Health

Summary

C’s spouse (A) was admitted to hospital following a stroke. A remained in hospital for several weeks before transferring to another hospital. A later died. C complained to the board about A’s hospital stay and raised concerns about wound management, fall pain management and the identification of hip and shoulder injuries.

The board’s response highlighted several areas for improvement. Firstly, there should have been a referral for A’s wounds, with more robust documentation. Staff training has been conducted to address these issues. Secondly, A fell twice in the ward, prompting a thorough medical review after each fall. Staff training regarding falls has been provided. Thirdly, although A was on regular pain medication, there should have been a pain recording chart in place. Staff will receive training on this aspect. Lastly, A’s hip dislocation likely stemmed from their stroke rather than a fall, with no evidence of shoulder dislocation occurring the ward.

C was dissatisfied with the board’s response and brought their complaint to us. We took independent advice from a nurse with a speciality in wound care and a consultant geriatrician (a specialist in medicine of the elderly). We found that staff failed to follow the board’s policy on wound management. We also found that whilst the medical care of A’s falls was reasonable, the nursing documentation about A’s falls was unreasonable, because documentation was incomplete and at times inaccurate. A’s care plan was also poor, making it difficult to manage A’s pain, and there was a delay in A receiving a medical review over the weekend. Therefore, we upheld these parts of C’s complaint. We found that the board’s explanation of A’s injuries was reasonable. We did not uphold this part of C’s complaint.

We also found that the board’s complaint response did not provide C with a timely, full and informed response to their complaints about the board’s management of A’s wounds and falls. Therefore, we made an additional recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures in A’s care. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

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

• Nursing staff should be competent in the accurate completion of falls documentation.
• Patients should receive appropriate pain management including regular structured assessment of their pain, e.g. through the use of a structured pain assessment tool or chart. This should be documented. Patients should receive appropriate medical review on escalation, and reviews should be carried out promptly.
• Patients should receive care as required and prescribed in care rounding bundles. Those requiring wound care should be appropriately managed in line with local and national guidance on wound management. This should be appropriately documented.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are properly investigated and responded to; are accurate; timely; and that failings and good practice are 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 contacted the Scottish Ambulance Service (SAS) when they began experiencing abdominal pain. An ambulance attended but did not take C to hospital. The crew provided advice to contact the service again if their symptoms worsened. C contacted the service again the following day. A telephone assessment was completed but no ambulance was sent. C later made their own way to hospital where they required surgery for a perforated bowel.

C complained that the SAS failed to recognise the seriousness of their symptoms and failed to provide appropriate care and treatment. C said that as a result, they required more extensive surgery than if they had been taken to hospital sooner.

We took independent advice from a paramedic. We found that the ambulance crew had unreasonably failed to carry out an adequate assessment of C. The crew assessed that C had withdrawn consent for further assessment, and did not provide adequate advice on the benefits of assessment or the risks of not completing the assessment. We also found that the telephone assessment the following day was inadequate and was poorly documented. Therefore, we upheld C's complaints.

Recommendations

• What we asked the organisation to do in this case
• Apologise to C for failing to conduct an adequate assessment, failing to recognise the potential seriousness of their symptoms, and failing to provide them with the care that they required. 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 are able to recognise symptoms of potentially serious abdominal conditions.
• Clinical staff ensure that benefits of assessment, treatment and transport to hospital, and the risks of declining care, are fully discussed with the patient and recorded.
• Clinical staff reflect on and learn from patient experience to improve future practice.

In relation to complaints handling, we recommended:

• Relevant staff and senior managers are familiar with the Adverse Events Policy, understand the criteria for a Significant Adverse Event Review, and apply it correctly.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Amendment - 27/06/2024

When this complaint was originally published (19/03/2024) we made the following recommendation: "Clinical staff are aware of Kehr’s sign and are able to recognise symptoms of potentially serious abdominal conditions."  This has since been amended to "Clinical staff are able to recognise symptoms of potentially serious abdominal conditions." following receipt of new information.  

