Health

Summary

Mrs C complained about the care and treatment provided to her late mother (Ms  A) at Woodland View. Ms A was transferred there for rehabilitation after several weeks in hospital, where she was treated for recurrent urinary tract infections (UTIs), and delirium. Ms A suffered further UTIs and did not make progress with her medication. She was transferred to a mental health ward for treatment of her delirium, low mood and physical symptoms. Ms A also had a background history of bipolar disorder (a mental health condition marked by alternating periods of elation and depression). Ms A's condition deteriorated further and she was transferred back to hospital with aspiration pneumonia (a  type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). She was given palliative care and died in hospital.

Mrs C complained that there was inadequate care planning to manage Ms A's delirium and UTIs. She felt staff focussed on Ms A's age and bipolar disorder as an explanation for her condition and did not fully appreciate the impact of the UTIs and delirium. Mrs C was also concerned about the way the hospital and ward transitions were managed, and about Ms A's overall care and treatment. Mrs C said she was not involved in care planning and decisions, despite being Ms A's carer and welfare power of attorney, and she felt some nursing staff were hostile or resistant when she made suggestions for Ms A's care. The board met with Mrs C when she first complained (during Ms A's admission) and a number of actions were agreed, but Mrs C said these were never completed. The board also gave a written response to Mrs C's later complaint (following Ms A's transfer back to hospital). Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a mental health nurse. We found there was a lack of proactive care planning for Ms A's UTIs and delirium at times, and Ms A had also had an untreated UTI for about ten days. While we did not find evidence that staff were hostile or lacked compassion, we found that Mrs C was not always included in care planning for her mother, and there were not always clear and comprehensive records of communication. We also found that the board did not have evidence to show they had fully followed through on some of the actions agreed at the complaint meeting. We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in care planning, communication and complaint handling. 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:

• Where a patient suffers from recurrent urinary tract infections and/or delirium, there should be dedicated care planning to address this (and this should be carried over where a patient changes wards).
• The patient's carer or welfare power of attorney should be fully and proactively involved in care planning.

In relation to complaints handling, we recommended:

• Any actions agreed following a complaint should be completed.
• Where a complaint investigation finds that errors or failings have occurred (although not in relation to the specific complaints raised), the board should still acknowledge and apologise for this.

Summary

Mr C attended University Hospital Crosshouse after sustaining a tear in the anterior cruciate ligament (a ligament in the knee) and damaged cartilage (connective tissue). Mr C complained that the board took too long to provide appropriate treatment following a referral from his GP, failed to provide a reasonable standard of treatment and failed to communicate reasonably with him about his condition and treatment.

In relation to the treatment time, we found that the board had breached the treatment time guarantee of 12 weeks and considered that this was unreasonable. We upheld this aspect of Mr C's complaint.

In relation to Mr C's treatment, we took independent advice from a consultant orthopaedic surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system). We found that the original injury Mr  C sustained to the knee appeared to be significant but that he had also sustained further injury to the knee while waiting for surgery. However, no updated scan of Mr C's knee was performed and the first time that Mr C was examined by the surgeon under the anaesthetic was when the situation was found to be more complex. The surgery did not proceed and Mr C required to be referred to another specialist for surgery. We considered that there was a failure to provide Mr C with a reasonable standard of treatment and upheld this aspect of his complaint.

Finally, we found that the board could have been more proactive about communicating with Mr C and should have ensured that their response was mindful of the relevant legislation and guidance. Therefore, we considered that the board failed to communicate reasonably with Mr C and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide him with treatment within a reasonable time, to consider obtaining an updated scan, to examine him prior to the surgery and to reasonably communicate with him about his clinical condition and treatment. 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:

• Treatment should be provided within the 12 week treatment time guarantee. All staff should understand the legislation and guidance on the waiting time guarantee.
• Patients should receive appropriate and relevant scans and be reviewed/examined as appropriate prior to surgery.
• Identify any training needs to ensure staff fully understand the treatment time legislation and guidance, and its application.

Summary

Mrs C complained about the medical and nursing care and treatment provided to her late mother (Mrs A) at Royal Alexandra Hospital. Mrs A was admitted to the hospital from her nursing home and was treated for a urinary tract infection. She was discharged home, but returned to hospital a few days later. A scan showed that Mrs A had suffered a brain haemorrhage (bleed in the brain) and she was started on end-of-life care. About a week later, nurses noticed bruising on Mrs A's hip, and she was found to have suffered a hip fracture. Mrs A continued on end of life care for about three weeks before she died in hospital.

