Health

Summary

Ms C, who is an advocacy and support worker, complained on behalf of her client (Mr A) regarding the care and treatment he received at the medical practice. In particular, she complained that the practice did not do more to assist Mr A in obtaining a clear diagnosis and appropriate treatment for his mental health difficulties. This included concerns that Mr A's repeated requests for cognitive behavioural therapy (CBT) were not actioned.

We took independent medical advice from a GP, who considered that the practice arranged appropriate referrals for Mr A to mental health services. They noted that the specialists involved in these clinics had shown reluctance to give a specific diagnosis. They observed from one of the clinic letters that a psychiatrist had suggested a CBT approach and, while this did not appear to have progressed, they said it was not the role of a GP to follow up treatment plans arranged by a separate specialty. The adviser concluded that the care provided to Mr A by the practice was reasonable. We accepted this advice and did not uphold this aspect of complaint.

As Mr A had moved to a new GP practice, the practice were only able to access his electronic records and not any older paper records. Ms C also raised concerns that the complaint was not fully investigated as all medical records were not accessed. The practice considered that they had enough information to respond to the complaint and the adviser agreed that sufficient records were accessible to enable a response to the concerns and queries raised. We concluded that the practice's investigation was reasonable and proportionate to the issues raised and we did not uphold this aspect of the complaint. We noted that the practice had failed to provide details of our office in their complaint response, but they acknowledged this and we were satisfied that this had since been appropriately addressed through the revision of their complaints handling procedure.

Summary

Mrs C complained to us about the care and treatment provided to her late husband (Mr A) at the Victoria Infirmary. Mr A had been referred to the board for investigation of macroscopic (visible) haematuria (blood in urine). Mr A had subsequently died from cancer of the bladder.

Mrs C complained that a discharge letter inappropriately referred to Mr A as having been treated for microscopic (non-visible) haematuria. We found that the letter did incorrectly say that Mr A had undergone a cystoscopy (a procedure to look inside the bladder using a thin camera) for microscopic haematuria instead of macroscopic haematuria. The board said that this had been due to a typing error. We upheld the complaint and recommended that the board apologise to Mrs C for this. However, we noted that the investigations that had been carried out where appropriate for a man presenting with macroscopic haematuria and that this typing error had not impacted on Mr A's care.

Mrs C also complained that the board failed to carry out a CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) at the time that Mr A underwent the cystoscopy. We took independent advice from a consultant urologist and we found that there had been no requirement at that time for the board to carry out a CT scan. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board's response to her complaint had incorrectly stated that there had been no subsequent contact between Mr A's GP practice and the hospital after Mr A's cystoscopy. Mrs C provided evidence which showed that the GP practice had phoned the hospital after Mr A's cystoscopy to report that there was still blood in Mr A's urine. We found that, in line with the relevant guidance, this should have prompted the board to request a CT scan at that time. However, we found that even if a CT scan had been carried out, it was unlikely that Mr A's outcome would have been significantly different. Due to the evidence we saw that there had been contact between the GP and the hospital, 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 the incorrect information on the discharge letter which inappropriately referred to microscopic haematuria. Also apologise for incorrectly stating in the complaints response that there was no subsequent contact from Mr A's GP practice after the cystoscopy. These apologies should be in line with SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• When a GP surgery contacts a hospital with additional information, it should be recorded and acted on.

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 unreasonably failed to provide him with appropriate dental treatment when he was held on remand in prison. He said that the board failed to x-ray his tooth and should have tried to save his tooth, rather than only offering tooth extraction. Mr C was concerned that the board advised him that, as an untried prisoner, he did not qualify for the same dental treatment as a convicted prisoner or a person who was not in prison.

We took independent advice from a dental practitioner. The adviser said that the board should have carried out an x-ray of Mr C's tooth as part of his dental treatment. They said that the board failed to discuss the risks and benefits of all treatment options with Mr C and record the discussion in the dental records. The adviser also said that the board should have offered to provide root canal treatment for Mr C's affected tooth, in accordance with the NHS Guidance. As a result of these failings, Mr C suffered intermittent pain from his affected tooth for a considerable period.