Summary

C underwent a coronary artery bypass surgery (a surgical procedure that creates a new path for blood to flow around a blocked or partially blocked artery in the heart). C required three further surgical procedures on their chest wound over a period of seven years after their bypass surgery. C’s chest wound developed a sinus (a track that extends from the surface of an organ to an underlying area) and did not heal properly. C also developed osteomyelitis (a bone infection) in their chest wound. C raised concerns about the care and treatment that they received from the hospital.

We took independent advice from a consultant cardiac surgeon. We found that the clinical treatment provided to C was reasonable. However, we found that the hospital failed to provide timely discharge information after C’s bypass surgery and after C’s surgery over a year later. We also found that the hospital failed to reasonably follow up C after discharge from two of their surgical procedures. Therefore, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in providing timely discharge information and failure to reasonably follow up two of their surgical procedures. 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:

• Discharge letters following surgical procedures should be sent out in a timely manner and clear follow-up arrangements should be given in the discharge letters following surgical procedures.

In relation to complaints handling, we recommended:

• When a complaint involves more than one NHS board, the boards should decide who will lead on the complaint and provide a joint response.

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 submitted a complaint on behalf of their relative (A) who received treatment at hospital. A had previously suffered a stroke (causing left sided weakness) and was admitted after being unwell for a few days. C complained about the nursing care provided to A while they were in hospital.

We took independent advice from a nursing adviser. We found that there were failings in relation to nursing documentation, moving and handling practices, a lack of equipment, and a lack of assessments as to A’s needs. In particular, there was no falls assessment and appropriate action and recording did not take place after A’s fall. In relation to moving and handling, we found that glide sheets should have been utilised and that appropriate equipment should have been available in the ward. The board failed to reasonably record the care that they provided, or carried out appropriate assessments to ensure person-centred care to confirm that A’s needs were met. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• All patients must have a falls risk assessment completed on admission and after a fall a post falls assessment should be completed.
• Every patient should have a person-centred plan of care.
• All patients must have a moving and handling risk assessment undertaken within 24 hours of admission.
• Nursing documentation should be complete and reflect a person's care needs, plan of care, care delivered and evaluation of the care delivered.
• Basic moving and handling equipment should be readily accessible for all patients and staff.
• All patients should have their care needs identified and risk assessments undertaken in order to develop a person-centred plan of care.

In relation to complaints handling, we recommended:

• Complaint investigations should respond to all of the main points raised and identify failings and take learning from what happened.

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 that they received from the practice prior to their diagnosis of an abdominal cyst, which was surgically removed some years after C first attended the practice with symptoms. C complained that they did not receive a referral for an ultrasound scan until many months after first attending the practice with symptoms. C also complained that four different doctors were involved in their care and that the practice’s complaint handling was unreasonable.

We took independent GP advice. C’s case was complex and challenging due to the nature of C’s cyst, C’s other diagnoses and the timing of C’s consultations during the COVID-19 pandemic. Nevertheless, we found that there was a missed opportunity for the practice to refer C to the colorectal service based on the positive result of a qFIT test (a test to detect blood in the stool) when C first attended the practice with symptoms, based on the National Institute for Health and Care Excellence (NICE) guidance. We found that there was a further missed opportunity for the practice to consider referring C to secondary care based on C’s subsequent positive qFIT test result, which was taken many months after the first positive qFIT test. We also found that there were delays in the practice contacting C after receiving the result of the subsequent qFIT test and when the practice received the result of C’s ultrasound. We found that, given the state of NHS services at the time C attended the practice, there was not likely a significant delay in C receiving a diagnosis or surgery for their cyst. On balance, we upheld C’s complaint about their care and treatment from the practice.

We found that the practice’s complaints handling was unreasonable, because the first complaint response did not address the issues C raised as a complaint. We upheld C’s complaint about the practice’s complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to action the results of qFIT tests, for the delays and for the unreasonable complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Administrative systems at the practice should support timely actioning of abnormal results.
• Clinical staff should be knowledgeable about the indication and interpretation of qFIT tests, as per NICE guidance.

