Health

Summary

Mrs C complained about the care and treatment she received from Ninewells Hospital regarding a delay in physiotherapy and the board's handling of her complaint concerning the matter.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in childbirth and the female reproductive system). We found that the handling of Mrs C's referral to physiotherapy was unreasonable and caused a delay of around seven months in her receiving her first appointment. We acknowledged that the board had apologised to Mrs C for the failure to action the referral to physiotherapy and for problems both Mrs C and her GP had when trying to expedite the referral through the doctor's secretarial staff. We considered that there was an unreasonable failure to amend Mrs C's management plan (regarding the decision to refer her for physiotherapy) after she was reviewed post-operatively.

We found that there was poor internal communication across two hospital sites and a missed opportunity for the problem with the referral to be addressed at an earlier stage when Mrs C and her GP contacted the doctor's support staff. We considered that the board had taken reasonable action to improve communication between hospital sites. We considered that the delay in receiving physiotherapy was unlikely to have affected the progression of Mrs C's condition. However, we upheld the complaint and made a further recommendation to ensure learning and improvement.

In terms of the board's handling of Mrs C's complaint, we acknowledged that they had apologised to Mrs C about their delay in responding. We found that the board had delayed by three weeks in updating Mrs C when they were unable to meet the 20 working day timescale for responding to complaints. Were were also critical that the board had not responded to all of the concerns Mrs C had raised in her complaint correspondence. The board accepted that they should have responded to this aspect. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not responding to all aspects of her complaint.The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should ensure that management plans are updated between theatre and post-operative review.

Summary

Mr C complained that he had been on two types of long term painkilling medication which the practice had failed to keep under regular review. Mr C was admitted to hospital as an emergency with symptoms of bleeding from his rectum. Mr C believed that he should not have been on both medications at the same time and that they caused his rectal bleeding. He felt that if the medication had been reviewed regularly then the bleeding would have been prevented.

We took independent advice from a general practitioner. We found that it was appropriate for the practice to have prescribed both types of medication for Mr C and that there was no requirement to keep the medication under regular review. It was also found that there was another cause of Mr C's bleeding which was not connected with the medication. We did not uphold Mr C's complaint.

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received in A&E at the Royal Infirmary of Edinburgh. Mr A was taken to hospital after becoming unwell with chest pains and was treated for a suspected heart attack. Tests carried out showed that Mr A was not having a heart attack and he was referred for a CT scan (a scan that creates detailed images of the inside of the body) to investigate other causes. Before the scan took place, Mr A collapsed and staff were not able to resuscitate him. The cause of death was a thoracic aortic dissection (a condition where the lining of the main blood vessel from the heart is injured). Mrs C felt that a CT scan should have been ordered sooner.

We took independent advice from a consultant in emergency medicine. We found that it was appropriate to investigate and treat Mr A for a heart attack as this is what his symptoms suggested. When a heart attack was ruled out, we noted that a CT scan was ordered within a few minutes and that there was no unreasonable delay in relation to the wait for the scanner to become available. We did, however, identify an unreasonable failing in the observations of Mr A's vital signs as there was a gap in the records of over four hours. On balance, we upheld the complaint and made recommendations in this connection.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the gap in recording vital signs. 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:

• Vital signs should be recorded at appropriate intervals for patients in the emergency department.

Summary

Mr C complained that the practice had unreasonably stopped prescribing his Capasal (medicated shampoo) medication on NHS prescription. Mr C said that he had psoriasis (a skin condition) and had been prescribed Capasal for many years. He was suddenly told by the practice that in accordance with health board guidance, he would have to purchase Capasal over the counter at a chemist.

We took independent advice from a general practitioner. We found that Mr C's medical records contained information that Mr C had been diagnosed with psoriasis in the past and as such he did satisfy the health board criteria which would allow the practice to prescribe the medication on NHS prescription. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for stopping prescribing his medication shampoo. 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:

• Staff should review their decision on Mr C's medication based on health board guidelines and ensure that when considering medication reviews they have considered all the available clinical evidence in order to support their decision.

