Health

Summary

Ms C complained about the urological surgery care provided to her son (child A). At birth, child A was diagnosed with hypospadias (a condition where the opening of the urethra is on the underside of the penis). He also had severe chordee (where the penis is curved) and a right side hydrocele (accumulation of fluid in a body sac). He underwent a number of operations over several years to attempt to correct these issues. Ms C complained that her son was now in a worse condition that when the treatment began, and she felt that the multiple operations he had been through had not been done correctly.

We took independent advice from a paediatric urological surgeon. We found that the type of surgeries child A had undergone have a high rate of complication and that there was no evidence that the surgeries had not been carried out to a reasonable standard. However, we found that there was at one point a delay of over a year between child A being reviewed and him being listed for further surgery. We considered this delay in adding child A to the waiting list to be unreasonable. We upheld this aspect of Ms C's complaint.

Ms C also complained that the board had failed to provide a response to her complaint within a reasonable timescale. We found no evidence that the board had failed to follow their complaints procedure or that there had been an unreasonable delay, and therefore we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to enter child A onto the waiting list for further surgery after his review. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Robust mechanisms should be in place to ensure that patients are entered on the surgical waiting list in a timely manner.

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 given to her late husband (Mr A) on a number of occasions that he was admitted to Southern General University Hospital. Mr A suffered from a number of medical conditions, including heart failure, vascular disease, kidney impairment and epilepsy. Mrs C said that he was not treated holistically and she complained that her concerns about this were ignored. Mrs C said that this had severe consequences and that, when Mr A died, the family were totally unprepared and shocked as they had been given no indication of the seriousness of his condition. Mrs C also complained that Mr A had not been offered palliative care towards the end of his life.

The board accepted that communication with Mrs C and the family had been poor, but said that the nature of Mr A's condition meant that it could change very quickly. The board considered that Mr A had been treated and cared for reasonably.

We took independent advice from consultants in acute medicine and cardiology and from a senior nurse. We found that communication with the family was limited and that there was very poor documentation of what was said. We found that staff did not respond to the issues Mrs C and her family raised with them. We further found that there was no evidence to suggest that Mr A's seriously deteriorating condition was discussed with the family, and that opportunities to do so were lost. As a consequence, the family were unprepared for Mr A's death. Finally, we found that there were no discussions about palliative care. Had these taken place, there would have been an opportunity to establish what Mr A's wishes were and how to best manage his symptoms. We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for:
• failing to respond to her concerns
• failing to advise her and the family about Mr A's condition
• missing opportunities to start a discussion about palliative care
• 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:

• Any concerns raised by a patient's family should be recorded appropriately in the notes.
• Where appropriate, families should be kept fully informed of a patient's medical condition and the options for treatment.
• Unless otherwise indicated, patients and their families should be given clear and honest information about the severity of illness and risk of death.

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 she had been given morphine both during and after an operation at the Royal Alexandra Hospital, despite refusing consent for this to be used because she was allergic to it. The board had disputed that Ms C had refused consent. They told us that the anaesthetist had explained to Ms C before the operation that she had a sensitivity to morphine, but was not allergic to it. They said that they also told Ms C that it would be almost impossible to give a general anaesthetic for an operation of this nature without the use of morphine or a derivative.

We took independent advice from a consultant in anaesthesia and intensive care medicine. We found that the anaesthetic technique used by the anaesthetist was appropriate for the procedure Ms C had, even with the risk of side effects. However, given Ms C's concerns about morphine, we found that there should have been an informed discussion about the risks and benefits, which should have been documented. The anaesthetist failed to adequately document such a discussion. Given the importance of this in relation to whether morphine should have been used, we upheld this aspect of Ms C's complaint.

Ms C also complained that the anaesthetist had failed to consider alternative anaesthetic for the operation. We found that the anaesthetist had acted reasonably by putting measures in place to treat any complications during the operation and by ensuring that anti-sickness drugs were available. However, we also upheld this aspect of the complaint, as the anaesthetist had failed to document any discussion with Ms C about alternative anaesthetic for the operation, in line with the relevant guidance.