Mrs C felt that doctors did not treat Mrs A immediately when she first attended hospital, and she was unhappy that staff had instead asked the family what level of treatment they would prefer for Mrs A. Mrs C also felt that Mrs A was discharged too early. Mrs C raised concerns about the hip fracture; querying how this could have happened and why it was not discovered earlier by staff. Finally, Mrs C was concerned that Mrs A was kept on end-of-life care for an extended period of time without fluids or sustenance.

We took independent advice from a consultant in general medicine and from a nurse. We considered that it was appropriate for staff to discuss the level of treatment the family wanted for Mrs A when she was first admitted, and that this did not impact on the promptness or thoroughness of her treatment. We also did not find failings in the end-of-life care.

However, we found that staff had failed to establish Mrs A's normal level of functioning (known as baseline level of health) and therefore failed to adequately investigate her deterioration before discharging her. We found that staff should have done more to find out Mrs A's baseline level of health and that this may have alerted them to the fact that she was not back to normal when she was discharged.

We also found that Mrs A had been discharged without thickened liquids that had been prescribed.

Whilst we noted that the board had apologised for the hip fracture, which had probably occurred in the hospital, we found that they had not investigated the cause of the unexplained fracture at the time it was reported.

We upheld Mrs C's complaints about the medical and nursing care provided to Mrs A.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to establish Mrs A's baseline level of functioning and for failing to adequately investigate her deterioration. Also apologise for discharging Mrs A without the thickened liquids prescribed to her and for failing to promptly investigate the cause of Mrs A's hip fracture. 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:

• Where a patient is unable to communicate, staff should clearly document their normal level of functioning, based on information from their family and/or carers.
• Prescribed dietary products should be provided on discharge or available within a few hours.

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 care and treatment provided by the ambulance crew who attended to her husband (Mr A). Mrs C had called an ambulance in the early hours of the morning as her husband was unwell. The crew examined Mr A and told Mrs C that they were not going to take Mr A to hospital, but that she should contact her GP for a home visit when the medical practice opened later that morning. A GP made a home visit and found Mr A to be disorientated and confused, which had been mentioned by Mrs C in her phone call to the ambulance service. The GP arranged for Mr A to be taken to hospital for further assessment and it was later diagnosed that he had suffered a stroke. Mrs C felt Mr A should have been taken to hospital by the ambulance crew.

We took independent advice from a clinician involved in the training of paramedics and concluded that the ambulance crew had failed to adequately record Mr A's symptoms and that he should have been transported to hospital for further clinical assessment. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failure to adequately record Mr A’s symptoms and for failing to transport him to hospital for further assessment and investigations.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:

• The ambulance crew should be competent to adequately record the patient’s full symptoms and be aware of the need to transport patients to hospital for further assessment.

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

Mr C complained about the way in which the ambulance service handled him after he had a seizure and fell at home, injuring his lower back. Mr C was concerned about the lack of assistance he received from the ambulance crew before they took steps to immobilise his spine and transfer him to hospital. It was later established that Mr C had sustained two fractures of his spine.

We took independent advice from a consultant in emergency medicine. Given that there had been restricted space in the room that Mr C had fallen, together with a number of factors that made it unlikely that he had sustained such fractures, we considered that it was reasonable of the ambulance crew to have provided spinal immobilisation in an area with greater room to do so. However, we noted that there was no evidence of a clinical assessment of Mr C's back and neurological function, nor evidence of a risk assessment prior to the decision to move Mr C. We considered that the assessment of Mr C was unreasonable and upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of clinical assessment of his back and lower limb neurological function. 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:

• Where a patient has potentially sustained a spinal injury staff should carry out a full clinical assessment and risk assessment prior to making decisions about moving and handling the patient. The assessments should also be clearly documented.

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

Mr C complained that NHS National Services Scotland’s practitioner services division (PSD) had changed his Community Heath Index (CHI – a ten digit number that identifies a patient in the NHS in Scotland) number without his permission. PSD had given Mr C a new CHI number in order that his results from a national screening programme could be recorded on the relevant database. Mr C was unhappy with this and complained that he did not want to be part of the national screening programme. He asked that the new CHI number was deleted. PSD agreed to do this.

We found that, ideally, PSD should have discussed the matter with Mr C before they changed his CHI number. We also found that PSD had apologised to Mr C for any distress or upset that had been caused. However, Mr C’s complaint was that PSD unreasonably made changes to his CHI number without his permission. We found that PSD were not required to seek Mr C’s permission to make changes to the CHI number. Therefore, we did not uphold this complaint.

Mr C also complained that PSD had failed to ensure that correct information was applied to the new CHI number. He said that PSD had entered a previous GP practice on his record. However, the evidence that PSD sent us showed that the correct details had been recorded for Mr C. There was no evidence that incorrect information had been recorded and we did not uphold this aspect of his complaint.

