Upheld, recommendations

Summary

C complained about the care and treatment their late parent (A) received from board. A was admitted to A&E at Victoria Hospital following a fall at home. A was found to have fractured their femur and was subsequently transferred to a ward. A died shortly after transferring to the ward. No post-mortem was required by the Procurator Fiscal and a heart attack was recorded as the likely cause of death.

C said that they were told by the board's staff that tests carried out in the A&E did not indicate any problems with A's heart. As such, no additional monitoring was required when A transferred to the ward.

C complained that the board's staff failed to note and act upon a number of “red flag” symptoms that should have highlighted that A was at increased risk of a heart attack. C noted that A had been given a high dose of morphine by the ambulance crew. C complained that the board's staff failed to adequately monitor A's general condition or their reaction to the morphine.

We found that A's general condition was reasonably assessed in the A&E. An echocardiogram (a heart scan that uses sound waves to create images) was carried out and did not raise any concerns about A's heart. Whilst A displayed a number of symptoms that could have been linked to a heart problem, the tests carried out by hospital staff were thorough and gave no indication that there was a need for any specific additional heart monitoring when A transferred to the ward.

A was given a high dosage of morphine by the ambulance crew. We accepted medical advice that the hospital staff should have been aware of this and that they should have monitored A's response to this medication. We found no record of the morphine dosage having been recorded upon A's admission to hospital, or of specific monitoring taking place to check for any adverse reactions to the medication. A displayed symptoms that could have been caused by morphine. It was not possible to determine whether A's death was caused by a problem with their heart, or a reaction to the morphine. However, we were critical of the board's failure to record the morphine dosage and monitor A's reaction to it throughout their admission. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failures identified. The apology should meet the standards 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:

• That the board confirms to this office whether they assess patient care against the Scottish Standards for the Care of Hip Fracture patients and provides details of any learning and improvements resulting from C's complaint.
• That the board share a copy of this decision with the departments involved in A's care with a view to preventing similar issues in the 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 complained about the care and treatment of their late parent (A) in the weeks prior to their death in Queen Margaret Hospital. C raised concerns that staff failed to notice and act upon A's deteriorating condition, and particularly a dramatic deterioration on the day that A died. C noted that the post mortem identified evidence of a chest infection, and they complained that A died of an easily treatable condition. C raised concerns about the stoppage of A's diuretic medication (drugs that enable the body to get rid of excess fluids), which they considered contributed to a fluid build-up in A's lungs.

We obtained independent medical advice from a consultant geriatrician (a doctor specialising in medical care for the elderly), who noted from the records that the expected level of observations took place. We found that sufficient attention was paid to A's fluid build-up, and that the decision to stop their diuretic medication was reasonable in the circumstances. However, we noted that A's vomiting and unstable observations in the days prior to their death were not acted upon. We noted that this should have prompted further clinical review. While we could not be certain that this would have identified a chest infection or how unwell A was, we considered that this should have received more attention from medical staff. We found no evidence to support that any dramatic deterioration in A's condition was overlooked on the day A died. On balance, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to act on A's vomiting and abnormal observations in the last few days of their life. 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:

• Abnormal clinical observations (such as low blood pressure and high heart rate) and vomiting should prompt timely clinical review / further assessment of 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 complained about the nursing care and treatment they received during their admission to Ninewells Hospital. This related to the treatment of a pressure ulcer which C complained was left to deteriorate to the extent that on discharge it was worse than on admission. They said that as a consequence, their treatment had to be continued intensively at home.

The board apologised that C's wound had been worse on discharge and accepted that the simple dressings used by nursing staff would not have encouraged wound healing. They also accepted that there was a requirement to support all staff members to attend an update training session on wound care and that encouragement needed to be given to all team members to have the confidence to ask their peers or others working within the multidisciplinary team for advice and assistance.

We took independent advice from a nursing adviser. We found that there had been a failure to assess, measure and treat C's wound in accordance with the Scottish adapted pressure ulcer grading tool and Healthcare Improvement Scotland (HIS) Pressure Ulcer Standards (2018). We also found that the review carried out by the board had not been thorough enough, a number of failings had not been identified and that the action already taken by the board was not enough to demonstrate that there had been improvement with regard to pressure ulcer assessment and grading. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to assess, measure and treat their pressure ulcer in accordance with the Scottish adapted pressure ulcer grading tool and HIS Pressure Ulcer Standards (2018). 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 pressure ulcers should be assessed, measured and treated in accordance with the Scottish adapted pressure ulcer grading tool and HIS Pressure Ulcer Standards (2018).

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 late parent (A) about the care and treatment provided by their GP at the practice. A had been attending the practice with shortness of breath and a persistent cough. An urgent referral for suspected cancer was made, however C considered that the practice should have made the referral sooner.