Ms C complained that the board had lost images taken during the surgery. In their response to our enquiries, the board said that they had been unable to locate the images referred to and apologised for this. We, therefore, also upheld this aspect of the complaint.

Finally, Ms C complained about the board's handling of her complaint. We found that although there had been a short delay in responding to her complaint, this delay had not been unreasonable. We did not uphold this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• not adequately documenting any discussion about the risks/benefits of using morphine and any alternatives
• being unable to locate the images taken during the operation.
• The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Discussions about the risks and benefits of using medication that the patients is concerned about, and discussions about any alternatives, should be documented appropriately.

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 mother (Mrs A) about the way her medical practice managed the medication for her thyroid condition. Mrs A had a condition called hypothyroidism (where the thyroid gland is underactive and does not produce enough thyroxine hormone) and had received treatment for this for a number of years. Mrs A had attended the practice for a blood test to measure her levels of thyroxine. When the test results showed that her thyroxine level was too high, a GP at the practice advised Mrs A to stop taking her thyroxine replacement medication and to attend the practice in six weeks to have the levels checked again.

Shortly before Mrs A was due to return to the practice, she had a seizure and was hospitalised. Doctors at the hospital concluded that the seizure was caused by profound hypothyroidism following the withdrawal of thyroxine medication. Ms C complained that the medication should have been reduced more gradually and that follow-up tests should have been arranged sooner than they were. She also complained that Mrs A was not informed of the side effects of withdrawing the medication.

We took independent advice from a GP adviser who said that there were a number of risks associated with high thyroxine levels. In view of this, they considered that the GP's decision to cease thyroxine medication and review Mrs A in six weeks was reasonable. They did not consider that Mrs A's rapid development of hypothyroidism followed by a seizure was predictable, and noted this was a rare complication of her condition. While there was no evidence that discussion of side effects had taken place, the adviser did not think it was unreasonable had the GP not discussed the rare complications of a seizure in the circumstances of this case. We did not uphold this complaint.

Summary

Mrs C raised concerns about the care and treatment she received for urinary incontinence at a number of hospitals within the board's area.

Mrs C complained that there was a failure to provide her with a reasonable standard of care and treatment and a failure to provide her with a treatment plan. We took independent advice from a consultant urologist. We found that it was clear that Mrs C had struggled with severe urinary incontinence for several years. While the initial care and treatment that she received was managed correctly, there was subsequently unreasonable delays in her treatment and in providing her with an appropriate treatment plan. We therefore upheld these aspects of Mrs C's complaint.

Mrs C also complained that there was a failure to communicate with her appropriately about her treatment. The adviser found that the board had not been supportive of Mrs C, considering the unnecessary delays which she had experienced and the impact this had evidently had on her. The adviser concluded that, as Mrs C did not appear to have an understanding of the cause of her problem, she should have been offered an urgent discussion about this and should have been told about the best treatment to restore urinary control. We considered that this should have been recognised by the board at an earlier stage and we upheld this aspect of Mrs C's complaint.

Mrs C further complained that there was a failure by the board to respond to her complaint appropriately. The board accepted that their complaint response letter did not make it clear to Mrs C that they could only consider her treatment covering a specified period of time. We found that the board should have explained this to Mrs C and should also have explained the reasons why this was the case. Therefore, we upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in our investigation, including:
• delays in Mrs C's care and treatment
• a delay in providing Mrs C with an appropriate treatment plan
• failing to communicate with Mrs C appropriately about her treatment
• failing to respond appropriately to Mrs C's complaint
• The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Measures should be in place so that other patients are not affected similarly by delays in treatment.
• Measures should be in place so that patients are provided with a treatment plan without delay.
• Staff should be reminded of the need to be supportive and to show empathy to patients, where there are delays in 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, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Ms C complained that the board had failed to provide a reasonable standard of nursing care to Mrs A's late husband (Mr A) when he was a patient at Inverclyde Royal Hospital. Ms C further complained that the board failed to provide Mr A's family with a definitive cause of death, and that their significant clinical incident investigation was not completed in a timely manner.

