Health

Summary

Ms C, who works for an advocacy and support service, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) when he was admitted to Dr Gray's Hospital. Mr A suffered from congestive heart failure and was admitted to the hospital due to feeling tired and unwell, having chest pain, weight gain, nausea and vomiting. Ms C complained that the medical care and treatment provided to Mr A was unreasonable, and that he was not discharged in a reasonable way.

We took independent advice from a consultant physician. We found that, whilst overall assessments of Mr A and the general care and treatment provided to him was of a reasonable standard, there were gaps in weight monitoring. We noted that the board had previously addressed this matter. We also found that the issue of Mr A's internal defibrillator (a small device implanted into the body used to treat abnormal heart rhythms) was not recorded as having been discussed when a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) was put in place, and that the general record-keeping around the DNACPR decision was poor. We upheld this aspect of Ms C's complaint.

With regards to Mr A's discharge, we found that it was not reasonable to discharge Mr A as he had only recently been changed from having his medicine administered intravenously (into a vein) to taking it orally, and he was still on supplemental oxygen therapy at the point of the discharge decision. The adviser was critical that these issues were not monitored further prior to Mr A's discharge. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to provide a reasonable standard of medical care and treatment to Mr A during his admission and for failing to ensure that Mr A was discharged in a reasonable way. 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:

• Discussions around de-activation of internal defibrillators should occur and be documented at the same time as discussions around DNACPR. DNACPR decisions should be adequately documented and should include the reason for the decision.
• Any switch from intravenous to oral medication should be checked to be effective, supplementary oxygen should be stopped and oxygen levels should be monitored prior to discharge.

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, who works for an advocacy and support agency, complained on behalf of her client (Mrs A) about the care provided by the practice following a phone consultation. The day following her discharge from hospital for heart bypass surgery, Mrs A called the practice for advice. A GP called her back a short time later and discussed medication with her. At this time, Mrs A reported a clicking sensation in her chest. The GP reassured her about this sensation and advised her to contact the practice again if she became more unwell. Mrs A's condition deteriorated later that day and she was admitted to hospital, where she was treated for an infection.

Ms C raised concern that the GP did not identify that Mrs A had an infection and felt that a home visit should have been carried out. We took independent advice from a GP adviser. Whilst they noted that the GP's clinical record of the consultation was brief, on balance, the adviser considered that the assessment and care provided was reasonable. We accepted this advice and we did not uphold this complaint.

Summary

Mrs C complained about the care and treatment that staff at Forth Valley Royal Hospital provided to her over a number of years.

Mrs C was seen by the board's consultant orthopaedic surgeon and elected to have knee replacement surgery. She experienced some pain and discomfort following the surgery, and was seen during this time by an orthopaedic nurse. Approximately three years later, Mrs C continued to experience pain and discomfort and was then seen by two additional consultant orthopaedic surgeons.

Mrs C raised concerns that the knee replacement surgery was carried out inadequately as she felt that the board had provided her with a knee prosthesis that was too small. She also raised concerns about the monitoring that the board provided following her surgery. She also complained about the level of care and treatment that the board provided when she was seen by consultant orthopaedic surgeons over the following years.

We took independent advice from a consultant orthopaedic surgeon. We found that there was no evidence from the records and x-rays that the prosthesis was the wrong size, or that there was any other error in the initial surgery. We noted that there is an inherent risk that surgery will result in a patient experiencing ongoing pain and difficulties, without this being caused by any failure in the surgery. We did not uphold this aspect of Mrs C's complaint.

We upheld Mrs C's complaint about monitoring. We found that there was evidence of Mrs C expressing pain and discomfort during her reviews with an orthopaedic nurse that should have led to her being reviewed by a consultant orthopaedic surgeon, or should have led to some communication from a consultant.

We did not uphold Mrs C's complaint about the subsequent care and treatment she received when she reported problems with her knee in the following years. We found that the documented views of the board's consultant orthopaedic surgeons were not unreasonable, and that the treatment provided was appropriate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in monitoring following her surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at 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 complained about the care and treatment that the board provided to her late brother (Mr A).

