Health

Summary

Ms C complained that the board failed to provide reasonable care and treatment to her friend (Mr A) at the Queen Elizabeth University Hospital, before his death. Mr A had been admitted to the hospital due to exacerbation of his asthma and flu. After a few days, his condition deteriorated. He died six days after being admitted to hospital.

We took independent advice from a consultant in acute medicine. We found that:

• more information about Mr A’s alcohol intake should have been obtained;

• if the alcohol liaison nurse’s entry had been read or actioned, his diazepam (a tranquillizingmuscle-relaxant drug used to relieve anxiety) prescription would probably have been cancelled;

• there was a failure to respond promptly to his deterioration;

• it was unreasonable that he was seen by a junior grade doctor when he was clearly very unwell;

• prescribing sedation and planning to review him four hours later was not an appropriate response to a patient who was deteriorating and showing evidence of lower oxygen levels than normal;

• he should have been seen more promptly after his initial deterioration by a more senior doctor;

• he should have had important investigations such as X-rays and blood tests as soon as he was settled enough to comply with them;

• it was unreasonable that he was not on a fluid balance chart daily from admission;

• he should have been assessed more thoroughly for potential sepsis (blood infection) when he deteriorated; and

• what was written down in the notes did not seem to be have been read by other members of the team.

Therefore, we upheld this aspect of Ms C's complaint.

Ms C also complained about the lack of communication from staff about Mr A’s deterioration. We found that staff should have contacted her earlier than they did. The failure to do so substantiated the concern that staff did not recognise or respond to Mr A’s deterioration appropriately and that they did not recognise how unwell he was. We upheld this aspect of the complaint.

Finally, Ms C complained that the board failed to accept that Mr A had sepsis. She considered that sepsis should have been recorded on his death certificate. We found that the tests that were carried out at that time showed serious infection but did not indicate sepsis. Based on the information available, it was reasonable that sepsis was not recorded on Mr A’s death certificate. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

• Clinical entries in medical notes should be read and acted on. If a decision is taken not to act on the entry, this should be noted. Caution needs to be exercised when sedating patients with respiratory failure.
• Patients who have an elevated Early Warning score should be reviewed regularly, particularly if no definitive management plan has been established. The appropriate tests and investigations should also be carried out, including the tests for sepsis.
• Medical and nursing staff responsible for the care and treatment of a patient should ensure that they read the relevant notes.

Summary

Ms C complained that the board failed to provide a reasonable standard of care and treatment to her brother (Mr A) after he was referred by his GP for bowel problems. Mr A underwent a number of tests and was diagnosed with rectal cancer with liver metastases (tumours that have spread to the liver from other areas of the body).

We took independent advice from a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer) . We found that there were no unreasonable delays in progressing Mr A’s treatment. The actions of staff in relation to carrying out liver and pelvic MRI scans were also reasonable. However, it had not been reasonable to wait until after a multidisciplinary team meeting to confirm the diagnosis of cancer to Mr A. There also should have been more evidence of involvement from a colorectal cancer nurse specialist, and it should have been clear to Mr A who to contact for information and support.

In relation to a consultation that Ms C and Mr A attended about Mr A’s treatment, we found that there should not have been a formal discussion with Mr A and his family about treatment until the relevant investigations had been completed. When he was seen, this should have been by an oncologist and not a colorectal surgeon. In addition, at the meeting Mr A was told that a further test had been arranged the previous week, whereas this test was only requested on the day of the meeting. In view of these failings, we upheld Ms C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mr A with reasonable care and treatment. The apology should meet the standardsset 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:

• There should be early contact with patients to discuss the diagnosis
• All patients, newly diagnosed or with a suspected diagnosis of colorectal cancer, should have access at diagnosis to a clinical nurse specialist for support, advice and information.
• The board should consider when to arrange the key out-patient appointment and who the primary clinician should be.

Summary

Mr C complained about the clinical and nursing care and treatment his late wife (Mrs A) received during two admissions to Vale of Leven Hospital (VOLH) and the clinical care and treatment she received during her admission to Royal Alexandra Hospital (RAH) when she was transferred there from VOLH.

We took independent advice from a consultant in acute medicine and a nursing adviser. We considered that the overall clinical care and treatment Mrs A received during her first admission to VOLH was reasonable and that appropriate assessments and investigations were carried out. However, we found that during her second admission there was a failure to carry out a medical review following an increase in Mrs A's National Early Warning Score (NEWS). NEWS is a tool used to determine the severity of a patient's condition and to highlight any deterioration. We also found that there was a failure to recheck Mrs A's NEWS within six hours. We found that, had this been done, it may have alerted staff to how unwell Mrs A was and allowed staff to speak to Mr C. We considered that the failure to respond appropriately to the elevated NEWS and the failure in relation to the communication with Mr C was unreasonable and we upheld this aspect of the complaint.