Finally, Mr C complained that PSD’s response to his complaint had been inaccurate. We found that part of the response had been inaccurate and we upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the response to his complaint included inaccurate information. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-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

Mrs C was referred by her GP to the orthopaedic department (the area of medicine which deals with the musculoskeletal system) at Ninewells Hospital for consideration of knee replacement surgery. However, there were problems with the communications from the board which resulted in her missing a scheduled out-patient clinic appointment. Mrs C questioned this with the board and she was told that arrangements had been made to reschedule the clinic appointment. However, she was then told that the rescheduled appointment had been cancelled and that the consultant had carried out a virtual assessment of the symptoms reported by the GP, and had subsequently discharged her. Mrs C complained that it was unreasonable that she had been discharged from the orthopaedic clinic without a face-to-face consultation.

We took independent advice from an orthopaedic consultant. We found that, on occasions, it can be appropriate for clinicians to carry out virtual assessments based on the information provided from the GP referral and that, in Mrs C's case, it was reasonable to discharge her from the clinic without a face-to-face consultation. We did not uphold the complaint. However, we were critical of the letter sent to Mrs C by the consultant as it did not contain sufficient advice as to what alternative options could be considered, and we fed this back to the board for their consideration.

Summary

Ms C complained that the care and treatment she received from her medical practice was unreasonable. Ms C said that she called the practice for an emergency appointment because she was experiencing extreme pain, and that it was only after she called a number of times that she was given an appointment. She was diagnosed with a vaginal swelling, given antibiotics and advised what to do should her condition worsen. Ms C was seen again at the practice the next day, when it was decided that she should be admitted to hospital. Ms C complained that there had been a delay in offering her a GP appointment, and that she had been incorrectly treated with antibiotics rather than referred to hospital.

We took independent advice from a GP adviser. We found that Ms C was given an appointment within a reasonable time. We also found that it was in accordance with General Medical Council good practice advice that she was given antibiotics and advice in the first instance. We did not uphold the complaint.

Summary

Mrs C complained about the care and treatment which she received during her pregnancy at the Royal Infirmary of Edinburgh. She had attended for a check-up where her baby's heartbeat was checked and blood tests were taken. Mrs C said that a nurse said that she might have an infection, but sent her home without medication. Mrs C then developed acute back pain and returned to hospital where she was admitted. Mrs C's condition deteriorated and she developed abdominal pain and was placed on a monitor. There were signs of fetal distress and it was decided to proceed to caesarean section (an operation to deliver a baby involving cutting the front of the abdomen and womb) where her baby was born. Mrs C then suffered a massive bleed and a hysterectomy (a surgery to remove the womb) had to be performed. Mrs C complained that there had been a delay in deciding to proceed to caesarean section and that antibiotics should have been prescribed earlier which would also have stopped her suffering from sepsis (a blood infection).

We took independent advice from a consultant obstetrician (a doctor who specialises in pregnancy, childbirth and a woman's reproductive system) and we found that Mrs C had received a reasonable standard of care and treatment. We found that staff adopted a conservative approach initially to establish if Mrs C would be able to deliver naturally and they kept her under observation. When it became clear that there were signs of fetal distress then it was appropriate to move to a caesarean section. There was no evidence of any delay and the caesarean section was carried out to an acceptable timescale. There was also no evidence that antibiotics should have been administered to Mrs C at an earlier stage and they were provided when she showed symptoms of infection. We also found that, when it was realised that Mrs C had suffered a bleed, staff acted appropriately in accordance with the national guidance that in such cases staff should resort to hysterectomy sooner rather than later. While we noted that the decision to proceed to hysterectomy appeared to be taken by a single consultant, it would have been normal practice to have a discussion with a senior colleague if appropriate. That said, the decision to proceed to hysterectomy was appropriate and completed in a timely manner. We did not uphold the complaints.

Summary

Miss C complained about the care and treatment provided to her by the board. She complained that the board did not identify that she had an anal fissure (cut or tear in the tissue inside the anus) during an examination under anaesthetic. She also complained about the length of time she had to wait for that examination.

We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that it was reasonable that the board did not identify an anal fissure because it was in remission at the time of Miss C's examination under anaesthetic. However, we found that there was a delay in Miss C receiving the examination and that this exceeded the national waiting time standards. We considered that this was unreasonable given the amount of pain she was experiencing. We upheld Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the amount of time she had to wait to receive an examination under anaesthetic. 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 with a suspected anal fissure should be treated within national wait time standards and the board should consider mechanisms to allow patients with severe anal pain to be seen as soon as possible. The board should consider advising patients in a timely manner that they may not be seen within waiting time targets.

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.