Mr A attended the emergency department at Forth Valley Royal Hospital. After performing an examination and taking blood tests, staff considered that he had gastroenteritis (inflammation of the stomach and intestines). Mr A returned the next day, and staff continued to feel he was suffering from a viral illness. Mr A was seen the following day by an out-of-hours GP. He was then admitted to the board's acute assessment unit, who performed a range of further tests. The tests were normal, and Mr A returned home. He was seen the next day by a further out-of-hours GP. Mr A returned to the board's emergency department the following day, and was again admitted to the acute assessment unit. Over the subsequent days, Mr A's condition deteriorated and he was diagnosed with carcinomatous meningitis (a type of cancer). Mr A died a number of days after his second admission to the acute assessment unit.

Mrs C complained that the board unreasonably delayed in diagnosing Mr A with carcinomatous meningitis. She also said that staff unreasonably discharged Mr A from the hospital on several occasions. Finally, she said that staff unreasonably failed to provide effective pain relief.

We took independent advice from a consultant in emergency medicine, an out-of-hours GP, and a consultant in acute medicine. We found that carcinomatous meningitis is a rare form of cancer that is aggressive and that it presented atypically in this case. We found that staff carried out appropriate investigations, and that it was not unreasonable for them not to identify the cancer at an earlier stage. We identified one delay in reporting an x-ray, although this did not appear to impact on the timescale for diagnosis. As such, we did not uphold Mrs C's complaint about an unreasonable delay in diagnosing Mr A.

Regarding Mrs C's complaint about the discharges, we found that staff had a reasonable basis for considering Mr A was suffering from gastroenteritis, and therefore, it was appropriate to discharge him. We did not uphold this aspect of Mrs C's complaint.

In relation to Mr A's pain relief, we found that this could have been managed better during Mr A's final admission. While we noted the board's concern to balance pain control with consciousness level, we considered that the dosage could have been adjusted to a more appropriate level. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the failings in pain control and the delay in reporting the x-ray. 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:

• X-rays should be reported promptly, to minimise the danger that results are missed.
• In similar cases, staff should effectively balance pain control with level of consciousness.

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 to her late mother (Mrs A) at Forth Valley Royal Hospital. Mrs A was admitted to the hospital following a collapse at home. During her admission, she fell and sustained serious injuries. Mrs C believed that the fall in hospital contributed to Mrs A's death a few days later, and that healthcare professionals failed to take appropriate action to minimise the risk of Mrs A falling, particularly in light of her complex medical history. Mrs C also raised concerns about complaints handling issues, including a failure to respond thoroughly and a delay.

We took independent advice from a nursing adviser who specialises in falls prevention and a medical adviser who specialises in acute medicine. We found that, while there was evidence that nursing staff had highlighted Mrs A's risk of falling and had put in place a number of interventions to address it, there were shortcomings in this. Mrs A's condition deteriorated shortly before her fall and we found that a further review of her needs should have been carried out then. We also found that, in the lead up to the fall, the amount of time that Mrs A was left on a commode with little supervision was excessive. Having said that, the advice we accepted was that the fall did not directly lead to her death. On balance, we upheld this aspect of Mrs C's complaint.

With regards to Mrs C's concerns about complaints handling, we found that the board's investigation was thorough and their position that they could not give Mrs C a definitive account of how Mrs A fell because nobody saw it was reasonable in the circumstances. However, we upheld the complaint because the time it took the board to respond to Mrs C was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to take all reasonable steps to minimise the risk of Mrs A falling.
• Apologise to Mrs C for failing to deal with her complaint within a reasonable timescale.

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

• All reasonable steps should be taken to minimise the risk of patients falling.

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

Miss C complained about the dental care and treatment provided to her after she was diagnosed with gum disease. She complained that the dentist did not offer to refer her to a specialist for treatment, and instead recommended that she have her teeth professionally cleaned every three months. Miss C also complained that the dentist had not taken x-rays to assess for bone loss in the four years since she was diagnosed with gum disease. Miss C felt that as a result of the dentist's ineffective treatment of her gum disease, her condition had become worse.

We took independent dental advice. We found that whilst the treatment provided by the dentist to Miss C was reasonable in some respects, we found that they had not offered Miss C the opportunity to see a specialist for her gum disease when she was first diagnosed. We also found that the dentist had failed to follow guidelines with regards to charting the progression of the gum disease. We further found that the dentist had failed to record basic periodontal examination (BPE) scores, which according to the relevant guidance should be recorded at every appointment. We also found that the dentist failed to follow good practice and take radiographs when Miss C's BPE score was four (any score of four or above is considered to require monitoring and/or treatment). On this basis, we upheld Miss C's complaint.