In relation to complaints handling, we recommended:

• Complaints should be appropriately acknowledged in line with the Model Complaints Handling Procedure for NHS Scotland, and the complaint response should fully address the substantive issues raised in a complaint.

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 that they received from the practice prior to receiving a diagnosis of a cancerous brain tumour, for which C underwent surgery, radiotherapy and chemotherapy. C had eight consultations at the practice over the course of ten months prior to receiving a referral to the neurology department.

We took independent advice from a GP. We found that there was a missed opportunity for the practice to review C in person and consider an earlier neurological referral on the basis of C’s worsening symptoms. We upheld the complaint. During the course of the investigation, the practice acknowledged these failings and took action to address them.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to offer a face-to-face appointment and neurology referrals, and for the practice’s shortcomings in their complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• The practice’s complaints handling procedure should ensure that complaints are properly investigated and responded to, are accurate and that failings are 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 the care and treatment that their late parent (A) received from the board. A was admitted to hospital after a fall at home. A’s condition declined whilst in hospital. C complained that during A’s admission there were clinical errors, inappropriate treatment and insufficient diagnosis work. In C’s view, this contributed to and hastened A’s death. C stated that clinicians had fixated on alcohol as the primary cause of A’s condition. A post-mortem later confirmed this not to be the case and that A had Lewy Body dementia (a brain disorder that can lead to problems with thinking, movement, behaviour, and mood) or similar when they died. C also asserted that A’s two brain bleeds sustained in the fall were not adequately monitored or treated. C highlighted concerns that there was no intervention and no repeat computed tomography (CT) scan carried out to check the condition/size of the two brain bleeds. This was despite a decline in A’s neurological condition.

In addition to this, C complained that the board’s communication with A’s family fell below a reasonable standard. C stated that, in their view, A’s two brain bleeds were more significant than clinicians had led the family to believe at the time of admission. They also highlighted an unwitnessed fall on the ward that was not reported to the family.

We took independent advice from a neurologist adviser. We found that the treatment provided by the board was reasonable. Given A’s circumstances and presentation, we did not consider the focus on alcohol-related cognitive failure to be unreasonable or that it materially affected the treatment provided. We also found that the decision not to carry out an additional CT scan to be reasonable. However, we highlighted concerns about some of the board’s justification for not carrying out an additional CT scan. We also received a limited amount of advice from an independent nursing adviser about some additional concerns raised by C. We found that in the context of the difficult circumstances of A’s condition, the nursing care provided was reasonable. Overall, we concluded that the board provided a reasonable standard of treatment during A’s admission. Therefore, we did not uphold this aspect of the complaint.

Summary

C complained about the standard of care and treatment provided to their parent (A) whilst A was in hospital. C's concerns covered A’s medical care, nursing care and physiotherapy care.

C said that A’s myeloma (blood cancer) treatment was delayed by a failure to provide the specialists treating A with blood samples for analysis. Additionally, A was not given an infusion correctly, as nursing staff failed to give A intravenous fluids first to ensure A was hydrated. C felt A’s pain relief was inappropriately managed, with A’s medication being unnecessarily reduced, resulting in A suffering significant and avoidable pain. C also believed that A was injured during a physiotherapy session and that this contributed to A’s decline.

We took independent advice from a registered nurse, a consultant haematologist (specialist in the the diagnosis and treatment of patients who have disorders of the blood and bone marrow) and a chartered physiotherapist. We found that nursing staff had not followed written instructions for the administration of A’s treatment, and A’s records showed that they had consumed only around 15% of the food and water that they should have in the period leading up to the infusion treatment. Nursing staff could not therefore have ascertained that A was properly hydrated. Nursing staff did not appear to have taken all the requested blood samples from A, and they had not taken steps to address A’s pain management. Therefore, we upheld this part of C's complaint.

In relation to A's medical care and treatment, we noted that their condition was progressing rapidly and that they had already had a number of treatments. The decision that A was not suitable for further treatment was not impacted by the missing blood sample and overall, we found that the medical care A received was reasonable. Therefore, we did not uphold this part of C's complaint.

