Health

Summary

C complained about the treatment that their sibling (A) received from the practice. In responding to C, the practice accepted that a diagnosis had been missed. The practice also conducted a Significant Event Analysis (SEA) which resulted in learning around consideration of A’s symptoms and consideration of blood testing.

C was dissatisfied and raised their complaints with SPSO. We found that while there were aspects of the treatment provided to A that were appropriate, a number of aspects were not, including taking a blood sample before all concerns had been explored, poor recording of symptoms and examination findings, and the undertaking of a telephone consultation. Additionally we found that the refusal to undertake further blood tests in the circumstances, lack of recording of reasons for, or makers of, decisions and the failure of the SEA to explore significant decisions were also aspects of treatment that were not appropriate. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and their family 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:

• Any Significant Event Analysis undertaken by the practice fully explores all relevant decisions.
• Doctors should undertake reasonable consultations with patients and fully consider what the appropriate blood tests would be for patients.
• The standard of record keeping at the practice meets General Medical Council “Good Medical Practice” standards.

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

Summary

C complained about the process followed by the board in commissioning and completing a Level 1 Significant Adverse Event Review (SAER) with respect to the care provided to their partner (A), after they had been diagnosed with Barrett’s oesophagus (a condition where some of the cells in the oesophagus grow abnormally). The SAER was commissioned following the death of A.

C complained to the board about their lack of inclusion and involvement in the SAER process. In response to the complaint, the board concluded that whilst the SAER was carried out appropriately and C had been involved in the process, they failed to adhere to their own and published national guidelines in a number of ways. The lack of an appropriate Family Liaison contact had negatively impacted communication with C during the process.

C was dissatisfied with the board’s complaints response and brought their complaint to our office. We took independent advice from a consultant hepatologist (medical doctor who specialises in diagnosing and treating liver disease) and gastroenterologist (a medical doctor who specialises in conditions affecting your digestive system)

We found that in conducting the SAER, the board had acted in the spirt of national policy and guidance with respect to including C in the SAER process. However, the board’s own policy sets more concrete standards about how communication should be managed. We found that overall C’s level of involvement with the SAER process was reasonable, but that there was issues with respect to miscommunication and managing C’s expectations in this regard. Whilst the board responded to C’s requests to meet relevant members of the SAER team, again the communications were not always consistently responded to by the board.

Issues with communication were impacted by the board’s failure to follow process and appoint an appropriate point of contact to assist C and provide them with support. Given the failure to follow process, and issues with respect to communication, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should provide the complainant with confirmation that the apologies highlighted in Recommendations 2 and 3 of the SAER will be provided.

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

• Problems identified in the management of the adverse event review will be collated and used to create a Shared Learning Notice to ensure learning is board wide.
• Work following this complaint will include that family members must be involved at the earliest point to agree the TOR and are provided with ongoing support for any review, in accordance with the board’s procedures. They must support those identified to take on the role of Family Liaison Manager to have adequate time to carry out this role to a high standard. All staff involved in the adverse event review process will be reminded, via a Shared Learning Notice, of the need to be vigilant and accurate in recording communications in relation to adverse event review management.
• A flowchart had been developed to assist staff with the management of Level 1 adverse events.

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 their attendance at the A&E after their child (A) had a seizure. C said that A’s observations (to measure vital signs like heart rate, blood pressure, and temperature) had not been taken, but that the nurse had told C that they were. C also raised concerns about attitude and behaviour.

The board’s complaint response said that the nurse had intended to reflect to C that observations had been taken by the ambulance crew, and that the nurse had triaged A and determined that A was able to wait for a doctor. C was dissatisfied with the explanations provided. The board told us that a further review of the records showed that the nurse had taken observations, but staff present concluded that there was no physical evidence of the nurse taking observations at any point at triage.

We took independent advice from a qualified nurse. The evidence suggested that observations were not carried out, and that there were failings during the triage of A to act on their abnormal heart and pulse rate promptly. Appropriate repeat observations and a Glasgow Coma Scale score were not taken. There was also a lack of clarity as to whether A was assessed as an adult or paediatric patient. We upheld this complaint.

We found that there had been record keeping failings, including records which did not match the accounts provided by the nurse, paediatric assessment tools not being completed, incorrect oxygen saturation levels having been recorded, and nursing and medical entries not being time stamped. There was also a lack of explanation for the discrepancies in the board’s accounts of observations being taken. We upheld this complaint.

