Health

Summary

Miss C was told by dental staff that she would require dental braces. She was subsequently told by orthodontic staff that she would not be provided with braces and she was discharged from the service. Miss C complained that the board failed to provide her with appropriate dental care.

We took independent advice from an orthodontics adviser who explained that the assessment criteria to consider whether a patient qualifies for orthodontic treatment funded through the NHS is covered by the Index of Orthodontic Treatment Need (IOTN). It would be expected that an orthodontics practitioner would provide a grade of IOTN which would substantiate their decision as to whether or not the criteria had been satisfied. We found that in Miss C's case the orthodontic staff had assessed her on a number of occasions as having a low IOTN, which was a reasonable judgement for them to make and had indicated that they had considered the IOTN criteria. As such, Miss C would not have qualified for orthodontic treatment and so we considered that the dental care provided had been appropriate. We did not uphold the complaint.

However, we did note that there was a failure by orthodontic staff to record the actual IOTN grade in the dental records, and so we made a recommendation in relation to this.

Recommendations

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

• The staff should be aware of the requirement to record the IOTN category in order to substantiate whether the criteria for providing orthodontic treatment has been met.

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 attended his dentist over a period of months for treatment for severe tooth pain. The dentist extracted one tooth and referred Mr C to the dental hospital to have a second tooth extracted. When Mr C attended the hospital, they identified a number of issues regarding his teeth. Mr C complained that his dentist had failed to provide the appropriate dental treatment and that, as a result, he had suffered with severe pain over a prolonged period of time.

We took independent dental advice. The adviser noted that the dentist did not keep adequate clinical notes in accordance with the guidance published by the General Dental Council. The dentist also did not appear to carry out some of the more basic investigations available for determining the cause of dental pain, and he did not report the findings of an x-ray he took of his Mr C's teeth, which is a requirement of the Ionising Radiation (Medical Exposure) Regulations (2000). We upheld Mr C's complaint and made recommendations.

Recommendations

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

• The dentist should consider the requirements for good clinical records as stipulated in the General Dental Council Standards and should consider the available guidance for good note taking.
• The dentist should consult Clinical Examination and Record Keeping Standards (FGDP RCS (Eng)), Key Skills in Primary Dental Care (FGDP RCS (Eng)) and the Management of Acute Dental Problems (SDCEP) for guidance on carrying out the more basic investigations available for determining the cause of dental pain and the treatments that are available.
• The dentist should make themselves aware of the requirements for reporting the findings of x-rays under the Ionising Radiation (Medical Exposure) Regulations (2000).
• The dentist should write up this incident as an Enhanced Significant Event Analysis and should include the incident as an agenda item in the next in-house dental practice team meeting so that learning can be shared among the practice.

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 care and treatment he received from the board in relation to his mental health whilst he was in prison. We took independent advice on the complaint from a consultant psychiatrist. We found that the care and treatment provided to Mr C had been reasonable. He had received mental health nursing reviews, a full psychiatric assessment and had also seen a number of other healthcare staff. The management of his medication had also been reasonable. Whilst there had been a delay in arranging for Mr C to see a psychiatrist, we found that this was not unreasonable. He saw other healthcare staff during this period and they discussed his care with the psychiatrist and put interim measures in place. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that staff in the prison health centre failed to provide appropriate treatment in relation to his cellulitis (an infection of the deeper layers of skin and the underlying tissue). We took independent advice on this aspect of his complaint from a GP adviser. There was no evidence in Mr C's medical records that he had cellulitis, although the records showed that he had been treated for scabies. We found that the care and medication provided by the board in relation to scabies had been reasonable and we did not uphold this complaint.

Finally, Mr C complained that the board had failed to respond appropriately to his complaints. We found that Mr C had made a large number of complaints. Whilst there had been some delays by the board in responding to these complaints, these delays had not been unreasonable. We considered that the board had issued a reasonable response to the issues Mr C had raised and did not uphold this aspect of the complaint.

Summary

Mrs C underwent a pubovaginal sling procedure (a surgical procedure used to manage urinary incontinence) and a cystoscopy (a bladder examination using a narrow tube-like telescopic camera) to address her stress incontinence. She was reviewed a few months later, and she reported a loss of sensation and significant distress about the appearance of her scars. She was referred to plastic surgery to see if anything could be done about the scarring.