We reviewed the relevant medical records and sought independent advice from a GP. We found that as A was high-risk patient who was failing to respond to antibiotics, an urgent referral to the chest clinic should have been made eleven months earlier and as such, we concluded that the practice failed to correctly follow the Scottish Suspected Cancer Referral guidelines. We upheld the 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:

• Clinical staff should be familiar with the Scottish Suspected Cancer Referral Guidelines and refer patients for specialist assessment in accordance with the guidelines.

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 to discharge their late parent (A) from University Hospital Monklands. A had metastatic cancer (cancer that has spread from the part of the body where it started) and had been admitted to hospital with blood in their urine. A was treated with antibiotics and antifungals, however, their infection markers remained elevated. As A showed no other signs of infection, their elevated infection markers were attributed to their cancer and they were discharged home. A was readmitted to hospital the following day with a deep vein thrombosis (DVT, blood clot in a vein). Their condition deteriorated and they died eight days later.

C complained that A had been discharged from the hospital before they were fit to return home. C also raised concerns about the hospital staff's communication regarding A's condition and discharge. C considered that failings by the board meant that A endured unnecessary suffering which distressed family members.

We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We were satisfied that the hospital staff communicated clearly and regularly with C throughout A's admission to the extent that C was kept informed as to how A was fairing on the ward. We were also satisfied that nursing and clinical staff appropriately monitored and recorded changes in A's mobility and attempted to provide physiotherapy when A was willing and able to participate.

We found that, in the days before A's discharge, C had raised concerns with the nursing staff regarding A's foot being swollen. We noted that this should have raised the suspicion of a DVT specifically and that investigations should have been carried out prior to A being discharged. Whilst the nursing staff advised C that their concerns would be passed on to the medical team, we found no evidence of this happening and concluded that an opportunity was missed to investigate and diagnose A's DVT prior to their discharge. 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 setout 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 developed an infection following a wisdom tooth extraction, which was not diagnosed and subsequently spread to their brain. C was reviewed in hospital on several occasions, including out-patient reviews by oral and maxillofacial (OMF) surgeons (specialists in treating diseases and injuries of the mouth and face) and an in-patient admission to Victoria Hospital. C questioned how the infection was missed on so many different occasions by so many different people.

The board indicated in their response that there were no clinical signs which led them to suspect bacterial infection, and jaw joint problems were being considered as the cause of C's symptoms. C was then suspected, during their in-patient admission, to have viral encephalitis (inflammation of the brain). A plan to carry out an MRI wasn't pursued due to noted improvement in C's condition. The responsible consultant reflected that an MRI should have been performed during the admission, and that not doing so may have delayed the identification and treatment of the infection in C's brain.

We took independent medical advice from a consultant OMF surgeon and a consultant physician. While it was noted that C's infection presented atypically and was difficult to diagnose, their C-reactive protein (CRP, inflammation marker) was raised when they initially presented and this wasn't acted upon. A CT scan also showed subtle signs of infection but this wasn't picked up at the time. An urgent out-patient MRI was requested to look for joint problems and not to exclude infection, otherwise it may have been carried out sooner. We also found that the subsequent in-patient assessment didn't give due care and attention to C's recent wisdom tooth extraction and hospital attendances. It was agreed that the failure to pursue an in-patient MRI contributed to the failure to correctly diagnose and appropriately treat C's infection. We considered that the decision to discharge C with a persistent headache was unreasonable. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to diagnose and treat their infection earlier. 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:

• This case should have joint Mortality & Morbidity review. The findings of this investigation should be presented, to ensure relevant learning for staff from the OMF service, radiology and medicine.

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 practice did not take reasonable action in response to their late spouse (A)'s symptoms and condition. A had a long history of degenerative disc disease affecting their spine (when normal changes that take place in the discs of your spine cause pain) and a history of stomach cancer. A visited or contacted the practice several times over three months regarding pain in the neck and shoulder, numbness in the right hand and jerking of the right leg. Tests were undertaken, medication and therapies prescribed and a referral to an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was made. Following a fall at home, A was admitted to hospital where a spread of cancer to A's spine was diagnosed.

A died shortly after C submitted a complaint to the practice about their response to A's symptoms and condition over the previous few months. In response, the practice recounted the actions they had taken in response to A's visits and contacts in their final months, highlighted blood tests whose results did not indicate any significant abnormality or spread of cancer and explained that A's symptoms were relatable to their ongoing diagnosis of degenerative cervical disc and spinal stenosis (a condition where the space around the spinal cord narrows, compressing a section of nerve tissue). The practice advised that a significant case review had been carried out. This had highlighted that A's orthopaedic referral could have been upgraded to urgent when it was clear A's symptoms were not being controlled, but stated that it was doubtful this would have had any impact on the outcome. C was unhappy with this response and brought their complaint to this office.