We took independent advice from a nursing adviser and a consultant physician. We found that there were failings in the nursing care provided to Mr A and we upheld this complaint. However, we considered that the board had appropriately identified and apologised for these failings, and had carried out a large number of improvement actions. We did not make any recommendations in relation to this aspect of Ms C's complaint.

We found that, whilst it was reasonable that clinicians were initially uncertain as to Mr A's cause of death, it was unreasonable that they disagreed about it in front of Mrs A and other family members at a meeting. Therefore, we upheld this complaint. We noted that the board had apologised for this matter, and we made a recommendation in relation to this aspect of the complaint.

Finally, we found that the board had unreasonably failed to complete their significant clinical incident investigation report in a timely manner, and we upheld this aspect of the complaint. However, we found that the board had taken appropriate action to address this failing and so we did not make any recommendations in this regard.

Recommendations

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

• When appropriate, a preparatory meeting of the staff involved should be carried out prior to meeting with families about complaints, in order to allow meetings to go more smoothly and to avoid potential disagreements amongst staff in front of families.

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 made a number of complaints to us about the care and treatment she received from the board's community psychiatric nurse (CPN) service. Her complaints included concerns about the allocation of a CPN and discharge arrangements. She also complained about the board's handling of her complaint.

We took independent advice from a mental health nurse and from a consultant psychiatrist. Ms C complained that the board had arranged a meeting without her consent after she made a complaint about a support worker. We found that the board's records indicated that Ms C had agreed to the meeting and we did not uphold the complaint.

Ms C also complained that the board had unreasonably allocated her a CPN that she could not work with. We found that it had been reasonable for the board to appoint this member of staff as Ms C's CPN. We did not uphold this aspect of her complaint.

Ms C complained that the board refused her support from a CPN that had previously been agreed. We found that staff had met Ms C to discuss the support she needed from CPNs. They then arranged to speak to her consultant psychiatrist to clarify what had been agreed. The psychiatrist said that this matter should be discussed at her next review meeting. We considered this had been reasonable and did not uphold this aspect of her complaint.

Ms C complained that she had then been discharged from the CPN service. We found that given the support she was receiving from other agencies at that time, there was no need for CPN involvement in her care. We did not uphold this complaint.

Finally, Ms C complained to us about the board's handling of her complaint. She said that she considered that the board should have contacted her mental health officer to discuss her complaints. We found that it had not been necessary for the board to do so to investigate the complaints. We did not uphold this aspect of Ms C's complaint.

Summary

Mr C, who works for a voluntary agency, complained on behalf of the family of Miss A. Miss A had suffered complex medical problems from birth. Mr C complained that Miss A had not been provided with appropriate care and treatment at the Southern General Hospital and Yorkhill Children's Hospital. He said the family believed there had been repeated failures by medical and nursing staff. They believed that they had not been communicated with appropriately and the board had failed to action their complaint in accordance with the NHS procedure. Miss A had had to undergo surgery on her windpipe and had multiple medical complications, which required on-going medical treatment.

We took independent advice from a consultant paediatrician and a paediatric nurse (specialists in the care of infants, children and young people). They concluded that the main failing on the part of the board was the failure to appoint a lead clinician to oversee Miss A's treatment. While we found that the clinical care and treatment provided to Miss A had been appropriate, this failure to appoint a lead clinician had contributed to the communication failures with the family. The nursing advice we received was that staff had not monitored Miss A's oxygen saturation levels appropriately and that the family had been forced to request that oxygen monitoring be provided.

We found that the board had failed to communicate adequately with the family and, although they had acknowledged this, we found that the board had provided no evidence to show that they had taken steps to avoid a reoccurrence. We also found that the board's response to the complaint had taken an unreasonable length of time and that the responses the family had received had been inaccurate.