Mrs C complained to the board about her treatment, and one month later she was advised that her complaint had been forwarded for investigation. Five months later Mrs C wrote to the board to raise concerns about the long wait for a response to her complaint. Upon receiving Mrs C's letter, the board discovered that her complaint had inadvertently been closed five months previously. Some weeks later, the board phoned Mrs C to explain that the complaint had been inadvertently closed and to discuss Mrs C's concerns about the delay in responding and her concerns about her treatment. The board then referred Mrs C to a different consultant urologist, and agreed that they would look into why the complaint had been closed. They also suggested that they would arrange an external review of the case, and they said that they would update Mrs C when they had further information. Despite phoning several times over a period of a further four months, Mrs C heard nothing from the board about her complaint. When she did manage to speak to the board again Mrs C asked to be sent a letter with the findings of the board's investigations. Mrs C did not receive a letter, and she then brought her complaints to us.

Mrs C complained to us about the medical treatment she received and the board's handling of her complaint. We took independent advice from a urologist. We found that the treatment that had been carried out was reasonable, and that it had achieved the outcome of restoring continence, even though there were some problems with loss of sensation. We found that Mrs C's scarring was considered to lie within the bounds of what can be seen following the types of surgery she had underwent. We did not uphold Mrs C's complaint about her treatment.

We were highly critical of the board's complaints handling. We found that there were delays, and that some of the board's communication with Mrs C about her complaint was misleading. We found that the board failed to investigate her complaint as agreed. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for closing Mrs C's complaint in error, for including misleading information in their communication with Mrs C and for failing to investigate her complaint as agreed. This apology should comply with SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints handling staff should ensure that complaints are not closed unless there is clear evidence that this is the correct course of action.
• Key staff should receive refresher training in complaints handling, in particular in relation to managing the expectations of complainants.

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 staff failed to communicate properly with him when he arrived at Hairmyres Hospital following his wife (Mrs A)'s admission with a suspected stroke. Mr C had told the paramedics who called at his home that he thought the time of onset for the stroke was about 02:00, when he heard Mrs A collapse. When he was with Mrs A in the emergency department, and subsequently on admission to a ward, no members of staff asked him for more information which may have narrowed the potential timing of the stroke. Mr C subsequently learned that thrombolysis treatment (medication to dissolve blood clots), which can limit the damage caused by a stroke, was available but has to be given within a certain timescale to be effective. Mrs A was not given thrombolysis treatment as the clinicians had deemed that there was insufficient information available which would have identified the potential time of onset of the stroke.

We took independent advice from an adviser in acute medicine. We found that, although the staff had taken into account the information provided to the paramedics, they missed the opportunity to question Mr C further as he may have been able to provide information which would have narrowed down the potential timings. The staff took the decision not to provide thrombolysis treatment without speaking to Mr C. We noted that even if they had obtained further information from Mr C it was possible that they may still have decided not to start the thrombolysis treatment. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate with him. 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 consider all available sources of information available before deciding whether or not to commence thrombolysis treatment.

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

Ms C complained about the medical practice on behalf of her five-year-old son. Ms C complained that the GP failed to diagnose her son's tonsillitis over the course of two appointments. Ms C told us that the GP should have diagnosed tonsillitis rather than referring her son to the paediatric team at a hospital in the board's area. The practice advised that, at the first appointment, the GP had been able to examine Ms C's son, despite him being upset. The GP did not observe any infection, and based on his symptoms, diagnosed Ms C's son with hand and mouth disease. At a second appointment, the GP examined Ms C's son. At this appointment the GP had not been able to take all of the measurements they had wanted to during the consultation. As a result, the GP felt that the diagnosis was unclear and referred Ms C's son to the paediatric team at the hospital. Ms C also complained that the GP refused to arrange an ambulance to transport her son to the hospital. The GP offered patient transport, however Ms C felt that this was not suitable as it would have taken too long.

We took independent GP advice. The adviser examined the records and confirmed that the GP examined Ms C's son in line with General Medical Council (GMC) guidance. The adviser confirmed that it was appropriate for the GP to refer Ms C's son to the hospital given that he was presenting with persistent symptoms. The adviser also confirmed that the GP's actions regarding transport to the hospital were appropriate as ambulances should only be used in an emergency. We found no evidence that the GP had failed to provide the appropriate clinical treatment. We did not uphold this complaint.

Summary

Mr C complained on behalf of his late brother (Mr A), who had been a patient at Monklands Hospital. Mr A went missing from the ward but staff failed to notice his absence for a period of several hours. Subsequently, Mr A died outwith the hospital premises a few days later. Mr C complained to the board about the care and treatment they provided to Mr A. His complaints related to observation, medication and shared accommodation on the ward.

