Health

Summary

C complained that the board failed to provide reasonable care and treatment to their sibling (A) after they were admitted to hospital. A had a cardiorespiratory arrest (the cessation of effective ventilation and circulation) in the hospital and suffered a brain injury as a result of this.

We took independent advice from a consultant in critical care. We found that the board had provided reasonable care and treatment to A and we did not uphold this aspect of the complaint.

C also complained that the adverse event review that the board subsequently carried out was unreasonable. In relation to this complaint, we found that the board had carried out a level 2 review when a level 1 review should have been carried out. The level 2 review had also been allocated to an inexperienced review team, it reviewed only part of A’s care journey, and it was short and poorly detailed. We also found that the record-keeping on the ward immediately before and after A’s cardiorespiratory arrest was limited and not of the standard expected. Detailed retrospective entries should have been completed shortly after these events occurred, by both medical and nursing staff. We therefore upheld this aspect of the complaint.

We also found that the board’s complaint handling of C’s complaint was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for causing confusion in their responses which related to the new structure that had been put in place. Apologise that part of the complaint handling process was uncoordinated and delayed and that they added to the stress and anxiety the family were feeling at that time. Finally, apologise that they failed to deal with C’s complaints in a timely or satisfactory manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that a level 1 review should have been performed in place of the level 2 review and that the level 2 review that was performed was allocated to an inexperienced review team, it reviewed only part of A’s care journey and it was short and poorly detailed. 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:

• For a level 1 review to be carried out.
• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant medical and nursing standards.
• Before an adverse event review is carried out, the board should appropriately identify the review level, identify the terms of reference (part of the patient’s care journey to be reviewed) and allocate a suitable staff review team.

In relation to complaints handling, we recommended:

• The board should ensure all complaints are handled in line with the guidance set out in the NHS Model Complaint Handling Procedures, in particular, respond in writing and in a timely manner and address all issues raised that the board is responsible for.

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 that their parent (A) received. A had dementia and was admitted following a fall in their care home, remaining in hospital until their death some weeks later. C complained that during A’s admission, A was not treated with dignity, that they were left without food or water, and that they were allowed to aspirate on pureed food because they were not safely positioned in bed.

The board maintained that overall the nursing care was of a reasonable standard, but they accepted that documentation had been poor. They provided us with a detailed action plan which they were implementing in response to the failings that they had identified.

We took independent nursing advice. We found gaps in record-keeping in relation to food and fluid intake. We found that the board had failed to evidence that A was cared for in a dignified and respectful manner. Comfort rounding was not provided as frequently as it should have been, taking into account A’s frailty and general condition. A had pressure ulcers and we found that the board had failed to demonstrate sufficiently frequent skin checks and repositioning. The board also failed to maintain wound charts, recording wound sizes and grade. There was no evidence of oral care having been provided.

We did not find evidence to support the account that A was left to choke on pureed food on the day before they died. The records indicated that A was being checked on regularly that morning, and that A was asleep much of the time and noted to be ‘too drowsy for oral intake’. A was being treated for secretions, which we considered may have accounted for the gurgling sound reported. Although it was not possible to establish precisely what had happened on this date, it was regrettable that this incident caused so much distress to the family, and we noted that the board had apologised for the distress caused.

Taking all of the above into account, we upheld the complaint. We found that the board’s action plan did not adequately address the failings in this case and we therefore made our own recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for the failings our investigation has found. 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 should receive appropriate pressure ulcer care, prevention and grading in line with relevant guidance.
• Records should document what is required to capture that person-centred care has been assessed, planned and the outcome of the plan evaluated.
• Patients should have wound charts completed as appropriate and in line with relevant guidance.
• There should be a discussion with family/carers as appropriate when a patient moves onto a palliative care treatment plan to facilitate understanding and an awareness of what to expect particularly in relation to fluid and nutrition in line with relevant guidance.