In relation to the clinical care and treatment given to Mrs A during her admission to the RAH, we found that this was reasonable and we did not uphold this aspect of the complaint.

In terms of the nursing care that Mrs A received at VOLH, we found that overall the nursing care and treatment had been reasonable. All reasonable assessments were carried out, including a falls assessmenta and the medical records were comprehensive and of a standard that met the National Midwifery Council guidance. However, we also found that there was no documentation within the medical records of the rationale for nursing staff not following NEWS guidance. In these circumstances we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide Mrs A withreasonable clinical and nursing care and treatment at VOLH. 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:

• Relevant staff should ensure they are able to recognise and respond to elevated NEWS in line with NEWS guidance.
• Relevant staff should be mindful of NEWS guidance and ensure that they document the rationale for not following the guidance.

Summary

Mr C complained about the care and treatment provided by the board to his child (Child A) at Royal Hospital for Children, Glasgow. Mr C also complained there was a lack of reasonable communication about Child A and that the board did not respond reasonably to his complaints. Child A had been transferred from another hospital with a history of focal seizure and decreased conscious level. They were admitted to the paediatric intensive care unit (PICU) and after a period of time transferred to a another ward. Child A was initially diagnosed with a type of encephalitis (an acute inflammation of the brain).

We took advice from a senior consultant paediatric neurologist and a senior paediatric nurse. We found that the care and treatment Child A received during their admission to the PICU was appropriate and there was no delay in considering, diagnosing and treating Child A’s condition while they were in the PICU. Child A was subsequently transferred from the PICU to another ward where they developed another type of encephalitis. While Child A received appropriate medical treatment, we raised concern that Child A was not re-admitted to PICU for closer nursing observation given their respiratory difficulties and low Glasgow Coma Scale (GCS) scores (a scoring system used to describe the level of consciousness of a patient). While this did not have an adverse effect on Child A’s short or long-term clinical outcome, we considered that their re-admission to the PICU would have allowed for closer and more appropriate nursing care and observation, and would have reduced significantly or avoided much of Child A’s family’s distress. Therefore, we upheld this aspect of the complaint.

In relation to the nursing care, we found that the nursing care including specialist nursing care which Child A received while he was in the PICU and in the ward, was reasonable. Accordingly, we did not uphold this aspect of Mr C’s complaint.

In relation to Mr C’s complaint about communication, we did not find evidence to conclude that staff failed to communicate reasonably with each other about Child A’s care and treatment or that Mr C was given conflicting advice concerning this. Overall, we found that there appeared to have been reasonable communication with Mr C and his family. However, we highlighted areas where communication with Mr C could have been improved. The board also acknowledged in their complaint response that communication with Mr C’s family could have been better when Child A was transferred to another ward for which they had apologised and taken action to address. Given the shortcomings identified in communication, on balance, we upheld this aspect of the complaint.

Mr C also complained about the board’s handling of his complaint. We considered the length of time that Mr C waited for a formal response to his original complaint to the board was excessive and that, on occasion, the board had failed to communicate reasonably with Mr C about his complaint which added to his distress. Given this, we upheld the complaint. We noted that the board had acknowledged that there were delays and had appropriately apologised to Mr C for this. The board also told us that their complaints department had put in place an agreed process of cover for staff who were on planned or unplanned leave. Taking account of this, we considered the action the board had taken was reasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for not re-admitting Child A to PICU given their clinical condition and that communication with Mr C's family about Child A's care and treatment could have been better. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Relevant staff should review their approach to admitting patients with low GCS scores and respiratory difficulties to PICU.
• Where a patient’s case is complex, consideration should be given to appointing senior named members of the clinical and nursing staff to communicate principally with the patient and/or their family

Summary

Mrs C complained that the board's decision to not provide her child (Child A) with an emergency appointment was unreasonable. Child A had been receiving treatment from the board's Child and Adolescent Mental Health Services (CAMHS). Mrs C's husband, and Child A's teacher and doctor, raised concerns with the clinical nurse specialist who was responsible for Child A, about an escalation in their behaviour and thought they should be assessed urgently. However, the decision was taken to wait until Child A's scheduled appointment a week later. Prior to that appointment, Child A's condition worsened and they were admitted to Stobhill Hospital. Mrs C also complained about the treatment Child A received over the course of a few years.

