Health

Summary

Ms C, who works for an advice and support agency, complained on behalf of Miss  A about the medical and nursing care and treatment Miss A received at Stracathro Hospital following hip replacement surgery. Ms C raised a number of concerns, including that Miss A suffered a stroke after surgery which was not picked up on by staff, despite her repeatedly reporting visual disturbance and blurred vision.

We took independent advice from a consultant physician and cardiologist (a  doctor who specialises in disorders of the heart), a consultant orthopaedic surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system) and a nursing adviser. We found that there were no case note entries by the junior medical staff at any time in Miss A's post-operative notes (including in relation to the complaint of visual blurring) and that the board failed to assess Miss A's complaint of post-operative visual blurring in an appropriate manner. The failing was not that they did not diagnose a stroke as the cause of her visual blurring, but rather that they did not assess it at all. We also found that the medical staff failed to take Miss A's medical history or carry out a simple bedside assessment of her eyes. We noted that the board appropriately prescribed aspirin to Miss A on discharge. However, prescribing aspirin alone does not follow the board's protocol and there was no reason recorded in Miss A's notes to explain why this decision was taken. There was also no evidence of a 'venous thromboembolism (VTE - condition where a blood clot forms in a vein) risk assessment tool' being completed. We considered that the medical treatment provided to Ms A was unreasonable and upheld this aspect of Ms C's complaint.

In terms of the nursing care and treatment, we found that the nurses acted reasonably by informing the medical staff about Miss A's complaints of visual blurring and ensuring Miss A was seen by a doctor. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for failing to respond appropriately to reported visual blurring, the lack of record-keeping and for not giving her appropriate blood thinning medication. 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:

• Medical staff should take a patient's medical history and respond to complaints of postoperative visual blurring in a timely and appropriate manner.
• Staff should complete patients' 'VTE risk assessment tool' forms in cases of this type, prescribe blood thinning medication following hip replacement surgery in line with national guidance, and give patients blood thinning medication in accordance with the board's protocol and, if the board consider it appropriate to deviate from the protocol, to record the reason for this in patients' records.

Summary

Mrs C complained about the care and treatment that her late husband (Mr A) received at Ninewells Hospital after he attended with painless jaundice (a  condition with yellowing of the skin or whites of the eyes). Mr A was later diagnosed with pancreatic cancer. Mrs C considered that the board had not taken appropriate action in terms of treating his symptoms as a red flag for cancer, carrying out appropriate investigations, diagnosing the primary source of cancer, acting on problems with a stent that had been inserted to drain a bile duct blockage, decision-making around surgical treatment and prescription of a medication to help digestion.

We took independent advice from a consultant hepatologist and gastroenterologist (a specialist in the study of the esophagus, stomach, small and large intestines, pancreas, gallbladder, and liver). We found that the initial action taken to investigate Mr A was reasonable and that appropriate tests for his presentation had been carried out. We found that the primary source of cancer had been appropriately diagnosed within a reasonable timeframe and that the action taken in relation to Mr A's stent was appropriate.

We found that surgical decision-making was also reasonable as, although it was initially thought that an operation could be carried out to remove the cancer, subsequent scans showed this treatment would have caused significant harm to Mr A with no benefit. However, we found failings in the prescription of Creon (a  medication that replaces pancreatic enzymes which help digest food) and also prescription of appropriate medication to treat itching caused by bile duct blockage. We noted that Creon could and should have been prescribed earlier and that the types of medication prescribed to treat Mr A's itching are known not to generally improve itching associated with bile duct blockages. We found that Mr A could have been made more comfortable with a different approach. Overall, we considered that the care and treatment Mr A received was unreasonable and upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to prescribe Mr A with Creon, and more appropriate medication to treat the itching associated with bile blockage, earlier. 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:

• Creon and appropriate medication to treat the itching associated with bile blockage should be prescribed when the symptoms are apparent.

Summary

Mr C complained about the care and treatment provided by the practice to his late child (Baby A). Baby A was taken to the practice with a blocked nose and congestion. The doctor considered that Baby A was suffering from a respiratory tract infection, but that there was no evidence of a more serious infection requiring any treatment or hospital admission at that time. The following day, Baby A suffered cardiac arrest at home and was taken by ambulance to hospital. They did not regain consciousness and died a number of weeks later.

Mr C complained that the practice failed to carry out an adequate assessment and failed to make a hospital referral for further investigation, despite Baby A's history of bronchiolitis (a lower respiratory tract infection that affects babies). Prior to Baby A's death, they were found to have been positive for Respiratory Syncytial Virus (RSV - a virus which causes respiratory tract infections, and the most common cause of bronchiolitis). Mr C complained that the practice failed to detect RSV.