Summary

Mrs C received cataract surgery (surgery to correct clouding of the lens of the eye) and complained that the board did not provide her with reasonable follow- up care and treatment afterwards. Mrs C complained that board staff were not listening to her concerns about losing her sight.

We took independent advice from a consultant ophthalmologist (eye doctor). We found that the care and treatment Mrs C received was reasonable. We found that Mrs C had appropriate tests and there was no obvious cause for her symptoms. Ongoing investigations were planned and no failings were identified in the care provided during the period covered by Mrs C's complaint. We did not uphold the complaint.

Summary

Mrs C complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's late father (Mr A). Mr A suffered from heart problems and had a history of diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) and a previous stroke. Over a period of about 18 months he had several hospital admissions and underwent two cardiac catheterisation procedures (where a tube is inserted into a blood vessel near the heart, to look at the condition of the blood vessels and/or insert a stent to widen them), but no stent was inserted. Doctors then referred Mr A for consideration of coronary bypass surgery (surgery to bypass a section of existing blood vessel that is narrowed with a graft). However, while he was waiting for review, Mr A suffered a further stroke and heart attack, and he died in hospital a few weeks after this. Mr A's family felt he should have been offered surgery earlier. They also raised concerns about the medical and nursing care during his admissions, and the board's response to their complaint.

The board considered the medical care and communication was reasonable. However, they agreed there were some failings in the nursing care for Mr A's pressure ulcers and they apologised for this and took action to prevent a recurrence.

We took independent medical, cardiology and nursing advice. We found that the overall management of Mr A's heart problems was reasonable, and it was appropriate that surgery was not offered earlier as this would have been a very high risk for Mr A (in view of his pre-existing conditions). We did not uphold this aspect of Mrs C's complaint. However, we found that there was no evidence Mr  A or his family were told about Mr A's heart attack for several days, and we made a recommendation in light of this finding.

We upheld the complaint about nursing care, as we found failings in relation to fluid monitoring, pressure ulcers, falls monitoring and communication with the family about Mr A's palliative care.

We also upheld the complaint about complaints handling, as there were errors in the board's complaint response, which appeared to be due to the medical records being misread.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the delay in informing them about the heart attack, the failings in nursing care and communication, and the errors in the complaint response. 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:

• Patients and/or family should be promptly updated about significant events, such as a heart attack, and a record made of the communication.
• Good palliative care should ensure a comfortable and peaceful time for the patients, with support for relevant others and person-centred communication.
• There should be clear handover communication between staff, to ensure all staff are aware of a patient's needs.
• Fluid balance charts should be completed for patients requiring fluid restriction.

In relation to complaints handling, we recommended:

• Complaint investigations should involve a careful and thorough review of the medical records, having particular regard to the points of complaint raised.

Summary

Mr C, who is an MSP, complained on behalf of his constituent (Mr A). He said that the board had failed to provide Mr A with reasonable care and treatment in Monklands Hospital. We took independent advice from a general medical adviser, a nursing adviser and from a consultant orthopaedic and trauma surgeon.

Firstly, Mr C complained that the board had unreasonably discharged Mr A with a bacterial infection and that he then had to be readmitted to hospital. We found that Mr A's discharge had been reasonable, as his symptoms appeared to be acceptably controlled at that time on oral medication; he had been appropriately reviewed; and no concerns about his discharge were raised. The blood tests results showing the infection did not become available until after he was discharged. We did not uphold this complaint.

Mr C also complained that staff failed to prevent Mr A falling on two occasions when he was readmitted to hospital. We found that there had been a failure to complete and document a falls risk assessment when Mr A was admitted in line with standards of care for older people in hospital. There was also a failure to document communication with the family. We upheld this complaint.