We found that C and SPSO have, at times, been provided with inaccurate and inconsistent information in relation to whether A’s observations were taken. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for failings in care and treatment, record keeping, communication, and complaint handling. 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 documentation should be in line with GMC and NMC guidance (all records accurate, dated and signed and attributable to the person who entered the data).
• If a child is admitted then the documentation should reflect that paediatric tools and assessments have been used.
• Patients should be appropriately triaged on arrival to A&E, observations carried out promptly and accurately, findings acted upon, and GCS scoring carried out where appropriate. Observations should be appropriately recorded in the patient record.
• Reflection by staff, whether for complaint processes or revalidation, should be accurate and take into account what is reflected in the medical records. If it differs from what is in the medical records there should be an explanation provided for this.

In relation to complaints handling, we recommended:

• Complaint investigations should be thorough and identify any inaccuracies in record keeping to ensure a full and accurate complaint response is provided. Information provided to SPSO should be accurate, complete and on time. All relevant records in relation to an SPSO investigation should be provided from the outset of our enquiries. The failure to do so in this case led to delays in the investigation.

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 spouse (A) received during two admissions to hospital. C complained that the board had failed to provide A with adequate personal care during both admissions and failed to adequately manage their medication during their first admission. C also complained that A had been unreasonably discharged following their first admission and that there had been inadequate preparation for A’s second discharge.

The board apologised for failures in A’s care and for aspects of their communication. They also apologised for a failure to adequately prepare A’s medication prior to their second discharge. They identified learning from these failures. However, C remained unhappy and asked us to investigate.

We took independent advice from a consultant in geriatric medicine and an advanced nurse practitioner. We found that A was unreasonably discharged at the end of their first admission. Therefore, we upheld this part of C’s complaint. However, the board managed A’s medication reasonably and provided adequate personal care during A’s first admission. Therefore, we did not uphold these part’s of C’s complaint.

In relation to A’s second discharge, we found that there had been a failure to provide A with adequate personal care and that they had been discharged at the end of this without adequate preparation. We upheld these parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Where a patient has a lack of bowel movements for several days, this should be highlighted and discussed with the relevant nursing, medical and allied healthcare teams.
• Where blood tests have been carried out, the patient’s results should be reviewed prior to their discharge.
• Where there is a delay in a patient being discharged, they should receive any medications they are due whilst waiting to be discharged. Patients should receive all appropriate prescribed medication when they are discharged. All relevant patient discharge documentation should be completed.
• Staff should obtain the precise details of a patient’s usual medication regime for Parkinson’s and act upon this to improve patient 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.

Summary

C complained that the practice failed to provide them with reasonable care and treatment. C was involved in a road traffic accident after they momentarily lost consciousness while driving. C had a phone and then a face-to-face consultation with a physician associate (PA, a healthcare professional who support doctors in the diagnosis and management of patients) who referred them to respiratory medicine to investigate possible sleep apnoea caused by hypersomnia (excessive daytime sleepiness). Another telephone consultation was held, during which the PA indicated their intention to refer C to the DVLA due to concerns that C was continuing to drive despite their advice to stop.

C was unhappy with their level of care. C disputed having been told that they must not drive, and complained that the referral was made on the basis of a suspected rather than confirmed diagnosis. They also said that they had not received fair warning of the consequences. C complained that it had not been made apparent that they were being seen by a PA rather than a GP. Lastly, C complained about the practice’s complaints handling, and the accuracy of their responses.

We took independent advice from a GP. We found that the questionnaire used to assess hypersomnia had been incorrectly completed by the PA which provided misleading results. C’s prescribed medication had not been followed up as a contributing factor in the accident and C’s significantly low pulse rate had not been identified or acted upon. We found that the PA appeared to have been acting without sufficient supervision from a GP, particularly once the complex nature of C’s situation became apparent. It would have been reasonable for C’s case to be transferred to a GP.

We also found that the referral to the DVLA had not been made in line with either DVLA or GMC guidance. Furthermore, the practice had failed to take appropriate steps to ensure that it was clear to C that they were receiving care from a PA and not a GP. Lastly, we found that there had been a failure to proactively update C on the progress of their complaint and that there were inaccuracies in the complaint responses. Therefore, we upheld C’s complaints.

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:

• A PA should be working within a defined scope of practice as determined by their employer. There should also be appropriate supervision and oversight from GPs when care and treatment is being provided by a PA. Supervision needs to take place in a timely fashion to ensure that complex cases are identified.
• The practice should ensure that all paperwork and IT systems are set up to allow for staff members to appropriately identify their job role.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the NHS complaints handling procedure and all efforts should be made to ensure the accuracy of complaints responses. Complainants should be kept updated on their complaints and clearly signposted to the SPSO in all stage 2 complaints 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.