We took independent advice from a GP adviser. We found that the doctor's assessment was reasonable and in line with relevant guidelines, which did not indicate that a hospital admission was required, based on the clinical findings. We found that hospital admission with bronchiolitis is normally only required when there are difficulties breathing or feeding, and the GP assessment did not identify any difficulties in Baby A in either regard. We found that the hospital consultant did not consider that RSV and bronchiolitis was the definitive cause of Baby A's death. We found no evidence that the practice overlooked any relevant factors in their assessment of Baby A and we did not uphold the complaint.

Summary

Mr C complained that there was a delay in him receiving medication at St John's hospital when he was admitted after having seizures during the night.

We took independent advice from a hospital doctor. We found that, when Mr C initially arrived in A&E at the hospital, a consultant set out a plan for the medication he was to receive. We found that Mr C was to be prescribed and administered medication in A&E, but that when he was transferred to a ward this had not happened and he ultimately did not receive his medication until he was seen by a doctor the following morning.

We found that Mr C should have received the medication in A&E, and we upheld his complaint. We noted that the delay in receiving the medication did not put Mr  C at high risk of having another seizure, however we considered that this should have been communicated to him. The board said that they had already taken action to ensure that medical staff in A&E were aware of the importance of giving medications to patients when appropriate. We asked for evidence of this.

We also noted that in their complaints responses the board issued inconsistent accounts of what staff were aware of, and when they were aware of it, on the night of Mr C's admission, and so we made some recommendations regarding this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for issuing unclear accounts of what the medical staff were aware of, and when. To confirm this was because it is not possible to determine exactly what the doctors were aware of, on the evening of Mr C's admission to the following morning, due to a lack of clinical nursing notes. 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:

• Ensure accurate records are kept in the clinical nursing notes regarding what is communicated by the patient and what is communicated to the medical staff.

In relation to complaints handling, we recommended:

• To explain to a complainant when it is not possible to provide a definitive account of events and provide the reason why.

Summary

Mr C complained about the care provided to his wife (Mrs A) when she attended A&E at the Royal Infirmary of Edinburgh. Mrs A presented to the department with severe pain in her shoulder. Shortly after admission Mrs A was given morphine for her pain and was assessed by an emergency medicine consultant.

Mr C raised concern about the delay in triage (a process in which things are ranked in terms of importance or priority), inadequate pain management, and the failure to use a cubicle. The board acknowledged that Mrs A should have been moved to a cubicle after morphine was given and apologised for this. We took independent advice from an emergency medicine adviser. We found the care provided to be reasonable, however, the failure to use a cubicle may have impacted on Mrs A's dignity. We upheld this aspect of Mr C's complaint. As the board had apologised for this failing and taken adequate steps to address this issue, we did not make any further recommendations.

Mr C also raised concern about a letter sent to Mrs A's GP in relation to the admission. We found that the letter contained an inaccuracy and upheld this aspect of Mr C's complaint.

Finally, Mr C complained that the board failed to investigate his complaint reasonably. We noted that many aspects of the complaint handling were reasonable, however, we found that the board had not investigated his complaints about hygiene. 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 the inaccuracy within the letter documenting the admission and for failing to investigate part of Mr C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mr C complained about two consultations he attended at Edinburgh Dental Institute following a referral from his dental practice relating to temporomandibular disorder (a problem affecting the 'chewing' muscles and the joints between the lower jaw and the base of the skull). In particular, Mr C was unhappy with the assessments carried out and the lack of treatment provided.

We took independent advice from a consultant oral and maxillofacial surgeon (a specialist in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck). They considered that most aspects of the clinical management in the department were reasonable. However, they considered that Mr C's medication history was not recorded adequately at the first consultation. In relation to the second consultation, they were critical that an examination was not performed. We upheld these aspects of Mr C's complaint.

Mr C was also unhappy that a clinic letter relating to one of the consultations contained an error and was sent to the wrong address. We upheld this aspect of Mr C's complaint. However, we noted that the board had apologised to Mr C and identified appropriate action to help prevent the issue reoccurring.

Finally, Mr C was unhappy about the way the board handled his complaint. The board acknowledged that their response was delayed and apologised to Mr C for this. We considered that the board's communication about the delay was poor and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to adequately record his medication history, failing to perform an examination, and the poor communication during the handling of his complaint. 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 presenting with pain should have their medication history appropriately recorded within the documentation of the management plan. Consultations should include an examination where this is indicated clinically or because of the particular circumstances of the patient's situation.

In relation to complaints handling, we recommended:

• Where it is not possible to complete an investigation within 20 working days, the person making the complaint should be given an update about the delay and a revised timescale for completion. Communication about revised timescales should be accurate and further contact should be made if it emerges that the revised timescale is not achievable.

Summary

Mrs C had knee replacement surgery at the Royal Infirmary of Edinburgh. She also underwent manipulation under anaesthetic (MUA - a procedure to try and improve movement) to try and relieve knee stiffness after the operation. Mrs C complained about the board's communication with her following the knee replacement surgery. In particular, she complained that she was not properly informed that, should MUA be unsuccessful, there was a possibility that nothing more could be done for her knee. She also complained that she was not told why she had been sent for a second opinion.