On reflection, the board said that they should have offered Child A an urgent appointment. They apologised for this and explained the steps they had taken to improve practice. With respect to the overall care, they considered that the records demonstrated appropriate assessments and care throughout. Mrs C was not satisfied with this response and brought her complaint to us.

We took independent advice from a registered nurse experienced in child and adolescent mental health. We found that, on the basis of the records existing at the time, the actions of the clinical nurse specialist in not arranging an urgent appointment, were reasonable. The expressions of concern made by Child A's family and teacher, whilst in hindsight could be reflected on and improvements made to the board's service, would not have suggested to a reasonable clinician that Child A was experiencing a psychotic crisis. We considered that the concerns expressed could have supported the existing understanding of their mental health. Therefore, we did not uphold this aspect of Mrs C's complaint. With respect to Child A's treatment and diagnosis, we found that the level of support offered was reasonable and the tools used to assess Child A were reasonable. We did not uphold this aspect of Mrs C's complaint.

Summary

Ms C complained that the board unreasonably administered morphine to her during her admission to Woodend Hospital. Ms C complained that during her operation she was administered morphine by an anaesthetist despite being severely allergic to the drug and this being known to board staff. Ms C said this caused her to become very unwell and her admission to be extended.

We took independent advice from a specialist in acute and internal medicine. We found that it was reasonable for the board to have administered morphine to Ms C, and there was no evidence to support it was known that Ms C was allergic to the drug prior to it being administered. We did not uphold this aspect of the complaint.

Ms C also complained that the board unreasonably failed to obtain all relevant information before determining her complaint. Ms C said that when she submitted the complaint to the board, she referred to the attending consultant being aware of her allergy, and the doctor's views were not sought by the board before they issued their response.

We found that the board took reasonable steps to seek comments from the clinician directly involved in the complaint as well as to consider the contemporaneous record from the events complained about before they issued their response. We did not uphold this aspect of the complaint.

Summary

Ms C complained that the board failed to provide her with reasonable information about a fistulotomy (a surgical procedure to treat a fistula - a small tunnel that develops between the end of the bowel and the skin near the anus), the risks involved and the other options available, before carrying out the procedure. Ms C was left incontinent after the surgery.

We took independent advice from a consultant surgeon. We found that Ms C had not been seen prior to the fistulotomy to discuss the risks and incontinence was not documented on the consent form. We found that although it had been reasonable to offer the surgery to Ms C, she should have been seen in clinic to discuss the risks and benefits as well as the other options for surgery. We considered that Ms C had not been provided with reasonable information about the fistulotomy before the operation was carried out. We, therefore, upheld this aspect of the complaint.

Ms C also complained that the board’s response to her complaint was inaccurate. The board’s response to her complaint had stated that other surgical options had been discussed with her. There was no evidence in the documentation we received from the board that this had been discussed with Ms C. We found that if this had been discussed, it should have been documented. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide her with reasonable information about a fistulotomy, the risks involved, the other options available before carrying out the surgery and for providing an inaccurate response to her complaint. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• The board should ensure that patients being considered for a fistulotomy are given reasonable information about the risks and benefits and other options and that this is documented. Patients should also be given sufficient time before the operation to consider this information.

In relation to complaints handling, we recommended:

• Where appropriate, statements in complaint responses should be supported by evidence.

Summary

Mr C complained about a number of concerns about the service and treatment he received while in the Golden Jubilee National Hospital. He was admitted to hospital in preparation for receiving a heart transplant.

Firstly, Mr C complained about the behaviour and attitude of hospital staff towards him during a grand ward round. He stated that they spoke to him in an aggressive and threatening manner. Although there was no evidence of what members of staff the board spoke to as part of their complaint investigation, we noted that Mr C's medical records contained an entry written by a member of staff not named in the complaint. This case note provided a different account from the one Mr C provided. We did not take a view on which account was the definitive one but concluded that there was not sufficient evidence to confirm Mr C's account. Therefore, we did not uphold this aspect of the complaint.

Mr C's second complaint was about the fact that all his teeth were removed in preparation for the transplant surgery. We took independent advice from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that, based on the medical records, it was appropriate for Mr C's teeth to be removed. This was because Mr C's records showed he had significant dental and gum disease. Following transplant, Mr C would have to take long-term immunosuppressant medication. As a result, such dental issues would present an on-going risk of potentially life-threatening infection. Therefore, the hospital's actions were appropriate, and we did not uphold this aspect of the complaint.