Miss C also complained that the dentist did not reasonably respond to her complaint. We found that the complaint response did not tell Miss C that she could bring her complaint to us if she remained dissatisfied. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to provide her with appropriate dental care and treatment for her gum disease.
• Apologise to Miss C for failing to respond reasonably to her complaint.

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

• When appropriate, offers to refer should be made. The offer and the response should be recorded.
• Charting should be carried out annually for patients who have undergone periodontal treatment.
• BPE scoring should be undertaken at least annually for all patients, in line with guidance.
• Radiographs should be taken for patients with a BPE score of four, in line with good practice.

In relation to complaints handling, we recommended:

• Complaint responses should include details for the SPSO.

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 that the board unreasonably made changes to the arrangements for her to see the board's community psychiatric nursing (CPN) service. She said that her appointments with the CPN service had been changed from weekly to once every three weeks and that the appointments were held in a hospital rather than at her home. We took independent advice from a mental health nurse. We found that the board did not adequately listen to Ms C and did not take her views into account when it was decided to make these changes to her appointments. We upheld this aspect of Ms C's complaint.

Ms C also complained about the care she had received from the CPN service. We also took independent advice from a mental health nurse on this aspect of the complaint. We found that the care Ms C had received had not been of a reasonable standard. Ms C said that she had left messages on the service's answer machine, but that no one had called her back. The board's response to Ms C's complaint referred to restrictions in relation to the frequency of her phone calls, but there was no care plan or documentation within the case notes that outlined what these restrictions should be. We found that a care plan or protocol should have been in place to manage phone communication with Ms C, which could then have been followed by any member of staff. We also found that the board had failed to respond to correspondence from Ms C's GP and had failed to keep the GP adequately informed about her care. In light of these failings, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not adequately listening to her and for not taking into account her views when it was decided to change her CPN appointment arrangements. Also apologise for the failings in CPN care 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.
• Arrange a discussion with Ms C about her needs and wishes. A care plan should be created which reflects these. A mutually suitable location for visits should also be agreed between Ms C and a member of the CPN team. If Ms C does not wish to engage with this process, a care plan should still be created to guide the interventions of the team and this should be shared with Ms C.
• The care plan referred to above should be put in place and within it there should be:
• risk assessments
• agreements on phone use and any limitations around this
• what can reasonably be expected in terms of return of any messages left for staff to ensure no misunderstanding
• the frequency and location of visits
• identification of goals
• any psychological therapies.

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

• To ensure that care is provided to a reasonable standard, the pathway and available interventions for people with Ms C's conditions should be reasonable, evidence-based and appropriate. The board should ensure that staff are implementing them appropriately.
• To ensure that care is provided to a reasonable standard, the arrangements for clinical and case load supervision of CPNs should be adequate and should enable staff to reflect upon their performance and discuss individual cases in depth.
• There should be regular and timely communication of any changes to care to relevant GPs and other health care providers who are part of the wider multi-disciplinary team.

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 on behalf of his wife (Mrs A). Mrs A had undergone a colonoscopy (a procedure to examine the inner lining of the large intestine) at University Hospital Crosshouse and, during the procedure, a complication had occurred which caused a perforated bowel. As a result of the perforated bowel, Mrs A had to undergo emergency surgery and she spent time in an intensive care unit. Mrs A required a temporary colostomy (a surgical procedure where an opening is formed in the abdomen). Mr C complained that the colonoscopy was not carried out to a reasonable standard.

We took independent advice from a consultant general and colorectal surgeon. We found that a colonoscopy was the appropriate and recommended procedure in Mrs A's case, taking into account her existing medical conditions. We also found that the doctors involved in the colonoscopy had the relevant experience and were suitably qualified to carry it out. The board said that the perforated bowel was a recognised complication and risk of the colonoscopy. They also said that when the perforation occurred it was quickly recognised and prompt and appropriate action was taken. The board had apologised for the complication that had occurred, and had set out the action they had taken to improve clinical safety.

Taking account of the evidence and the independent advice we received, we did not uphold Mr C's complaint. However, we did ask the board to provide us with evidence of the action they said they had taken, and we made a recommendation to the board with a view to encouraging learning from this complaint.