We took independent advice from an orthopaedic consultant (a doctor who specialises in the musculoskeletal system). We found that the majority of the communication with Mrs C had been reasonable, and that the advice she was given about MUA was reasonable. However, we found that consent process for the MUA was unreasonable, and that the communication around the second opinion had been poor. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the communication failings. 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 receive full and comprehensive information during the consent process and second opinion process.

Summary

Ms C complained about the care and treatment she received at St John's Hospital following breast surgery. In particular, that the board failed to listen to her when she asked for medication for the pain she was experiencing, failed to provide appropriate medication to address her pain and failed to appropriately recognise and act on seeing her red wristband for known allergies to certain painkillers.

We took independent advice from a consultant in general medicine and a senior nurse. We found that Ms C's records suggested medical and nursing staff had listened to her regarding her post-operative symptoms, made appropriate changes to her pain medication and provided a reasonable level of care. We also found that staff were aware of Ms C's allergies and acted appropriately. We considered that Ms C's care was reasonable and did not uphold her complaint.

Summary

Mrs C complained about the care and treatment her late son (Mr A) received when he was admitted to the Western General Hospital. Mr A had duchenne muscular dystrophy (a genetic disorder characterised by progressive muscle degeneration and weakness) and an associated heart condition and was admitted to the hospital with abdominal pain and swelling. He died in the hospital a week after he was admitted.

We took independent advice from a consultant general surgeon and a nurse. We found that it had been reasonable to admit Mr A to a surgical ward. He was examined by a surgical registrar and the on-call medical registrar which was an example of good care. However, we found that there had been a number of failings in the care and treatment provided to Mr A. In particular that:

• he should have been treated by a multi-disciplinary group of consultants, including a cardiologist (a doctor who specialises in the study or treatment of heart diseases and heart abnormalities);

• it was unreasonable for a consultant from the hospital's ventilation service not to take appropriate steps to evaluate Mr A when they were informed of his admission;

• it was unreasonable not to record Mr A's fluid intake/output;

• staff failed to act appropriately on an abnormal CT scan;

• staff unreasonably failed to reconsider the diagnosis of kidney infection;

• it was unreasonable for a junior doctor to propose discharging him;

• communication between general surgery and urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system) was poor;

• no moving and handling assessment was carried out when Mr A was admitted to hospital; and

• no equipment was available for the safe movement and transfer of Mr A three days after he was admitted to hospital.

We upheld Mrs C's complaint about the care and treatment provided to Mr A, however, we found that it was highly likely that the outcome would have been the same for Mr A if these failings had not occurred.

Mrs C also complained that the communication with her family had been unreasonable. We found that whilst there was evidence of discussions with the family and of staff responding to their concerns, Mr A had complex needs and the family should have been involved in his care in a planned and collaborative way. There was no evidence of this. We found that there had been a lack of appropriate engagement with the family in the assessment and care planning for Mr A and that the communication with his family had been poor. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with reasonable care and treatment in the hospital and for the poor communication with her family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• The board should ensure that appropriate multi-disciplinary management is triggered when a deteriorating adult with duchenne muscular dystrophy is admitted to hospital.
• Patients identified as being at risk should have their fluid intake and output accurately monitored.
• The board should ensure that CT scans are acted on appropriately and that the diagnosis is reconsidered in the light of any new findings.
• Patients should be appropriately reviewed and discussed with a relevant member of staff before discharge is proposed.

Summary

Mr C was seeking a referral to children's Occupational Therapy (OT) services for an assessment. Mr C was told he was not eligible for this service as he was 17  and no longer attended school. He was asked to make a new referral for adult OT services. Mr C did this and was assessed but discharged as the OT decided that his needs would be best met by local services in a community setting. Mr C was unhappy about this and complained to the board. He made a further referral to children's OT Services at the same time as his complaint and was this time seen by the service. Mr C complained that the board failed to progress his referrals to OT in a reasonable manner.

Mr C had also highlighted that the NHS website states the children's OT service is for children aged 0-18 and, therefore, he should have been assessed by them from the outset. The board responded by initially reiterating that Mr C was 17  years old and not at school so was more suited for adult services. However, in subsequent responses to Mr C they clarified that the children's OT service only has standardised assessments from age 0-16. They also advised there is no set criteria but instead, a flexible approach is adopted depending on the patient's individual circumstances. They acknowledged that Mr C had not received a clear explanation about why he was referred to adult OT services and apologised for this failing.

We considered that there had been poor communication and mixed reasons given to Mr C for directing his referral and upheld his complaint. However, the board advised that they had taken steps to review the triage service (a process in which things are ranked in terms of importance or priority) for the OT department. This included staff phoning children or parents who made referrals to gather more information to help signpost or assess patients from the outset. Additional staff have had training to make these calls and the board advised that the data they had reviewed so far indicated this was a positive change to the process. As a result of the positive steps taken by the board, we made no further recommendations.