Mr C's third complaint was that the board did not investigate and respond to his complaint appropriately or reasonably. We found that there were some areas where the board's investigation and response to Mr C's complaint could have been improved. In particular, we highlighted a lack of records of who was spoken with as part of the complaint investigation. However, we did not consider there to be significant failings that would lead us to conclude that the board did not investigate Mr C's complaint reasonably or appropriately. Therefore, we did not uphold this aspect of the complaint.

Mr C's final complaint related to the board's decision to discontinue his treatment and to refer him elsewhere. This was done as the clinical team concluded that they could no longer provide safe and effective treatment to Mr C. We considered that the clinical team and the board acted appropriately and in line with relevant guidance. We also found that the clinical team's decision had been appropriately documented and justified. We recognised that this caused great upset and difficulty for Mr C. However, we did not consider their actions to be unreasonable. Therefore, we did not uphold this aspect of the complaint.

Summary

Miss C complained about the care and treatment which her late father (Mr A) received at Forth Valley Royal Hospital. Mr A, who had a number of pre-existing health conditions, had been admitted after a fall as his general health had deteriorated. He was in pain and died not long after the admission. The family felt that there had been a lack of investigations by staff into a diagnosis and that they failed to appropriately manage Mr A's pain control or provide him with a reasonable standard of nursing care.

We took independent advice from a consultant physician and from a senior nurse. We found that while Mr A received a reasonable level of overall care, the management of his pain could have been better in that the rationale behind the decisions to change/amend medication for pain relief were not clear. The level of communication between the staff and Mr A's family could also have been improved. We upheld this aspect of the complaint.

In regards to the nursing care, we found that, although there was evidence of good care at times, there was also a failure by nursing staff to fully record Mr A's pain score and other charts which would have evidenced whether appropriate care had been given. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings in managing Mr A’s pain control and in communication with the family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Apologise to Miss C for the failure to record whether action was taken to address Mr A’s pain; nutrition and fluid balance needs. 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:

• Staff should be aware of the importance of appropriately managing a patient’s pain control and ensuring that appropriate communication is given to family members.
• Staff should ensure that when action is taken to address patient needs that the appropriate records are completed in line with record-keeping guidelines.

Summary

Mrs C complained about the care and treatment her father (Mr A) received at Forth Valley Royal Hospital. Mr A had been admitted with sudden onset severe jaw pain, which was radiating to his chest and arms. He subsequently developed abdominal pain and a number of tests were carried out, including an abdominal ultrasound. On the following day, Mr A had a CT angiogram (a specialised scan using x-rays to look at the heart) of his aorta (the largest and main artery in the body). This confirmed a large aortic dissection (a tear) requiring urgent surgical intervention. Mr A was transferred to another board for this surgery. After the surgery, it was discovered that Mr A had suffered a spinal stroke. This left him paralysed and entirely reliant on carers.

We took independent advice from a GP, a radiologist (a specialist in the analysis of images of the body) and from a consultant cardiothoracic surgeon (a medical doctor who specialises in surgical procedures of the heart, lungs, oesophagus, and other organs in the chest.) We found that the ultrasound result should have been flagged up as highly significant and with greater urgency. Where a potential life-threatening abnormality emerges on a diagnostic test, every effort should be made to convey this result immediately to the clinical team involved. The failure to do so, in Mr A’s case, led to a delay in definitive diagnosis and potential treatment of the aortic dissection. We, therefore, upheld this aspect of Mrs C’s complaint. However, we found that earlier identification of the dissection and more timely surgery would not have necessarily changed the outcome for Mr A.

Mrs C also complained that the board had failed to comply with the relevant record-keeping guidance, as they had been unable to find some of Mr A’s clinical records. We found that the board had failed to follow their ‘Transportation of health records policy’ and we also upheld this aspect of Mrs C’s complaint.

Finally, Mrs C complained about the board’s response to her complaint. We found that in their response to her initial complaint, the board had failed to identify the major failing in Mr A’s treatment, which was the delay in highlighting the abdominal aortic dissection flap observed in the ultrasound examination. We also upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in reporting the ultrasound result to the clinical team involved, and for the failings in relation to their handling of Mrs C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

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

• All administrative, clerical and clinical staff who are involved in the transfer of medical records should follow the Board’s Transportation of Health Records Policy.

In relation to complaints handling, we recommended:

• The board should ensure that complaints are investigated appropriately and that, when requested, they provide further information about the action they have taken in response to any potential failings identified.