In relation to A's physiotherapy care, we found that there was no evidence within the physiotherapy records that A had sustained an injury. Although there were some unexplained gaps in A’s physiotherapy records, it was clear that the decision to cease physiotherapy treatment was driven by the decision to designate A for palliative care only, rather than active treatment. Therefore, we did not uphold this part of C's complaint.

C also complained about the way that their complaint was handled. We found that the board’s complaint investigation had fallen below a reasonable standard. The evidence showing the failings in A’s nursing care should have been identified by the board’s own investigation. Therefore, we upheld this part of 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 nursing care and for failing to provide C with a reasonable response 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:

• Patients fluid and nutrition needs should be appropriately monitored. Where there is evidence that fluid and hydration needs are not being met, appropriate action should be taken.
• Patients’ level of pain should be reviewed and where the patient is unable to comply with the administration of pain relief orally, action should be taken to explore alternative means of medication delivery.
• Staff should ensure that written instructions by medical staff and, where appropriate, manufacturer’s guidance is followed when administering infusions and that, where appropriate, the patient is adequately hydrated.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that responses are accurate and reflect the information available in the clinical record.

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 adult child (A) about the standard of care and treatment that they had received in relation to their mental health from their GP practice. In particular, C complained that the surgery did not provide the support recommended for A following an Adult Autism Disorder (ASD) assessment. C also complained that the surgery had prescribed medication for A without any follow-up despite knowing that they had expressed thoughts of suicide. Additionally, C complained that the surgery had failed to explain the nature and process of a mental health telephone review A had been referred for and that the surgery had failed to let them know when this had been cancelled by the receiving service.

The surgery explained that referrals had been made to mental health services on behalf of A, however, the decision to accept or decline them was made by the receiving service and not the GP surgery. Regarding the cancelled appointment, the surgery said that they had not received advanced notice and were, therefore, unable to let C know that it would not go ahead.

We took independent advice from a GP adviser. We found that the ASD assessment report did not contain any recommendations or actions for the surgery to arrange on behalf of A, that A had been regularly reviewed during the period of the complaint and referrals had been appropriately made to other services. We also found that the surgery could not influence whether a referral was accepted or declined. In relation to the cancelled telephone assessment, we found that there was no evidence to suggest the surgery received advance notice of it being cancelled. Therefore, we did not uphold the complaint.

Summary

C complained about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died.

C complained to the board about their parent contracting COVID-19, which they felt must have been hospital acquired as A was shielding prior to admission. C complained that A was unnecessarily transferred between wards which increased the risk of exposure to the virus. C reported concerns that there were known COVID-19 cases in a neighbouring ward and possibly within A’s ward. C was concerned that A wasn’t offered the opportunity of home rehabilitation.

The board’s response stated that national infection prevention and control guidance for COVID-19 was followed at all times. They advised that it wasn’t always possible to accommodate all shielding patients in a single room. They advised that A was transferred between wards according to their care needs. They said that they could not meet A’s rehabilitation needs at home due to capacity issues with their community stroke team.

We took independent clinical advice from a nursing adviser specialising in infection control. We found that A required inpatient care to ensure that they received appropriate investigations and treatment for their suspected stroke. We found that the care provided to A in treatment for their stroke was reasonable and in keeping with their diagnosis.

We found that the board did not comply with relevant guidance on COVID-19 by failing to document the assessment of A’s COVID-19 risk pathway during their admission. We found that there was an unreasonable delay in isolating A from the other patients once A’s diagnosis of COVID-19 was suspected. Given these failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to triage A’s level of risk, for failure to document A’s shielding status and failure to isolate and follow airborne precautions from the point at which COVID-19 was suspected. 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:

• Feedback the findings of this investigation to relevant staff for reflection and learning, and to inform future practice.
• Medical records should contain all relevant information including the outcomes of assessments and the information required to clarify the decision making regarding the delivery of care.

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.