In response to Mr C's complaints, the board carried out a significant adverse event review (SAER), which is a type of investigation designed to identify what, how and why a particular adverse event happened. The SAER concluded that ward staff had not observed Mr A properly in terms of their procedures and, therefore, his care fell below a reasonable standard. The review also found that, when Mr A's absence was established, staff did not properly share this information with each other and did not escalate the matter in a timely manner. As a result of the failings identified by the SAER, the board took action to address these issues. Mr C then brought his complaints to us.

We took independent advice from two clinical advisers. We found evidence to support that Mr A's medication was appropriately managed. In addition, his transfer from a single room to shared accommodation was reasonable. Although the board's SAER found that staff had not properly observed Mr A, we were critical that the SAER did not explore the reasons why this failing occurred. We were also concerned that the SAER did not identify evidence of poor recording-keeping by staff in terms of Mr A's medical and risk assessments. We considered that Mr A may have been at higher risk than what had been determined. Due to the poor standard of record-keeping we could not conclude for certain whether Mr A's observation level should have been increased. However, we considered that a greater awareness was required by staff. Whilst we noted that further steps had been taken by the board to address the failings they had identified, we recommended additional action to be taken to ensure these issues do not happen again.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the poor record-keeping and for the failings identified in relation to observations. 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:

• Standardised documents relating to medical and risk assessment should be completed properly.
• The board should ensure that adverse event reviews adequately identify all failures and the underlying causes of untoward events, in line with relevant guidance.
• The findings of this complaint should be fed back to relevant staff in a supportive way.
• Time off the ward should be properly documented and failure to return plans should identify when a patient fails to return to the ward.

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 to us that the board had failed to provide reasonable care and treatment to his late sister (Ms A) when she was admitted to Wishaw General Hospital. Ms A had injured her hip in a fall. Scans were carried out in the hospital to explore concerns that she may have fractured her pelvis. These scans did not show any obvious fractures and Ms A was discharged from hospital two days after her admission.

Ms A died several days later. A post-mortem was carried out and the cause of death was found to be deep vein thrombosis (DVT) resulting in pulmonary embolism (where a blood clot in the leg travels up and blocks one of the blood vessels in the lungs). Mr C complained that Ms A had not been given any medication to prevent this when she was discharged from hospital.

We took independent advice from a consultant trauma and orthopaedic surgeon. We found that a risk assessment for DVT should have been carried out when Ms A was admitted to the hospital ward, but that there was no evidence this had been done. Ms A's risk of DVT should also have been reviewed during her period of admission and this would have indicated that she was at increased risk of DVT.

We found that Ms A should have been prescribed medication to prevent DVT on the night she was admitted. There should also have been a documented discussion about whether she should receive this medication when she was discharged, although the records suggested that she had regained her full mobility at that time. A formal risk assessment for DVT when Ms A was admitted to hospital would have provided enough concern for her to be prescribed TED stockings (stockings that help to prevent blood clots) whilst she was a patient and also on discharge. Given these failings, we upheld Mr C's complaint, although we were unable to say whether or not adequate treatment would have prevented Ms A's death.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide appropriate care and treatment to Ms A. 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 admitted to hospital should be assessed for DVT risk in line with national guidance, appropriate treatment should be instigated and the patient's DVT risk should be routinely reviewed during their stay in hospital.
• Patients, particularly those admitted to an orthopaedic department, should be adequately assessed for their safety before discharge and the assessment should 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 the board did not obtain his consent to carry out a vasectomy (a procedure where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) at Hairmyres Hospital, as he said that he was not fully advised of the risks in advance. He also complained that his vasectomy was not performed appropriately, as afterwards he developed complications such as a blood clot and chronic pain.

We took independent advice from a consultant urologist. The adviser considered that Mr C was properly told about the risks of having a vasectomy in advance. However, the adviser said that Mr C should have been given or emailed an information leaflet, instead of being directed to a website for information about vasectomies. The adviser also considered that the consent form Mr C signed for the procedure should have included the need to use contraception until sterilisation (inability to reproduce) had been proven.

