Health

Summary

Mr C called 999 when his wife (Mrs A) became very unwell. A paramedic arrived five minutes later, and told Mr C that an ambulance would be on its way. However, the ambulance did not arrive for about half an hour, and only after the paramedic called to request back-up. During this time, Mrs A stopped breathing. The paramedic assisted her breathing and she recovered to some extent. However, after the ambulance arrived, Mrs A suffered a cardiac arrest. Staff carried out cardio-pulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops), which was successful at restoring her pulse. Staff transferred Mrs A to the ambulance and took her to hospital. While in the ambulance, Mrs A suffered a second cardiac arrest. Staff again began CPR, and this was continued until Mrs A was handed over to hospital staff. Hospital staff continued the CPR, but this was unsuccessful and Mrs A died in hospital shortly after her arrival. Mr C complained about the delay in the ambulance arriving and the lack of communication from ambulance service staff, including the way they handled his complaints.

The ambulance service upheld Mr C's complaints and apologised. They said there were opportunities to send an ambulance earlier, but these were missed. The ambulance service said they would discuss the communication complaint with the staff involved and senior managers would review their procedures to ensure that ambulance support is provided earlier in future. Mr C was dissatisfied with this response, and he brought his complaint to us.

We took independent advice from a consultant in emergency medicine. We found the delay in sending an ambulance was unreasonable, and a lack of clarity in the ambulance service's policies had contributed to this. However, we noted that the ambulance service have now updated their policies and adopted a new response model, which should prevent a recurrence of the failings in this case. We found the treatment of Mrs A's respiratory and cardiac arrests was appropriate. However, the clinical records were poor so it was not possible to determine whether the overall care and treatment was reasonable. We also found the ambulance service took an unreasonable time to respond to Mr C's complaint and did not provide a detailed explanation of the events, despite the investigating officer telling Mr C they would provide this. We upheld all of Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the poor records kept by the paramedic and ambulance crew as this poor record-keeping meant it was not possible to determine whether the overall care and treatment given to Mrs A was reasonable. This apology should comply with SPSO guidance on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Adverse incidents such as this should be reported and investigated through the ambulance service datix system (a system for tracking and reporting incidents).
• The Ambulance Control Centre dispatcher involved should reflect on and learn from Mr C's family's experience, with appropriate support.

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 to us about the care and treatment her husband (Mr A) had received from the board's evening district nursing service. Mrs C contacted us before we completed our investigation to say that she no longer wished to pursue the complaint, as the circumstances had changed. As such, we did not reach a decision on Mrs C's complaint.

Summary

Mr C complained about the care and treatment given to his grandmother (Mrs A), both at home and at Monklands Hospital, in the days prior to her death. He said that while Mrs A was at home, staff changed her opiate-based medication. He believed that Mrs A suffered withdrawal symptoms causing her to fall and he was unhappy that she had been persuaded to go to hospital when she had a long-standing wish to remain at home. He said that there was confusion after Mrs A's admittance and that her family were not kept informed of either her whereabouts or her condition. Mr C said that when the family were reunited with Mrs A, she was very distressed and wanted to go home. He said that the family were not told about Mrs A needing an ECG (electrocardiogram - a test to check the heart's rhythm), which caused her further distress. Following this ECG, and at the end of visiting time, Mrs A's family were asked to leave. Mrs A's condition deteriorated rapidly and she died. Mr C complained that he was not advised of the seriousness of his grandmother's condition and that her resuscitation status should have been discussed. He said the family were totally unprepared for her death and he was upset that Mrs A had died alone.

He complained to the board who acknowledged failures in communication but said that Mrs A's deterioration and death had not been anticipated. They explained the reasons why her resuscitation status had not been discussed and added that since Mr C's complaint, Mrs A's case had been discussed with staff and changes had been made to avoid a repetition of the situation for other patients under the board's care in future. Mr C remained dissatisfied and complained to us.

