Health

Summary

Mr C complained about the care and treatment provided to him during two admissions at Dumfries and Galloway Royal Infirmary.

Mr C had Hodgkin's Lymphoma (a cancer of the lymphatic system, which is part of the immune system). Mr C complained that he should not have been discharged after he felt unwell during an admission for a blood transfusion. We took independent advice from a consultant haematologist (a doctor who specialises in blood). We found that the follow-up arrangements made prior to discharge were unreasonable. We, therefore, upheld this part of Mr C's complaint.

During a subsequent admission, Mr C experienced a build-up of fluid in the lining of his lungs. He complained that there was a delay in carrying out a procedure to drain the fluid. We found that medical staff appropriately monitored whether a drain was needed to improve Mr C's symptoms and we did not consider that there was an unreasonable delay. We did not uphold this aspect of the complaint.

Mr C also experienced a build-up of fluid around his heart which required a procedure (pericardiocentesis) to drain the fluid. Mr C complained that the two attempts to carry out this procedure were not of a reasonable standard. We found that the first attempt was halted after Mr C became uncomfortable. The second attempt was stopped after concern was raised that Mr C's heart was damaged. Mr C was then transferred for emergency assessment, where the procedure was carried out successfully and no significant damage to Mr C's heart was identified.

We took independent advice on this from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that the first attempt at pericardiocentesis was not performed to a reasonable standard and was not documented adequately. However, we found that the board had carried out an internal investigation and that the operator involved had since reflected on what had happened and identified learning points. Despite the complication, we were not critical of the second attempt at the procedure as we found that staff took appropriate action once it was apparent that Mr C's heart had potentially sustained damage. On balance, we upheld this aspect of the complaint.

Lastly, Mr C complained about the level of communication with him during his second admission. We found that haematology staff did not update Mr C about the overall picture frequently enough, which may have added to his anxiety about his situation. We noted that Mr C had not been informed of the small risk of death prior to the attempts at pericardiocentesis. We upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that they did not make sufficient follow-up arrangements prior to discharge; did not adequately explain the risks of pericardiocentesis; and did not communicate with Mr C frequently enough during his second admission. 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 should be aware of what to do if they become unwell after discharge and how to contact the haematology department for advice. Patients with low blood cell count should be carefully monitored for changes in blood cell count.
• The approach and technique used in invasive procedures should be adequately documented in a patient's clinical records.
• Patients should be fully informed of the recognised risks, including death, as part of the consenting process prior to performing pericardiocentesis.
• Patients should receive the information they want or need to know in a way they can understand.

Summary

Ms C complained on behalf of her mother (Mrs A) about the care and treatment provided to Mrs A at Borders General Hospital.

After a fall breaking her hip, Mrs A was admitted to the hospital for an operation. At the time of her admission, Mrs A had hearing only in her right ear and staff were advised of this. Mrs A appeared to be making a reasonable recovery after her operation but, the next day, her condition deteriorated and she developed sepsis (a blood infection). She was given two doses of an antibiotic. Shortly afterwards, she developed a bowel obstruction for which she needed an operation and a few days afterwards, she had a heart attack. Mrs A remained in hospital for nearly six weeks and by then she had lost all her hearing. Mrs C complained about Mrs A's care and treatment and said that the antibiotic she had been given had led to her hearing loss. She also complained about poor communication and, amongst other things, not being told of Mrs A's heart attack.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and from a registered nurse. We found that Mrs A's operation had been performed promptly and without any problems but that afterwards, when her temperature and National Early Warning Score (NEWS - an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration) began to rise, no specific action was taken as it should have been. In relation to the antibiotics, Mrs A was very unwell and at risk of dying and, therefore, this risk outweighed the potential harm of giving Mrs  A the antibiotic (which was associated with hearing loss and balance problems after prolonged use). However, we also found that Mrs A was not given a detailed assessment or screened for sepsis. On balance, we upheld this aspect of Ms C's complaint.

In relation to communication, we found that staff had not told the family about Mrs  A's heart attack or made a plan to address or discuss Mrs A's communication needs, with no review of this taking place. We considered that the board's communication was unreasonable and upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for not fully assessing Mrs A; for failing to follow guidance; and for the communications failures. 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:

• Patients whose National Early Warning Scores trigger action should be appropriately assessed, including screening for sepsis and delirium.
• Patients and their carers should receive appropriate information about their condition in a way that suits their needs.

Summary

Miss C complained that she was unreasonably refused treatment in A&E at University Hospital Ayr. She said that staff referred her back to her GP as she was already receiving treatment for the same medical condition.

We took independent advice from an experienced practitioner in emergency medicine. We found that Miss C was appropriately assessed in A&E and did not have a life threatening illness or injury that required hospital admission or referral to another hospital specialist. We found that the appropriate route for Miss C was to report her health problems to her GP. We did not uphold Miss C's complaint.