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 over a series of interactions with the practice. C believed that their symptoms had not been properly investigated. C subsequently suffered a stroke and felt that the outcome for them could have been better if they had been listened to when they contacted the practice. C also felt that the practice’s complaint handling had been unreasonable, failing to provide C with information that they were entitled to and incorrectly directing them to the local NHS Board as part of the complaints process.

We took independent advice from a GP adviser. We found that some of the assessments of C did fall below a reasonable standard, although it was not possible to conclude that the stroke could have been predicted or prevented. Therefore, we upheld and did not uphold aspects of these complaints around the assessment of C's symptoms over different periods. We also found that the handling of C’s complaint fell below a reasonable standard. We upheld this aspect of 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:

• Patients should receive appropriate treatment in relation to their presenting symptoms and potential causes considered as appropriate.

In relation to complaints handling, we recommended:

• The practice should provide clear information about their complaints process.

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 actions of the board when carrying out a post-mortem examination of their adult child (A). C said that the board had failed to secure A’s admission blood samples, resulting in them being lost. C also believed that the board had failed to carry out the post-mortem properly, as no further blood samples had been taken.

We found that A’s admission blood samples had been collected by Police Scotland and taken to another board for tests. There was no audit trail of paperwork other than the police statement of their actions. Once Police Scotland had collected the samples they ceased to be the responsibility of the board. While the board are not responsible for the misplacement of A’s admission blood samples, they should have ensured the samples were signed for and copies of the paperwork retained. Therefore, we upheld this part of C's complaint. The board had already apologised for this failing and taken appropriate action so we did not make any further recommendations

In relation to the post-mortem, we found that the pathologist had followed the appropriate guidance. This recognised that admission samples were always preferable to post-mortem samples and at the time the post-mortem was carried out, there was no reason to suppose the admission samples were lost. Therefore, we did not uphold this part of C's complaint.

C also complained about the board's communication. We found that the board's communication with C was reasonable. Therefore, we did not uphold this part of C's complaint.

Summary

C complained about the care and treatment provided to their late child (A) by the medical practice. C was concerned that A had been misdiagnosed by their GP during a telephone appointment. During the appointment, A reported shortness of breath, experiencing breathlessness, and feeling faint when walking upstairs and putting on their shoes. A was diagnosed with anxiety and prescribed a beta blocker (drug that blocks the action of hormones like adrenaline). Later that week, A died suddenly due to pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung). C raised concerns that there was a delay in A receiving treatment, the treatment that A received was inappropriate, and that harm was caused as a result of A being given the wrong treatment.

We took independent advice from a GP adviser and subsequently from another GP adviser with a specialism in sexual and reproductive health. We found that there are numerous risk factors for pulmonary embolus and, in this case, the main risk factors were BMI, family medical history and prescription of combined oral contraceptive. Neither risk alone would preclude prescribing combined oral contraceptive, but consideration would be made for two risks, as in this case. We found that the health centre failed to provide A with reasonable medical care and treatment. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients presenting with similar symptoms should be carefully considered and where appropriate face-to-face appointments offered.
• Prior to prescribing the combined oral contraceptive pill for patients who have two or more risk factors for pulmonary embolus, careful consideration should be given to the risk factors, and a shared discussion should take place with the patient on the additional risks, ensuring that they understand that there may well be additional risk. This should be documented.

In relation to complaints handling, we recommended:

• The health centre should ensure that all complaints are handled in line with the NHS Model Complaints Handling Procedure (MCHP), particularly in terms of the requirement to respond in a timely manner. In particular, where a response to a complaint cannot be provided within the MCHP timescales, complainants should be provided with an updated timescale as to when they can expect to receive a response. Significant Adverse Event reviews should be accurate and reflect and record the available evidence and information, which should be reflected in the investigation report (and where appropriate, complaint responses).