We took independent advice from a nursing adviser and from a consultant geriatrician. We found that the opiate-based medication Mrs A had been prescribed at home for her pain could have side effects, particularly leading to the increased risk of a fall. Her medication had been given a detailed review and changed in view of her presenting symptoms. While Mrs A's fall required her to be admitted to hospital, we found that this was more likely due to her slow heart rate and swollen legs rather than to her change in medication. We did not uphold the aspect of Mr C's complaint regarding changes to Mrs A's medication.

We found that Mrs A's resuscitation status was not discussed with her or her family at the hospital, although there was evidence that they had been ready to talk about it. We upheld Mr C's complaints about the failure to discuss resuscitation status and keep the family updated, and the failure to reasonably take account of Mrs A's wishes regarding this. However, we found that there was no indication that Mrs A was close to death, and that she was being actively treated for her slow heart rate which is considered to be a reversible condition. As such, we did not uphold Mr C's complaint about the board failing to recognise deterioration in Mrs A's condition.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to listen to the family when they were ready to talk about resuscitation. This apology should comply with 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:

• Staff should be reminded to inform family members about what is happening to their relatives.

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 his late wife (Mrs A) received from the board at Monklands Hospital. Mrs A was initially admitted to hospital for seven days, with concerns about her eating and her bowels not moving. She was discharged home for three days and received some medical treatment at home but was then readmitted to hospital. Mrs A died in hospital four weeks later. Mr C also said that the board withheld long-standing medication from his wife and that they failed to reasonably communicate with him during his wife's admission. Mr C explained that his wife had suffered a stroke previously, which impaired her ability to communicate.

We took independent advice from a consultant in general/stroke medicine and geriatrics. We did not consider that the board failed to provide reasonable care and treatment for Mrs A and did not uphold this part of the complaint. However, there were failings in the note-taking by hospital staff and we made a recommendation to address this.

The evidence suggested that Mrs A's medication was not prescribed for her during her second admission and that there was no clearly documented decision for this. We found that, as it was a long-standing medication and Mr C would have been well placed to judge the effect of this being withdrawn, the cessation of the medication should have been discussed with Mr C. We upheld this part of the complaint. We also considered that the board failed to reasonably communicate with Mr C during his wife's admission and we upheld this part of the complaint. We asked the board to provide evidence of the remedial action they said they had already taken in both of these areas.

Recommendations

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

• Staff should note details of conversations with patients' family members regarding patients' care and treatment in patients' medical records.

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 care and treatment provided to her late father (Mr A). Mr A attended the board's out-of-hours service at Monklands Hospital with throat pain and difficulty swallowing. He was seen by an out-of-hours nurse practitioner and an out-of-hours GP. An examination was performed and Mr A was not admitted at that time. Mr A's condition worsened the next day and he was admitted to the hospital where staff identified an abscess in his throat. Over the following days, Mr A had a number of operations and spent time in the intensive care unit (ICU). He was then discharged to the ear, nose and throat (ENT) ward. While on the ENT ward, Mr A suffered a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs) and died.

Miss C complained that the board's staff failed to appropriately admit Mr A to hospital when he attended the out-of-hours service, that they inappropriately discharged him from the ICU to the ENT ward, and that they failed to appropriately monitor him on the ENT ward. The board considered that Mr A had been provided with reasonable care and treatment by the out-of-hours service, and that he had been reasonably discharged from the ICU. However, they acknowledged that there had been some failures in their clinical observation policy on the ENT ward.

After obtaining independent advice from out-of-hours practitioners, we did not uphold Miss C's complaint about Mr A not being admitted to hospital. We found that there was evidence of an appropriate examination being made, and a reasonable basis for concluding that the problems Mr A was experiencing were due to tonsillitis. We found that it was reasonable for staff not to have admitted Mr A to hospital at that time.

We obtained independent advice from an intensive care specialist regarding Miss C's complaint about the decision to discharge Mr A from the ICU. We found that this decision was consistent with the relevant guidance and adhered to the standards of general practice. Therefore, we did not uphold Miss C's complaint in this regard.