We asked the board to apologise for their failings and take a number of actions to address them.

Recommendations

We recommended that the board:

• provide evidence that they have reviewed their oxygen saturation monitoring policy to ensure it corresponds with national guidance for children;
• review care planning for children with respiratory vulnerabilities to ensure that pulse oximetry values (used to measure the oxygen level of the blood) are monitored;
• review care planning to ensure that parental concerns for the child are recorded;
• remind the nursing staff involved in Miss A's care of the importance of comprehensive respiratory care plans to ensure less experienced staff are able to monitor patients effectively;
• provide evidence of the outcomes of the multi-disciplinary review considering continuity of care between acute and community services;
• provide evidence of the outcomes from the multi-disciplinary review of the allocation of lead-care coordinators;
• provide evidence of the changes made to the process for feeding back sleep study results to the parents of children undergoing treatment;
• review their processes in relation to complaint handling of complex cases where more than one department is involved to ensure that a single clinical lead is appointed to oversee the response; and
• apologise for the failings we identified.

Summary

Mr C complained to us that the practice had failed to manage his medication in an appropriate manner. He had been on pramipexole medication (used as treatment for Parkinson's disease and restless legs syndrome) for four years and he said that during that period the practice had not reviewed the medication. Mr C said that the practice had also increased the medication dosage without telling him and that he had experienced severe side effects. Mr C felt that the practice should have kept the medication under review and informed him of the change in dosage.

We took independent advice from a GP adviser. We found that, during the period in question, Mr C had not reported to the practice that he was having side effects from the medication. The practice had invited Mr C to attend for a review of his medication on five occasions, but he had not responded. Mr C was also reviewed on two occasions when he attended the practice to discuss other clinical matters. We also found that it was appropriate for a pharmacist to advise Mr C of the increase in the dosage of the medication, rather than have him make an appointment with a GP. We did not uphold Mr C's complaint.

Summary

Miss C complained that the medical practice had failed to carry out an appropriate assessment or refer her late father (Mr A) to hospital when he attended a consultation. Mr A was very breathless and suffered from pulmonary fibrosis (scarring of the lungs). The GP did not take Mr A's temperature or provide medication, as they felt that no further treatment was required at that time. Mr A was told to wait until his next scheduled respiratory clinic at the hospital, which was in nine days time. When Mr A attended the clinic, a clinician arranged an immediate hospital admission. Mr A deteriorated and died a few days later. Miss C felt that the GP should have referred Mr A to hospital sooner.

We took independent advice from an adviser in general practice medicine. We concluded that, although the GP had arranged for an ECG (electrocardiogram - test to check the rhythm of the heart), the GP failed to record Mr A's oxygen saturation, temperature and blood pressure. We found that the GP had failed to carry out an examination of the heart, which would have been appropriate for a patient who had presented with increased breathlessness and chest pains. We also concluded that, while it was possible that the GP's decision for Mr A to wait until his clinic appointment may have been reasonable, we were unable to establish this as the standard of record-keeping for the consultation was inadequate. We upheld Miss C's complaint that the GP failed to provide Mr A with appropriate treatment in view of his reported symptoms. However, in view of the inadequate record-keeping, we could make no finding on the complaint that the GP should have referred Mr A for a hospital assessment.

Recommendations

What we asked the organisation to do in this case:

• Send Miss C a written apology for the failure to carry out a thorough assessment in view of Mr A's reported symptoms.
• Send a written apology to Miss C for the inadequacies in record-keeping which meant we could not determine whether a hospital referral was required.

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

• The GP involved should ensure that a thorough assessment is carried out in view of a patient's reported symptoms.
• The GP involved should ensure that their record-keeping meets the standard of what would be expected under the General Medical Council's Good Medical Practice guidance, in terms of clinical assessment, record-keeping and safety netting.

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.