Summary

Mr C complained to us about two periods when his brother (Mr A) was admitted to University Hospital Crosshouse. During these admissions, legislation contained in the Adults with Incapacity (Scotland) Act 2000 was utilised by the clinical team as they considered Mr A unable to consent or make decisions on treatment. Mr C complained that the Adults with Incapacity legislation was not used appropriately and that its use was not communicated reasonably to Mr A and his family. In addition to this, Mr C complained about the general level of care and treatment provided during Mr A's admissions.

We took independent advice from an adviser who is a registered medical practitioner with a background in psychiatry. We found that, given Mr A's circumstances during his admissions, the use of Adults with Incapacity legislation was reasonable. In addition to this, we did not identify any concerns about the general level of care provided, although we acknowledged that Mr A's experience may have differed from the information contained in the relevant documentation.

However, we identified shortcomings in relations to the recording and documentation of the use of Adults with Incapacity legislation. In addition to this, there was evidence of gaps in understanding of the Adults with Incapacity Act on a practical level, with factually incorrect information being provided on at least one occassion. Therefore, although it may have been appropriate to utilise Adults with Incapacity legislation, we concluded that there were service failings relating to the understanding of the legislation, the documentation of its use and the resulting communication with Mr A and his family. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for any distress caused due to any lack of understanding of Adults with Incapacity legislation and communication around its use in practice.

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

• Ensure that all relevant staff have an appropriate level of understanding of Adults with Incapacity legislation and its use in practice.

Summary

Mrs C complained on behalf of her father (Mr A) that the ambulance service unreasonably failed to dispatch an emergency ambulance. Mr A collapsed at work with a stroke and two calls were made for an ambulance, which took 50  minutes to arrive. Mrs C felt that the call handler who took the first call had not established sufficient information to determine whether Mr A was conscious or not, and that this affected the priority status of the ambulance response.

We took independent advice from a paramedic. We found that both phone calls were graded appropriately in view of the questions asked by the call handlers. However, in the first call it was not clearly established whether Mr A was conscious or not. Good practice would have been for the first call handler to have questioned the caller in more detail, which would have established an accurate consciousness level and may have affected the grading of the ambulance response. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mr A for failing to fully establish from the call maker whether Mr A was conscious or not. 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:

• The first call taker should ensure that, when talking to callers, they obtain accurate information about the condition of the patient so that an appropriate response level can be activated.

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

Mrs C complained about the length of time that her mother (Mrs A) had to wait for an ambulance.

We listened to the audio recordings of the relevant phone calls, and we took independent advice from a paramedic adviser. We found that Mrs A's GP surgery had requested that Mrs A be transported to hospital within two hours, and that this was not a request for an emergency 999 response. However, we found that, if a request to be transported goes beyond the agreed timescale, then ambulance service call handlers will carry out urgent welfare call backs to check whether the patient's condition has deteriorated. Where the call handler identifies that the patient's condition has worsened, they should upgrade the call to an emergency response and process it through the medical priority dispatch system. We found that during the first welfare call back Mrs A was reported to be struggling to breath and that during the second welfare call back she had reportedly stopped taking sips of water. We considered that there were failures to appropriately explore possible deteriorations in Mrs A's condition during the first and second welfare call backs. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that possible deterioration in Mrs A's condition were not appropriately explored during the first and second welfare call backs. 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:

• Where there is an indication of a patient's condition deteriorating this should be processed appropriately using the medical priority dispatch system.

Summary

Mr and Mrs C complained that the ambulance service delayed in sending an ambulance after Mr C suffered multiple fractures in an accident at his home. They also complained that there was a further delay in sending an ambulance when his local hospital asked the ambulance service to transfer him to a major trauma centre. Mr C subsequently developed fat embolism syndrome (a life-threatening condition where fat particles within the bone are released into the bloodstream) and went into a coma. He considers that this was at least partly due to the ambulance service's delay in sending ambulances to both his home and his local hospital.

We took independent advice from a paramedic. We found that a dispatcher in the ambulance control centre had failed to identify a paramedic crewed ambulance that was available at the time of Mr C's 999 call. This had caused an unreasonable delay by the ambulance service in sending an ambulance to Mr C's home. In view of this, we upheld this aspect of Mr and Mrs C's complaint, although we acknowledged that the ambulance service had already apologised for this and had taken some action to try to prevent this happening again.

We found that the delay by the ambulance service in sending an ambulance to transfer Mr C from his local hospital to a major trauma centre had not been unreasonable. Mr C was in a place of safety and could have been upgraded to an emergency by the hospital at any time. We did not uphold this aspect of Mr  and Mrs C's complaint. However, we considered that the communication between the ambulance service and clinicians in the hospital could have been better and we provided some feedback to the ambulance service in relation to this. We also provided some feedback to the ambulance service on trauma care and the documentation of this.