We obtained independent nursing and medical advice regarding the monitoring of Mr A on the ENT ward. We found failings by nursing staff in following the board's clinical observation policy to act on Mr A's deteriorating early warning scores. We found that on one day, Mr A did not receive a dose of medication given to help prevent the development of deep vein thrombosis and pulmonary embolism. However, we did not find that Mr A's outcome would likely have been any different if he had received this medication. On balance, we upheld Miss C's complaint about how Mr A was monitored on the ENT ward.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and to Mr A's family for the failings in medical and nursing care. The should comply with 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:

• Staff should be aware of, and follow, the board's clinical observation policy, which requires them to act on deterioration when alerted by early warning scores.
• The circumstances of this case should be fully considered for wider learning (for example by discussing the case at a mortality and morbidity meeting).
• Patients should receive appropriate preventative medication for deep vein thrombosis, and this should be reflected in the relevant records.

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 the board provided to her late husband (Mr A) at Wishaw General Hospital.

Mr A underwent an urgent left groin lymph node biopsy. He re-attended hospital the next day with a serious infection. Mr A remained at the hospital for approximately five months. He was discharged and remained out of hospital for approximately eight months. Mr A was readmitted with a urinary tract infection, but his condition deteriorated over approximately two months and he died.

Mrs C raised a number of concerns relating to the medical and nursing care during Mr A's admissions, as well as communication within the hospital and with Mr A's family. This included concerns that the initial procedure was carried out incorrectly, that Mr A was mishandled physically by staff, and that hygiene practices were poor.

We took independent advice from consultant in general medicine and from a nurse. We found that consent for the initial operation had been appropriately obtained, and that the infection was a rare but recognised complication of the procedure. We noted that the seriousness of this infection had severely impacted on Mr A's health and had led to two long and complicated admissions. We found that the nursing care was reasonable, with appropriate monitoring and wound care recorded. We also noted that we were unable to identify evidence to support Mrs C's concerns about Mr A being mishandled physically at the hospital. We did not uphold these aspects of Mrs C's complaint.

We upheld Mrs C's complaints regarding communication within the hospital and communication with the family. However, we found that the board had already accepted these failings and had apologised. As such, we made no further recommendations.

Summary

Mrs C complained about the treatment provided to her late husband (Mr A) by an advanced nurse practitioner (ANP). The ANP had attended Mr A at his nursing home as staff had reported that he was having breathing problems. Mrs C said that the ANP did not make arrangements for Mr A to be assessed by a doctor or arrange for him to be taken to hospital. Mr A continued to have breathing issues and was admitted to hospital the following day, where he died two days later.

We took independent advice from a nursing adviser. We concluded that the ANP had carried out an appropriate clinical assessment of Mr A's condition by listening to his chest and establishing that there was no evidence of a chest infection or that Mr A was in respiratory distress. We found that the ANP had also appropriately prescribed a treatment to assist Mr A's breathing, and that there was no indication at that time that Mr A had to be reviewed by a doctor or should have been referred to hospital for a specialist opinion. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment his wife (Mrs A) received at Dunbar Hospital. Mr C and Mrs A had just moved to the area and had not yet registered with a local GP practice when Mrs A became unwell with flu-like symptoms. NHS 24 advised her to attend Dunbar Hospital, where she was diagnosed with a respiratory infection and prescribed antibiotics. Mrs A had two further attendances and phone contact with the hospital, before registering with a local GP. The GP diagnosed pneumonia, prescribed a new course of antibiotics and subsequently arranged an emergency admission to a different hospital for treatment.

Mr C complained that the doctor who initially assessed Mrs A at Dunbar Hospital failed to diagnose her pneumonia. He also complained that Mrs A was assessed by nursing staff on her subsequent attendances at the hospital and not a doctor, despite his understanding that the plan was for further medical review. In addition, he complained that the nurse Mrs A spoke to when she phoned Dunbar Hospital did not make appropriate arrangements for her to be seen by a doctor and simply advised her to register with a local GP.