We took independent advice from a GP. We found that the practice took reasonable action in response to A's symptoms and condition until a point. However, when it was clear that A's symptoms were not being controlled and began to worsen, the practice's actions were unreasonable. We found that the potential significance of test results reported to the practice and the potential link with A's symptoms were not reasonably recognised by the practice until they reviewed A's care and treatment as a result of our investigation of the case. Therefore, we upheld C's complaint. However, while we noted that earlier action by the practice may have led to an earlier admission to hospital, it was extremely unlikely to have prevented A's death.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. The apology should make clear mention of each of the failings identified, whether that was identified by the practice or 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 review how it deals with blood samples that are significantly outwith the normal range. This would include consideration about how they are communicated with the patient, how they are highlighted in the notes and how they are followed up.
• The practice should review their current policy on home visiting patients who are too frail or too unwell to attend the practice to ensure there is a clear criteria for accepting or refusing a home visit and that safeguards are in pace when a home visit request is turned down.

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 late spouse (A) who was admitted to Ninewells Hospital. A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR, a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place some time after their admission and they died a week later.

C complained that clinicians failed to discuss the DNACPR with family prior to this being put in place and, when they were consulted, the family were clear that they were not in agreement with it. The family also complained that the DNACPR form was only signed by one clinician, rather than the two required for the form. C considered this was further evidence that the DNACPR decision was taken incorrectly.

In response, the board said that the decision to put a DNACPR in place was made following discussion at the multi-disciplinary team meeting, the records did not show any disagreement by the family at the time and the form was completed by one of the junior medical staff, on the lead consultant’s instruction.

We took independent advice from an appropriately qualified adviser. We found that the board failed to follow appropriate processes and procedures in relation to the implementation of the DNACPR, in as far as they failed to both adequately document conversations with family members, and to complete the required paperwork correctly. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow appropriate processes and procedures in relation to the implementation of the DNACPR, more specifically for failing to adequately document conversations with family members, and also in failing to complete the required paperwork correctly. 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 involved should reflect on the complaint and identified failures with respect to the implementation of the DNACPR, specifically documenting communications with family and completing the relevant paperwork and forms.
• Medical professionals and clinicians are aware of, and adhere to, relevant professional standards and guidance with respect to maintaining clinical records and recording decision-making.

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 been treated for chlamydia and gonorrhoea (two types of sexually transmitted infection) by the board. C continued to feel unwell and attended an appointment at the board. C was concerned that they were not physically examined or tested for pelvic inflammatory disease (an infection of the female upper genital tract, including the womb, fallopian tubes and ovaries) and that they were advised to isolate with a possible COVID-19 infection.

We took independent advice from a consultant in sexual and reproductive health with a background in hospital gynaecology (female reproductive system). We found that C reported symptoms which were consistent with pelvic inflammatory disease. In the circumstances, it was unreasonable that a physical assessment was not performed, or as an alternative, empirical antibiotic therapy commenced for possible pelvic inflammatory disease. It was unreasonable that further steps were not taken to assess for and exclude pelvic inflammatory disease as a possible diagnosis in this case, prior to providing the advice regarding self-isolation for possible COVID-19 infection.

In light of the above, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not performing a physical assessment for pelvic inflammatory disease or as an alternative commencing empirical antibiotic therapy. 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 present with abdominal pain and fever, in the context of a recent sexually transmitted infection, should be physically examined and/or commenced on empirical antibiotic therapy.

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 parent (A). A attended Raigmore Hospital with symptoms including lethargy, bruising and weight loss. A was found to be severely anaemic (a low level of red blood cells) and had a very low platelet count (small cells that help the blood to clot). A was asked to attend Caithness General Hospital for regular platelet treatment and further investigations into their condition.

Around a month later, A became unwell and they attended A&E at Caithness General Hospital. A was discharged home the same morning. Two days later, C became concerned about A as they looked 'black and blue'. C phoned the consultant haematologist (a specialist in diseases of the blood and bone marrow) for advice. They told C to contact A's GP if they were concerned about A's condition. By the next morning, A had become very unwell and they were taken to Caithness General Hospital by ambulance. A was found to have intracranial bleeding (bleeding within the skull). A was airlifted to Aberdeen Royal Infirmary that evening for platelet treatment. A's condition continued to worsen and they died the next day.

We took independent advice from a consultant haematologist. We found that there was no evidence A was told about the possible complications they could develop from their low platelet count, such as the risk of internal bleeding. We found A was unreasonably discharged home from Caithness General Hospital, as they should have been referred for emergency platelet treatment. In relation to C's phone call to the consultant haematologist, we acknowledged a GP should normally be the first point of contact. However, we considered appropriate action was not taken in response to the phone call, given C had described signs of A having internal bleeding. For these reasons, we upheld the 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:

• If a patient/family member contacts a clinician with information that indicates they are seriously unwell, this should be recognised and appropriate action should be taken.
• Patients at risk of developing serious complications should be given clear information about that, and it should be appropriately documented in their medical records.
• Patients, who are found to have low platelet levels, should be referred for timely and appropriate platelet treatment.
• 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.

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.