The adviser found that a highly unusual step was taken to complete the vasectomy. The adviser considered that it was not reasonable to do this without Mr C's specific consent, as it could have increased the risk of complications. Even if Mr C's consent had been obtained, the adviser considered that it would not have been reasonable to take this step, as it would not have made procedure easier to carry out. In addition, the adviser found a discrepancy between the typed and handwritten records of the procedure, which was of concern. The adviser also found that Mr C should have been given surgical stockings after the procedure to prevent deep vein thrombosis. We upheld both aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain appropriate consent from him and for failing to carry out the vasectomy to a reasonable standard. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients should either be given copies of the information leaflets or better guidance about how to find them, if they are directed to a website.
• The vasectomy consent form should tell patients to use back-up contraception (until they have provided enough semen specimens that are clear of sperm to confirm sterilisation has been achieved).
• Staff should ensure that more complex vasectomy cases are identified in advance of anaesthesia, so that additional or unusual steps can be planned with patient consent.
• All procedures should be appropriately documented in the medical records.
• The clinicians involved should reflect on the adviser's comments that it was not reasonable to take the unusual step that they did take to complete Mr C's vasectomy.
• Patients should be given surgical stockings to prevent deep vein thrombosis, unless it would cause the patient harm.

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, who is a solicitor, complained on behalf of his client (Mrs B) about the care and treatment provided to Mrs B's late brother (Mr A) during three admissions to Monklands Hospital in the months leading up to his death. Mr A suffered from alcohol liver disease and hepatic encephalopathy (a deterioration of brain function due to liver failure). Mr C complained that the medical care and treatment provided to Mr A was not of a reasonable standard, that the nursing care was unreasonable, that the communication with the family was poor and that the board failed to adequately investigate and respond to complaints.

Regarding medical care and treatment, the family were particularly concerned that Mr A had been discharged following his second admission when they felt he was not medically fit to be discharged. We took independent advice from a consultant physician and from a senior nurse. We found that Mr A's fitness was appropriately assessed at that time. We also found that, while on the whole Mr A received a reasonable standard of care and treatment, there were some failings in medical care and record-keeping. Specifically, we noted that a final discharge summary was not completed following Mr A's first admission, and that the actual date of discharge was not clear from the notes. We also found that, when Mr A suffered a fall overnight, he was not reviewed by a doctor until the following afternoon. The advice we received was that this review should have happened in the morning. We were also critical that, when this review did take place, the doctor who reviewed Mr A failed to document this assessment. The family had also expressed concerns about Mr A's weight loss and the board had said that this was due to deliberate fluid loss. Whilst we found that deliberate fluid loss was a factor, we considered that there was also a nutritional element that should have been acted upon sooner. In light of these failings, we upheld Mr C's complaint about medical care and treatment.

Mr C raised several concerns about the nursing care and treatment provided to Mr A. We identified that nursing staff had failed to make medical staff aware of a vomiting episode on the morning of Mr A's discharge following his second admission which, had it been shared, may have influenced the medical staff's thinking when assessing Mr A's fitness for discharge. However, we found that this appeared to be an isolated failing, which the board had already acknowledged and apologised for. The family had also been concerned that an appropriate package of home care was not in place for Mr A following his second discharge. We found that adequate arrangements were made, and we noted that responsibility for the delivery of these arrangements lay with social services and not the board. We did not uphold Mr C's complaint about nursing care.

In terms of communication, we found inconsistencies and a lack of clarity in the information conveyed to the family about the seriousness of Mr A's condition. We found that the language used may not have helped the family to fully understand that Mr A's illness was terminal. The family had also raised concerns that their repeated requests to speak to another consultant were not actioned. The board had noted that these requests did not appear to have been passed on, and they had agreed to implement a process to document requests for meetings with medical staff in the future. Overall, we concluded that the communication with the family was not of a reasonable standard and we upheld this complaint.

In relation to complaints handling, we considered that the board could have responded in more detail and could have provided clearer explanations in some instances. However, given the complexity of the complaint and the significant number of issues raised, we were satisfied that, on the whole, the board's response was reasonable and proportionate, and that considerable time and effort had been spent attempting to address the family's concerns. On balance, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the identified failings in relation to medical care and treatment, medical record-keeping and communication.

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

• Patient discharge dates should be clearly recorded in the clinical notes.
• Medical reviews should take place within a reasonable timeframe following patient falls.
• Medical reviews should be documented in patient records.
• Medical staff should ensure they remain aware of patients' nutritional status and take appropriate action to address any identified malnutrition.
• Consistent information should be provided, and clear language should be used, when communicating with patients and their relatives regarding the patient's condition and prognosis.

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.