We took independent advice from both a GP and a nurse. Both advisers considered that the respective assessments of Mrs A were reasonable and they considered it appropriate for her to have been advised to register with a local GP. They noted that the out-of-hours service at Dunbar Hospital is for emergency care when GP surgeries are closed. They also noted that routine follow-up and the arrangements of tests is usually carried out by the GP. The GP adviser considered that Mrs A's initial diagnosis and treatment were appropriate and noted that the treatment would have been the same if pneumonia had been suspected initially. We did not uphold this aspect of the complaint.

Mr C also raised concerns that the board's response to his complaint contained a number of inaccurate and misleading statements. In particular, he considered that it inappropriately contained continual reference to the GP registration issue and that the response did not justify the poor quality of care that he considered was provided by Dunbar Hospital. We reiterated that we found the advice to register with a GP to have been appropriate and we found no evidence to support Mr C's concerns that the detail of the board's response was inaccurate or misleading. We did not uphold this aspect of the complaint.

Summary

Miss C complained about the treatment that she received from her dentist, after they removed one of her teeth. She explained that, following the removal, she felt that the wrong tooth had been removed. This led her to attend another dentist, who found a crack in the remaining tooth, meaning this also had to be removed. Miss C was also unhappy with the dentist's handling of her complaint, as it took almost a year to receive a response.

In their response to Miss C's complaint, and in response to our enquiries, the dentist defended their decision to remove the tooth based on the symptoms Miss C presented with. They said that this tooth was loose and the area around it was badly infected, leading them to conclude that this was not saveable and the most likely source of Miss C's pain. We sought independent advice from a dental adviser, who reviewed the records and agreed with this assessment. For this reason, we did not uphold the first complaint.

With regards to the complaints handling, we found that there had been a considerable delay caused by the dentist awaiting an independent expert report they had commissioned in order to respond to Miss C's complaint. During this time, the dentist failed to provide Miss C with regular updates, or to formally agree extensions to the deadline for response, which is not in line with the most recent model complaints handling procedure. For these reasons, we upheld the second part of the complaint. However, we considered that the eventual response was reasonable in its content and conclusions.

Recommendations

In relation to complaints handling, we recommended:

• Adopt the model complaints handling procedure and ensure that all staff are aware of this.

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 A had a miscarriage and she felt that her appointment for a surgical evacuation of the uterus (SEU) (a procedure sometimes carried out after a miscarriage to ensure that the uterus is fully evacuated and to prevent infection) at Royal Alexandra Hospital was unreasonably delayed, which she felt put her at increased risk of infection or haemorrhage. Ms A also complained that the board had unreasonably failed to provide her with information about support groups and counselling in relation to miscarriage and that the board had unreasonably failed to provide her with details of her scan results when she elected to pursue private treatment at another hospital for the SEU.

We took independent advice from a consultant obstetrician and gynaecologist. We found that earlier treatment would have been desirable to minimise psychological distress to Ms A, but that the time she waited for the SEU was within the National Institute for Health and Care Excellence guidelines. We found that it was likely that the first available appointment was offered to Ms A, and that there was no reason to think that Ms A was at risk of infection or haemorrhage because of the wait. We concluded that the actions of the board were not unreasonable and we did not uphold the complaint.

The adviser noted that there was evidence in the medical records that Ms A had declined information about counselling and support organisations. We did not uphold this complaint.

The adviser said that it was evident from the medical records that the consultant obstetrician had refused to provide information about Ms A's scan results when she requested this information to help with pursuing private treatment for the SEU. Although the still images that were available would not have been helpful for staff at the private hospital, the adviser said that the board could have provided Ms A with copies of scan results or a handwritten letter with little inconvenience. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to provide Ms A with information about her scan results when she decided to pursue private health 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.