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 A by the Scottish Ambulance Service (SAS). A had a pacemaker fitted and developed a severe headache and rash. A phoned NHS 24 as they were finding it difficult to breathe. Paramedics attended A at home but A was not admitted to hospital. A phoned NHS 24 again the following day and when paramedics attended, they sought telephone advice from a consultant at the local hospital. The consultant advised that A should take paracetamol and see the GP the following morning. A phoned the GP the next day and was told to go to the COVID-19 hub where A collapsed and was taken to hospital by ambulance. A was admitted to hospital and died the following day from sepsis (blood infection). C complained about the decision not to take A to hospital and is concerned that the paramedics failed to recognise the signs of sepsis and to take the appropriate action.

We took independent advice from a registered paramedic. We found that in hindsight it was unreasonable that SAS did not recognise the seriousness of A’s condition, including applying any weighting to past medical history, in particular recent surgery and the fact that the presence of infection could have been the result of sepsis. However, we found that many of the clinical signs and symptoms observed in A would have been present in a patient experiencing COVID-19. Based on the conditions and guidelines SAS were operating to at the time we found that it was reasonable that the paramedics’ working diagnosis was COVID-19.

Whilst we considered it was reasonable that A was not taken to hospital, we were critical that there is no evidence that A was informed of the risks and benefits of the option of staying at home, going to hospital or of any alternative options available. We also found that it was unreasonable that key information was not passed to the consultant during a call and that record keeping was unreasonable. Furthermore, we found that it was unreasonable that during the paramedics second attendance, the further set of observations taken 20 minutes later unreasonably failed to include A’s temperature. Finally, in relation to the first attendance, we considered it was unreasonable to conclude that A was improving, particularly without carrying out a further set of observations. Overall, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific 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:

• Patients should be appropriately advised of the risks and benefits of the available options, for example the option of staying at home, going to hospital or of any alternative options available. This information should be documented to confirm the advice given, and details of discussions held regarding treatment options.
• Full and complete information should be obtained during observations of a patient so that advice is appropriately provided and recorded on the basis of that information. Where appropriate, consideration should be given to carrying out a further set of observations prior to reaching a view on a patient's condition.

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) about the care and treatment provided by the board. A was scheduled for a hip operation after experiencing increased pain which was affecting their daily function. The operation was cancelled on the day as the anaesthetist was not prepared to go ahead due to the high level of risk associated with the procedure and significant concerns about complications. C complained about the hospital’s process which they said caused great distress.

We took independent advice from a registered consultant physician. We found that there was a failure by the surgeon to share their concerns about A’s surgery with clinical colleagues in a timely way. There was also a break-down in communication between the key teams involved in the pre-assessment, resulting in failures in process and cancellation of surgery on the day. We also found that there was a lack of coordination in arranging A’s discharge home when the operation did not go ahead.

We also found failings in the board’s handling of the complaint, such as the complaint not addressing all the issues raised by C. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific communication and process failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to addressing all the elements of a complaint and accuracy of information.

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

A’s spouse (B) was admitted to hospital for a knee replacement. The operation went well but during B’s recovery their condition began to deteriorate and B was transferred to the High Dependency Unit. B went into cardiac arrest, CPR was administered but it was unsuccessful and B died.

C raised complaints on A’s behalf about B’s treatment during their admission. The board undertook a Local Adverse Event Review (LAER), identified issues with B’s care and treatment and made recommendations to address these issues. The board also responded to the complaints raised by C regarding B’s treatment. In their response the board reiterated the conclusions of the LAER, their recommendations made in relation to some aspects of B's treatment, and concluded that other aspects complained of by C had been reasonable.

In relation to specific questions about B’s admission that C had shared, the board indicated that responses to most of these had been provided at a meeting that had taken place between B’s family and a consultant orthopaedic surgeon (branch of surgery concerned with conditions involving the musculoskeletal system) or in the LAER report. The board provided a response to one other question in the response to C.

We took independent advice from a specialist in orthopaedic surgery. We found that observations of B should have been increased, their care escalated and that antibiotics should also have been commenced sooner. We upheld this aspect of the complaint.