Mr A also complained that staff delayed in obtaining an X-ray after Mr A's falls. We found that an X-ray had not been clinically indicated after the first fall. An X- ray was then obtained after the second fall. On balance, we did not uphold this complaint.

Mr C also complained that staff had given Mr A too much morphine (a medication for pain relief). We found that the approach to this and the doses prescribed had been reasonable. We did not uphold this complaint.

Mr C also complained that staff failed to follow-up Mr A's care after his discharge from hospital. We found that, although an interim discharge letter was issued, a follow-up discharge summary was not issued. There was also insufficient information about how Mr A's hypertension (abnormally high blood pressure) was to be followed up. We upheld this complaint.

Finally, Mr C complained that the board had unreasonably prescribed an antiepileptic drug to Mr A beyond the maximum of ten years. There is no guidance that states it should not be prescribed for more than ten years and there was no clear evidence that this had caused Mr A's health problems. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to complete an appropriate risk assessment to prevent falls when he was admitted to hospital and to appropriately document communication with Mr A's family. 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:

• Risk assessment and care planning in relation to falls prevention should be carried out in line with guidance and policy, when the patient is admitted to hospital.
• Nursing staff should involve patients and families in care planning where appropriate and should keep clear records of conversations with families/carers using the relevant documents.

Summary

Ms C complained about the nursing care her mother (Mrs A) received at Raigmore Hospital. Mrs A suffered from osteoporosis (weak or fragile bones) and fell during an admission to the hospital. A number of weeks following her discharge from hospital, Mrs A's GP arranged for x-rays to be taken which showed that she had suffered two fractures to her spine. Ms C complained that nursing staff failed to appropriately care for Mrs A following her fall.

We took independent advice from a nurse who is experienced in hospital falls prevention. We found that the nurses who attended Mrs A failed to act in accordance with falls prevention guidance. There was no record that an adequate assessment had been carried out to establish if Mrs A had sustained an injury following the fall. There was also a failure to arrange a medical review for Mrs A. We were unable to find out when the fractures actually occurred as Mrs A did not report to staff that she was in pain at the time and the actual diagnosis of fractures was not made until a number of weeks following the fall. However, we considered that the failings identified were unreasonable and upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to act in accordance with the guidance following her fall and failing to arrange a medical review. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Nursing staff should ensure that action is taken in accordance with guidance in relation to in-patient falls and ensure that a record is made on which examinations have taken place and that a medical review is arranged.

Summary

Mr C complained about the health care and treatment he had received in prison. In particular, he complained about problems he had experienced in receiving all his prescribed medication within the prison regime. The board acknowledged that there had been problems with Mr C receiving all his prescribed medication and they suggested that he discuss this with the GP. Mr C was unhappy with this response and brought his complaint to us.

We took independent medical advice. We found that the prison healthcare team were responsive to Mr C's concerns, including altering his medication to ensure he receives all of it, and liaising with pain specialists. We considered this treatment to be reasonable and did not uphold Mr C's complaint.

Summary

Ms C complained that the practice provided unreasonable treatment to her late mother (Mrs A). A GP from the practice attended Mrs A at home and prescribed an antibiotic. Mrs A was also on Warafin (a drug used to prevent blood clots) and other medication. She later became unwell and was admitted to hospital with bleeding from a peptic (stomach) ulcer and considered at risk of internal bleeding. Mrs A died a few weeks later. Mrs C complained that the prescription of the antibiotic was unreasonable and that Mrs A should have been advised to have her INR (a blood test which allows monitoring of Warafin levels) checked after she was started on the antibiotic.

We took independent advice from a GP. We found that the practice reasonably prescribed the antibiotic. However, the practice should have advised Mrs A that she should have her INR checked four to seven days after starting the antibiotic. Therefore, we upheld Ms C's complaint.

Recommendations

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

• This complaint should be discussed with the GP involved at their annual appraisal.