The adviser explained that the board were correct in their view that Mr C did not qualify for the same dental treatment as a convicted prisoner or a person who was not in prison. This was because the NHS Guidance indicated that an untried prisoner was entitled to some, but not all, of the NHS treatments available to a convicted prisoner or someone who was not in prison. However, we were concerned that it appeared that the board were not aware of the full range of treatment available to prisoners on remand. Given the failings identified, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for:
• failing to x-ray his tooth
• failing to discuss the risks and benefits of all treatment options with Mr C and record this discussion in the dental records
• failing to offer root canal treatment, in accordance with NHS Guidance.
• 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:

• In circumstances such as Mr C's, the board should x-ray patients' teeth.
• The risks and benefits of all treatment options should be discussed with patients and these discussions should be recorded in the dental records.
• Root canal treatment should be offered in cases such as Mr C's, in accordance with the NHS 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

Ms C, an advocacy and support worker, complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's daughter (Miss A) in the final months of Miss A's life. Miss A had Fanconi anaemia (a genetic disease that can lead to bone marrow failure and cancer) and had a complex medical history of complications following a bone marrow transplant. Miss A received treatment at the Beatson West of Scotland Cancer Centre over a number of admissions. She was treated for numerous health issues, including a bowel condition.

Ms C raised concerns that staff failed to inform the family of the severity of Miss A's bowel condition. We took independent advice from a consultant haematologist and from a registered nurse. We were unable to find evidence that staff had discussed with Miss A, or Ms B, the severity of Miss A's bowel condition. We concluded that communication with the family was poor and we upheld this complaint.

Ms C also complained that the board did not provide a reasonable standard of treatment during Miss A's final admission. We found that the treatment provided for Miss A was in line with the relevant guidance, but the advice we received was that no consideration appeared to have been given to the fact that Miss A was dying and needed palliative therapy to keep her comfortable. We found that this was unreasonable and we upheld this complaint.

Ms C also raised concern that the board did not make reasonable transport arrangements when Miss A was discharged on one occasion when she became unwell in the car of a volunteer driver. We found that Miss A was noted to be well prior to discharge, and that it seemed that she became suddenly unwell during the journey. We were satisfied that the transport arrangements in place were reasonable and we did not uphold this complaint.

Finally, Ms C complained that the board refused to admit Miss A on one occasion when Ms B called the hospital in the early hours of the morning. The advice we received noted that Miss A was advised to attend the clinic later that day, but to call back if she became more unwell. The adviser did not find evidence that admission was requested and considered that the board's advice in this situation was reasonable. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to communicate with Ms B and Miss A reasonably about the severity of Miss A's bowel condition and for the failure to provide palliative care and support to Miss A at the end of her life. 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 provided with any information on their condition that they want or need to know in a way that they can understand. This should be communicated in a way that is considerate to those close to the patient. Staff should be sensitive and responsive in giving patients and families information and support. Communication with patients and their family members should be documented.
• Patients who are approaching the end of their life should receive high-quality treatment and care that supports them to live as well as possible until they die, and they should be supported to die with dignity.

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 on behalf of her aunt (Mrs A) about the clinical treatment she received when she attended the emergency department at the Queen Elizabeth University Hospital following a fall. Ms C complained that the board failed to investigate and treat Mrs A's head injury and that the board unreasonably failed to diagnose a shoulder injury.

We took independent advice from a consultant in emergency medicine. We found that the board had not identified that Mrs A had fractured her shoulder. Prior to our investigation, the board had apologised for this and had taken action to address the error. We also found that, although an error had occurred in relation to identifying Mrs A's shoulder injury, overall the care and treatment she had received had been reasonable. In view of the failing to identify the shoulder injury, we upheld the complaint. However, as the board had accepted this failing and had already taken action to address this, we made no further recommendations.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) when he attended the out-of-hours primary care emergency centre at the Victoria Ambulatory Care Hospital. He was discharged home but a few days later was admitted to the emergency department of Queen Elizabeth University Hospital, where he was treated for a severe chest infection with possible underlying heart problems. After some hours Mr A's condition was considered to be near to death and it was indicated that he was suffering from aortic stenosis (a narrowing of the left ventricle of the heart, which can cause problems such as heart failure) and fluid on his lungs. Mr A was later transferred to the medical high dependency unit where he was reviewed and underwent numerous tests. He was then transferred to the intensive care unit, where he later died.