Recommendations

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

• Where serious incidents occur in colonoscopy procedures, they should be reviewed at least quarterly.

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 care and treatment provided to her late father (Mr A), who had bowel cancer. She complained that there was an unreasonable delay between a referral being made by Mr A's GP and his treatment starting at Ninewells Hospital. Ms C also complained that the care and treatment provided to Mr A in Ninewells Hospital was unreasonable. She raised further concerns that the standard of communication between the board and Mr A and his family was poor. Finally, Ms C complained that the board's handling of her complaint was unreasonable.

We took independent advice from a consultant gastroenterologist and a consultant colorectal surgeon. We found that there was an unreasonable delay between the referral by Mr A's GP and his treatment starting at the hospital. Mr A's GP had made a routine referral to the board's colorectal service and we found that this referral should have been reprioritised by the board as urgent because Mr A had high risk symptoms. In view of this, we upheld this aspect of Ms C's complaint.

Mr A had elective right hemicolectomy (removal of the right side of the large bowel through keyhole surgery). Four days after this, he returned to theatre for emergency surgery. Following this surgery Mr A was transferred to the intensive care unit (ICU), where he died the following day. We found that the surgery and the care Mr A received in the ICU had been reasonable. However, we found that there was an unreasonable delay in starting Mr A on antibiotics when his condition deteriorated in the ICU. We were also concerned that the frequency of consultant review following Mr A's surgery was not in line with published good surgical practice standards. We also found that the standard of record-keeping was unreasonable, particularly as there were gaps in the medical records. In light of this, we upheld this aspect of Ms C's complaint.

We found that the communication with Ms C, Mr A and the wider family about Mr A's care and treatment had been unreasonable. We further found that the consent for the initial surgery was not obtained in line with guidance from the Royal College of Surgeons. As such, we upheld Ms C's complaint.

Finally, the board accepted that the handling of Ms C's complaint had been unreasonable and said that they had taken action to improve their complaints handling. In view of the failings identified, we upheld this aspect of Ms C's complaint, but did not make any recommendations about this as the board had already taken action.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• the unreasonable delay between the referral to the board and the commencement of treatment
• the unreasonable care and treatment provided to Mr A
• the unreasonable communication and poor complaints handling.

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

• Referrals to the colorectal service from GPs should be appropriately validated to ensure that patients with high risk symptoms are prioritised. In order to facilitate this, the referral form for GP referrals to the colorectal service should ensure the proper documentation of details of symptoms, such as the extent of weight loss and anaemia.
• Appropriate action should be taken in the event of deterioration of a patient, especially in the event of a rise in early warning signs. Antibiotics should be administered in line with the board's observation chart.
• In-patients should be reviewed by a consultant surgeon (or equivalent), in line with the published good surgical practice standards.
• Surgeons should obtain the patient's consent in the pre-operative clinics, as per guidance from the Royal College of Surgeons. Patients should be provided with a copy of the consent form for reference and reflection at that time.
• Patients and/or their relatives should be kept fully informed after critical illness events.
• Medical staff should maintain reasonable medical records, in line with General Medical Council 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 complained to us that the Scottish Ambulance Service (the ambulance service) had delayed in responding to an alarm call made by her late mother (Mrs A). Mrs A lived in an assisted living complex and had made an alarm call to an alarm receiving centre (this was a private company that was not part of the ambulance service). She did not respond when the alarm receiving centre answered the call and they contacted the ambulance service. An emergency ambulance was dispatched to Mrs A's home, but it was then decided that this should be stood down and that another non-emergency ambulance would attend. On arrival at Mrs A's home paramedics found that she had died.

We took independent advice from a medical adviser, who is involved in the training of paramedics and who regularly works alongside them in the provision of pre-hospital care. We found that it had been reasonable for the ambulance service to cancel the emergency ambulance and to respond to the call using a non-emergency ambulance. This was in line with the agreed protocol and, as there was no information at that time to confirm that there was an urgent threat to life, we found that the time taken by the ambulance service to respond had been reasonable. The advice we received was that the risk of ambulances responding to calls using emergency blue light driving conditions for calls which turned out not to be life-threatening emergencies had to be taken into account. We did not uphold the complaint.