirmary. C was concerned that A did not receive appropriate treatment and was discharged on each occasion. A was initially admitted following a heart attack, and died a few months later due to heart failure.

We took independent advice from a consultant cardiologist (medical specialist dealing with disorders of the heart). We found that the care and treatment A received during two of these admissions was reasonable, including the decision to discharge A. However, during one admission the board acknowledged that there was a missed opportunity to provide cardiology input and seek an in-patient echocardiogram (a heart scan that uses sound waves to create images).

We found that it was unreasonable that no input was sought from the cardiology department during this particular admission and that an opportunity was lost to make the correct diagnosis and to optimise possible treatment options. We upheld the complaint but also noted that it was not possible to say definitively whether this would have changed A's survival prospects.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not seeking input from the cardiology department during A's admission. 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:

• Input should be sought from the cardiology department where a patient has reduced cardiac function following a recent history of heart attack.

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 child (A) about the service received from the practice and the way in which their complaint was handled.

A commenced a course of treatment with the practice because due to a dental overjet (when the upper teeth protrude outward and sit over the bottom teeth), they qualified for NHS funding. A and C agreed to proceed with a functional appliance to correct the overjet. A wore the appliance some of the time, but they did not comply with the treatment in full. A was warned of the necessity to comply and given several reminders. A also missed an appointment.

C was sent a 'wish to continue' letter in which they were advised that they should get in touch within four weeks or A would be discharged back to the dentist. C contacted the practice within this period of time to discuss other options for A. As C did not receive a response, they raised a complaint. During this period A was discharged back to the dentist.

We took independent advice from an orthodontist. We found that, although it is accepted that the clinical decision may not have been different, we considered there should have been a further clinical discussion before A was discharged. We upheld this aspect of C's complaint.

In relation to the complaint handling, we upheld this complaint on the basis that there was a delay in responding to C's concerns in full and C was not signposted to this office.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failing to have a clinical discussion with them, prior to discharging A, for a delay in responding to the complaint, for failing to provide a clinical explanation why A was discharged when C was trying to engage in discussions regarding A's future treatment and failing to signpost to this office. 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 practice should engage in clinical discussion before discharging the patient, when a patient or their representative asks to discuss clinical treatment within the timeframe set by the practice.

In relation to complaints handling, we recommended:

• To ensure a full explanation is provided to a complaint, with input from clinical staff, within a reasonable time, and that a complainant is signposted to this office.

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.