Mrs C complained to the board and when she remained unhappy with their response she brought her complaints to us. Mrs C complained to us that:

the assessment of Mr A at the out-of-hours service was unreasonable

the care and treatment provided to Mr A at Queen Elizabeth University Hospital was unreasonable

the communication with herself, Mr A, and the family during Mr A's admission was poor

the board failed to respond fully to her complaints.

We took independent advice from a nurse practitioner and from consultants in emergency medicine and cardiology. We found that Mr A had been reasonably and appropriately assessed at the out-of-hours service and we did not uphold this aspect of the complaint.

We found that it would have been better if Mr A had been seen and assessed by the cardiologist shortly after his admission to Queen Elizabeth University Hospital, rather than the cardiologist only speaking to the emergency medicine team on the phone, which is what had happened. A face-to-face assessment would have allowed for a better assessment, and for a discussion with Mr A and Mrs C about Mr A's symptoms, treatment and prognosis. We also found that opportunities were missed to keep Mrs C updated on Mr A's condition. As such, we upheld Mrs C's complaints about the care and treatment provided to Mr A, and about the communication with the family.

With regards to the board's complaints handling, we found that the board addressed all of the concerns that were raised with them. We were satisfied that the responses were provided promptly and with appropriate detail. We did not uphold Mrs C's complaint about the board's complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise that a cardiologist did not see Mr A sooner. The apology should meet the standards set out in the SPSO guidelines on an apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for missing opportunities to keep Mrs C fully updated on Mr A's condition.

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

• In cases of aortic stenosis, a cardiologist should assess and physically examine the patient as soon as possible.
• Relatives should be updated on their family member's condition and care.

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 his care and treatment over two admissions to the Royal Alexandra Hospital was inadequate.

Mr C had suffered from two separate incidences of a collapsed lung in quick succession. During the first admission, Mr C disputed the board's position that it had been reasonable to discharge him. During the second admission Mr C's condition worsened. An x-ray was requested and preparations were made for inserting a chest drain. There was then significant deterioration in Mr C's condition. The board accepted that Mr C could have died due to this deterioration. The board said that they did not believe a critical incident review (CIR) was appropriate in the circumstances. They said that Mr C had been suffering from a complex condition and that it was this, rather than any failings by staff, which had contributed to the deterioration. Mr C disputed this, and he disputed the standard of the nursing care he received. Mr C said his deterioration had not been noticed because he was not being monitored properly.

We took independent medical and nursing advice. The medical adviser said that the decision to discharge Mr C following his first admission was appropriate and was supported by the medical evidence. However, the adviser found that during Mr C's second admission there had been a failure by medical staff to identify that a chest drain had not been correctly inserted, which had contributed to his deterioration. It would therefore have been appropriate to conduct an CIR. The medical adviser noted that Mr C's condition could have deteriorated very quickly and it could not be assumed that the severity of Mr C's condition and deterioration was due to an absence of clinical observation. The nursing advice we received found that, aside from some acknowledged failings, the overall standard of care was reasonable. The board had accepted the nursing failings and had taken action to address them.

We found that the board should have conducted a CIR into Mr C's deterioration during his second admission, as this could have identified useful learning for staff. We also found that the board should provide evidence that it had followed through with the work it had committed to in order to address the nursing failings it had accepted had taken place. On balance, we upheld Mr C's complaint that the care and treatment provided to him across the two admissions had been inadequate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failings in his care, and for failing to carry out a critical incident review. This apology should comply with SPSO guidelines on making an apology.

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

• The board should review Mr C's second admission and his subsequent deterioration with the clinical staff involved. This review should include what action was taken to review the x-ray taken and the action taken on Mr C's subsequent deterioration. This review should also include evidence of the resultant learning or improvements.

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 on behalf of her husband (Mr A) about the care and treatment he received at the Institute of Neurological Sciences at the former Southern General Hospital. Mr A was treated for spontaneous intracranial hypotension (low fluid pressure inside the head) which is a condition that can be caused by the development of a leak of cerebrospinal fluid (a fluid found in the brain and spine that provides protection for the brain). Mrs C submitted three separate complaint letters to the board over a number of months. Her complaints related to the investigative procedures that were carried out in an attempt to locate the site of the leak, the care and treatment provided to Mr A, and the board's handling of her complaint.