In relation to the provision of answers to questions raised in the complaints submitted, we found that clear responses from a clinician were available to the board’s complaints team within a month of the questions having been raised. The board provided answers to some of the questions at a meeting the following month but clear answers to the remaining questions were not provided until SPSO became involved and specifically asked for them almost two years later. Given this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for an unreasonable delay in an urgent assessment being undertaken, a failure to escalate B to the medical team and the decision to administer antibiotics not being made sooner. 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 that clear answers to the questions raised were not provided within a reasonable timeframe. 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 should receive timely medical review and if appropriate antibiotic therapy commenced without delay.

In relation to complaints handling, we recommended:

• Complaints are properly responded to in line with the Board’s 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 provided to their late parent (A) by the board. A was under the care of another board and investigations undertaken were suggestive of cancer in the bile drainage system, which was initially thought to be operable. A was referred to the board and admitted to hospital for a percutaneous transhepatic biliary drain (a procedure to drain bile to relieve pressure in the bile ducts caused by a blockage) and biliary biopsies. This was carried out and the three biopsies taken were sent back to the ward with A.

The duty consultant and the clinical nurse specialist met with A and relayed the findings of the multi-disciplinary team discussion the previous day. The specialist radiologists felt that there was a thickening of the lining of the abdomen that may suggest the disease had spread and that the nature of the tumour was unresectable. A check tubogram (a dye test to check whether the stent had opened up) indicated that the stent inserted had not fully drained the bile ducts and a second stent was inserted, with the external component of the biliary drain removed.

A was discharged shortly afterwards. At a multi-disciplinary team discussion less than two weeks later, it was highlighted that there were no biopsies currently in the pathology laboratory. Further investigation found that A’s biopsies had been disposed of. Four months on, A was made aware by the referring board that the biopsies had not reached the laboratory. A died after a short period.

We took independent advice from a general and colorectal surgeon. We found that whilst A had been given sufficient information regarding their care and treatment and the need for a biopsy, the board unreasonably lost biopsy samples and failed to inform A that they had been lost. We also found that the communication between departments, wards and with another board was unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.
• Apologise to C for the specific failings in communication with them, between departments and with another board. 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 treating hospital should ensure all outstanding results are reviewed and subsequent forward planning is done. The episode of care should not be viewed as complete until all results are reviewed rather than the discharge status.
• Biopsy samples should have the correct form, details of the responsible clinician on the form and should be sent from the originating area. There should be a process in place to correct errors in specimen direction.
• The treating clinician should be responsible (directly or delegated) for notifying a patient as soon as is reasonably possible regarding a biopsy loss.
• Investigation of a datix incident should be thorough and ensure appropriate and adequate learning from the events.
• There should be clear communication between departments and wards regarding planned procedures. Patients should be informed without delay of any cancellation, and where appropriate a prompt apology made to reduce distress.

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 spouse (A) about the board not issuing a discharge plan at the point A was discharged from hospital for palliative care before A passed away. As their carer, C wanted to know how to provide care and support for A. C said that this plan was subsequently requested a number of times but not provided. C also complained that following A’s death, their GP provided a copy of the Inpatient Discharge Summary which said ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR). C said that they had not been aware a decision had been made on this and as A’s Power of Attorney, and in order to safeguard A, DNACPR should not have been discussed with A without C being present.

We took independent advice from a registered consultant geriatrician (a doctor specialising in medical care for the elderly). We found that the board could not have provided C with a discharge plan as C did not attend hospital that day. We also found that A was not given clear discharge information despite this being complex and their care needs being high. There was also a failure to subsequently provide C with a copy of the discharge plan when requested, and record keeping failures during A’s discharge. We also found that the board failed to communicate with C that a DNACPR decision had been made with A. 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:

• Open and honest discussions should be held with the patient and relevant others with regard to timely decisions about DNACPR and in accordance with relevant DNACPR guidance. This is particularly important where patients have Aphasia (language disorder) and where patients are discharged home for end of life care.
• Patients should be discharged with appropriate documentation which is clear and should be completed so that full discharge information is provided. This should include post discharge requests for further copies.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement.

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.