Correction 4/3/2025

When this case was originally published on 22 January 2025, it incorrectly stated the organisation as 'A GP Practice in the Lanarkshire NHS Board area'. This was due to human error. The GP practice is based in the Forth Valley NHS Board area. We apologise for any inconvenience this may have caused.

Summary

C complained that the board failed to provide them with reasonable care and treatment in relation to their breast cancer care. C raised concerns that that the board failed to carry out necessary scans and failed to offer neoadjuvant chemotherapy (treatment given before the primary course of treatment to reduce the size of the tumour). C also complained about the waiting times in relation to surgeries and the mastectomy report; and that the board failed to adhere to the relevant local and national guidelines.

We took independent advice from a consultant breast surgeon. We found that the care and treatment provided to C was reasonable. In particular, we found that C did not meet the requirements to receive neoadjuvant chemotherapy prior to surgery and, accordingly, it was not unreasonable that the board did not perform further scans. We found that the waiting times were reasonable. We also found that the board’s medical team had followed relevant local and national guidelines and C had been provided with reasonable care and treatment based on the information available to the clinicians at the time. Therefore, we did not uphold C’s complaint.

In relation to complaint handling, we found that C was provided with updates on the progress of their investigation and the reason for the delay. However, C was not given a revised timescale for completion so we provided feedback to the board on this point.

Summary

C complained about the care and treatment provided to their parent (A) by the practice. A was described as fit and well but had developed severe diarrhoea. Although the diarrhoea subsided, A continued to feel unwell and breathless. A was seen by an advanced nurse practitioner (ANP) and referred for an electrocardiogram (ECG) as an outpatient a few days later. A attended for these tests, but was not seen by a doctor, and returned home. A suffered a stroke that afternoon and died in hospital the following day.

C complained that although A spoke with a doctor by telephone, they were not seen in person by a doctor over a series of appointments. C believed that A should have seen a doctor much sooner and that A should have been considered for hospital admission at their appointment with the ANP. They also said that A’s ECG results were abnormal, had been misinterpreted by the practice and should have resulted in A’s admission to hospital as an emergency. C believed that had the practice provided a reasonable standard of care, A’s death could have been prevented. Although C met with the practice and received two responses to their complaint, they continued to believe the practice’s response was inadequate and brought their complaint to this office.

We took independent advice from a GP. We found that A’s care prior to their ECG was of a reasonable standard. It was noted that C disagreed with A’s medical records, but it was not possible to determine precisely what was said at A’s appointments. We did not uphold these parts of C’s complaint.

We found that A’s ECG was highly abnormal, indicating A’s heart was lacking in oxygenated blood flow. This should have resulted in a face-to-face appointment, followed by an immediate hospital referral. Therefore, we upheld this part of C’s complaint. However, it was not possible to determine whether A would have survived with an earlier admission as the cause of A’s death was a bleed on their brain. This was an unfortunate but recognised side effect of the medication given to A to treat the stroke they had suffered.

Finally, C complained about the practice’s complaint handling. We found that the practice failed to handle C’s complaint reasonably and upheld this part of their complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for the failure to provide A with a reasonable standard of care on the day of their ECG. 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:

• ECG results should be accurately interpreted, taking into consideration the condition of the patient and their medical history.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure.
• The practice’s complaint investigations should ensure that failings are accurately 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 standard of medical care and treatment provided by the practice. C attended the practice with a lesion on their back which was diagnosed as a seborrhoeic wart (a harmless growth on the skin). C underwent cryotherapy treatment (the use of extreme cold to freeze and remove abnormal tissue) but this was unsuccessful. Therefore, the practice made a a routine referral for an outpatient hospital appointment to have the lesion removed surgically. C opted to be see a private consultant dermatologist (skin specialist) and was diagnosed with cancer. C felt that the practice misdiagnosed their skin cancer which led to a delay in receiving appropriate treatment.

We took independent advice from a GP. We found that the care and treatment C received when they first attended the practice was reasonable. However, the practice failed to record a clear description of the lesion in the medical records. This is essential to ensure that subsequent viewers of the lesion can assess whether there has been any significant change. Therefore, we could not say that subsequent care and treatment had been reasonable and upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing 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:

• When managing and treating skin lesions, the medical records should contain all relevant information to ensure that subsequent viewers of the lesion can assess whether there has been any significant change in the lesion.

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.