Recommendations

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

• Dispatchers should be able to identify available resources and, where appropriate, ensure that these are dispatched promptly.

Summary

Mr C complained about a consultation which he had with a consultant surgeon following a referral from his GP. Mr C had a complex medical history, including abdominal pain, and he felt that the consultant was not interested in helping him. Mr C said that he was told by the consultant that his health problems could be in his mind and also that stress could be the cause of his problems, along with him being overweight. Mr C was not satisfied that the plan was for him to be reviewed in six months in the hope that he had managed to reduce his weight. He complained that he did not receive appropriate treatment.

We took independent advice from a consultant in general medicine. We found that Mr C's care was complex and that previously he had seen a number of clinicians who had difficulty in reaching a diagnosis. We found that the consultant had spent a considerable amount of time with Mr C and that it was reasonable to arrange a review appointment in 6 months in the hope that any weight loss could improve Mr C's symptoms. It was also reasonable that, as the consultant had not reached a specific diagnosis, no additional medication was prescribed. We did not uphold the complaint.

Summary

Mr C complained about a Do Not Attempt Cardiopulmonary Resuscitation decision (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) taken when his mother (Mrs A) was a patient in Ninewells Hospital where she was being treated for heart failure. Mr C held Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) in relation to his mother. He had been told of the decision in a public place, without being consulted. The doctor who spoke to him said he had spoken to Mrs A, who agreed with the decision. Mr C said his mother was very confused and unable to consent to this. Mr C complained that he had not had his views taken into account in relation to the DNACPR decision despite having POA and that the board unreasonably spoke to Mrs A and gained her consent despite her lacking capacity to give consent at the time.

We took independent advice from a doctor with specialism in acute and general medicine. We found that it was inappropriate to have a discussion with Mr C about the decision in such a public setting, however, we found that the board had acknowledged and apologised for this. We noted that where a patient has granted a POA, the attorney should be involved in the decision wherever possible, with the patient as well if appropriate. However, if cardiopulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops) is unlikely to be successful, healthcare staff are under no obligation to attempt CPR. The adviser considered that Mr C should have been involved in the discussions earlier, but ultimately it was the clinical team's decision to make. We did not uphold this aspect of Mr C's complaint.

In relation to gaining Mrs A's consent, we found that the board acknowledged that a discussion had taken place and, given it was recorded that she was confused at this time, they noted it would have been appropriate for a mental capacity assessment to have taken place. We acknowledged that assessing Mrs A's mental capacity was not the priority at the time the decision was taken as she was acutely unwell. However, the fact she was confused should have prompted an assessment of her capacity. We were also concerned that the board did not obtain a copy of the POA document. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for failing to assess Mrs A's capacity and for failing to obtain a copy of the POA document. The apology should meet the standards set out in the SPSO's Guidance on Apology at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should have a working knowledge of Adults with Incapacity legislation insofar as it applies to consent issues. Staff should be clear about the importance of Adults with Incapacity documentation.

Summary

Mrs C complained about the in-patient care she received at Ninewells Hospital. In particular, that there was a delay in diagnosing diverticulitis (where small pouches from the wall of the gut become inflamed or infected). She also complained that a consultant surgeon had not examined her when she attended an out-patient clinic appointment at Perth Royal Infirmary and that the care that she received from the out-of-hours service was unreasonable.

We took independent advice from a consultant colorectal surgeon (a specialist in the medical and surgical treatment of conditions that affect the lower digestive tract) in relation to Mrs C's concerns about a delay in diagnosing diverticulitis. We found that a computer tomography (CT) scan should have been carried out rather than an magnetic resonance imaging (MRI) scan because it would have provided a more complete examination of Mrs C's abdomen and pelvis. In addition, we considered that a CT scan should have been performed within a few days after Mrs C's discharge from Ninewells Hospital. We were also critical of the length of time it took for staff at Ninewells Hospital to contact the consultant surgeon at Perth Royal Infirmary to inform them about the results of the MRI scan. We also found that the letter to the consultant surgeon had not referred to Mrs  C's earlier hospital admission. In terms of the clinic appointment at Perth Royal Infirmary, we considered that the consultant surgeon should have examined Mrs  C given there was no evidence of her symptoms having settled. We considered that the time taken to diagnose diverticulitis was unreasonable and upheld this aspect of Mrs C's complaint.

In relation to Mrs C's out-of-hours appointment, we considered that the treatment she received was reasonable and appropriate. We did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unreasonable delay in performing the MRI scan, for not ensuring that an urgent CT scan was performed, the unreasonable delay in the consultant surgeon being informed about Mrs C's hospital admission and MRI results, and for not conducting a physical examination at Mrs C's clinical appointment. 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 urgent CT scanning is performed when recommended.
• Staff should ensure timely and appropriate communication with other specialities where relevant.
• Staff should ensure that relevant information is clearly recorded and physical examinations carried out where appropriate.