We took independent advice from a consultant neurologist and a consultant neuro-radiologist. We found that an initial scan was not accurately reported which the board had identified themselves and apologised for. They also took steps to address the matter to prevent recurrence. Whilst we noted that this error caused some delay in Mr A's treatment, we did not consider that it had significantly affected his outcome given that the scan had not shown the actual site of the leak. In addition, we did not consider that a neuro-surgery referral was indicated because no definite site of a leak had been identified. We also considered that the type of scanning machine used was appropriate. We did not uphold this aspect of the complaint.

We did not identify any significant failings in obtaining Mr A's consent to another investigative procedure but considered that there should have been a record of a discussion with Mr A that there was a risk it could cause worsening headaches. We did not identify any concerns about the way in which the procedure was carried out and considered it was accurately reported. A further scan carried out a week later was also properly reported and Mr A received reasonable care and treatment afterwards. We did not uphold this aspect of the complaint.

In terms of the board's handling of Mrs C's complaints correspondence, we identified that there was undue delay in their final response which the board accepted and had apologised for. We found that the board had regularly updated Mrs C about the delays and explained the reasons for this. We identified that the board had given inaccurate information to Mrs C about requesting and agreeing extensions to the 20-working-day target for responding to complaints. We also found that the board should have explained in an earlier letter to Mrs C that Mr A's initial scan was inaccurately reported, although they addressed this in later correspondence. We upheld this aspect of the complaint. The board explained that they had already taken action to prevent these issues from arising again in the future, and we requested that they send us evidence of this.

Summary

Mr C complained that, following his discharge from hospital, his medical practice unreasonably failed to contact him for more than 48 hours, and unreasonably failed to carry out a home visit despite his request for one. The practice responded to his complaint by apologising for any lack of care which Mr C felt he had received, but explained that the discharging unit at the hospital usually take responsibility for co-ordinating with community care and district nursing teams. They also noted that where there was a medical need for immediate post-discharge medical input, hospital clinicians would usually communicate this directly to the practice. We noted that Mr C requested a home visit when on the way home from hospital by visiting the practice and dropping off a letter.

We took independent advice from a GP adviser. The adviser reviewed Mr C's medical records and said there was no indication that a house visit was necessary, as it appeared that Mr C was able to attend the practice for an appointment. The adviser also noted that the decision whether or not to offer a home visit lies with the clinician, and should be based on clinical need. The adviser confirmed that it is not routine practice for GPs to contact patients who have been discharged from hospital once they have returned home, although they may do so following a review of the patient's discharge medication and history. The adviser noted that in this case the practice had reviewed Mr C's medication and history and contacted him by phone within 48 hours of his request and considered this reasonable.

The adviser also commented that if there was a clinical need for contact from the GP, this would have been detailed on the discharge letter from the hospital. There was no request for contact in Mr C's discharge letter. It was unfortunate that reception staff at the practice did not make clear to Mr C that home visits would only be carried out on the basis of clinical need, and by phone request on the day. However, we were satisfied that the evidence suggested that a home visit was not required, and that the time taken by the practice to contact Mr C following discharge was reasonable. We did not uphold this complaint.

Summary

Mrs C complained that the board failed to care for her in a sensitive manner at Aberdeen Maternity Hospital after she had a miscarriage. Mrs C said that she had found staff to be lacking in empathy. There had also been some confusion in relation to the forms which required to be completed to confirm her wishes for disposal of the foetal remains. Mrs C said that she understood that she had completed the forms required and that she would not be contacted again unless there was any foetal abnormality, but she was contacted a couple of days later and asked to return to the ward to complete another form. Although Mrs C had stated her wish for the cremated remains to be scattered without her being present, she then received a phone call several months later advising that the ashes were ready to be collected.

We took independent advice from a nursing adviser, who noted that the board's correspondence with Mrs C had been poor, and that their apology in their response to her complaint had fallen short of a reasonable standard. We found that, although the board had apologised for some of the failings in Mrs C's care, they had failed to address all of the questions she had raised with them. We upheld Mrs C's complaint. We noted that the board had changed their processes in relation to recording patients' wishes about foetal remains, so we did not make any recommendations in this regard. However, we did recommend that the board re-issue an apology to Mrs C that is in line with SPSO guidance on apology.

Recommendations

What we asked the organisation to do in this case:

• The board should re-issue an apology for the failings identified. The apology should comply with the SPSO guidance on apology.

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.