Health

Summary

C complained about the care and treatment received by their young child (A). A had a complex congenital (from birth) heart condition. C complained to the board after A received heart surgery, which had been part of the treatment planned for A. C complained that the board did not reasonably respond to C’s concerns prior to A’s operation. C also complained about the timing of A’s admission to hospital and the timing of the operation.

We took independent advice from a consultant paediatric cardiologist (specialist in children’s heart problems). We found that, overall, the board provided excellent care to A and a successful outcome was achieved through A’s surgery. We found that the timing of A’s operation was reasonable considering A’s age. However, we also found that A was not provided with appropriate follow-up plans in relation to care provided before A’s surgery and that A should have been admitted to hospital three days earlier. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should receive timely admission to hospital and follow-up appointments, based on their clinical needs and presentation.

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

C complained about the care and treatment provided to their parent (A). A had presented with foot pain and initially had been thought to have Plantar Fasciitis (an inflammation of the tissue along the bottom of the foot). A later returned to the practice with an infected toe, which failed to respond to antibiotics. A was referred to vascular medicine and later underwent surgery in hospital, but died a few months later. C believed that A should have been referred to vascular medicine sooner, as A was at high risk and displayed symptoms of vascular disease. C was also unhappy with the language used in the complaint response that the family received.

We took independent advice from a general practitioner. We found that A was given a reasonable standard of treatment and care. There was no evidence that symptoms of vascular disease were dismissed or overlooked. We did not uphold this aspect of the complaint. In relation to the language used in the complaint response, we found that the complaint response was inappropriately informal and contained some errors, which added to the family’s distress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the inappropriate language and incorrect dates in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

C complained that the board failed to reasonably respond to their complaint about the way a form was completed by the GP at their GP Practice.

We found that while the board provided regular updates, apologised for the delay and reasonably managed C’s contact, the length of time responding to the complaint and the inaccuracies of the updates provided to C, were unreasonable. The response to the complaint was unclear and did not answer all of the points raised by C. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failures in this case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Complaint responses are issued as soon as possible, with the response responding to the main points raised and agreed with the complainant, and any required updates accurately reflect the reasons for the delay.

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

C complained about the care and treatment provided to their friend (A) when they were admitted to hospital. A was in hospital for around three and a half months after being admitted with weakness and reduced mobility, with a short history of dysuria (pain or discomfort when urinating) and urinary urgency. A died during their stay in hospital.

C complained about several aspects of the nursing care provided to A. In addition to this, they complained about the physiotherapy input provided to A. Finally, C complained about what they considered to be insufficient detail in A’s death certificate.

In respect of the nursing care provided to A, the board acknowledged that there was learning or areas for improvement. We took independent nursing advice. We found that the board provided A with a reasonable standard of care. We recognised that there was learning to take from A’s experience, however, we did not consider that the care provided unreasonable. Therefore, we did not uphold this complaint.

In respect of the physiotherapy provided to A, we took independent physiotherapy advice. We found that the physiotherapy input provided to A was reasonable, given the circumstances at the time. Therefore, we did not uphold this complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the board. A, who had a history of breast cancer, was admitted to hospital with pain and vomiting. Tests were carried out and A underwent a liver biopsy. Following the biopsy, their condition deteriorated and they died a few days later. C felt that A’s death was premature and was hastened by the actions of the board.

The board said that CT scans showed that A had an abnormal liver and an MRI was requested. This wasn’t completed until eight days later due to high demand. The liver biopsy was undertaken the same day. When A began to deteriorate, an urgent CT scan showed that A was bleeding from an injury to the branch of the cystic artery from the biopsy site. The board said that this is a known complication of a liver biopsy. The bleed was successfully treated but A deteriorated further and died. A had shown signs of potential infection and was commenced on antibiotics. The post-mortem stated that the cause of death was ‘complications of liver biopsy and metastatic breast cancer in liver’, and could not conclude to what extent the infection contributed to A’s death.

We took independent advice from a consultant general and colorectal surgeon. We found that the MRI did not appear to have been reviewed prior to proceeding to biopsy and the breast team were not notified of the CT scan results. We also noted that A was not referred to the breast cancer multidisciplinary team (MDT). We found that antibiotics should ideally have been administered within one hour of deterioration and sepsis considered as a main cause of A’s deterioration. A was also given a cystic artery embolization (a minimally invasive procedure that blocks or closes the blood vessel) and two units of blood despite having a normal blood count and no evidence of significant bleeding. Therefore, we upheld this part of C’s complaint.

C complained about communication with A and A’s family, stating that A was not given sufficient information about their condition or results from tests. A’s family were unaware of test results until after A’s death. We found that communication with A and A’s family was unreasonable and that there had also been an absence of communication with the breast team and MDT, which was a missed opportunity. We upheld this part of C’s complaint.

C complained that the board unreasonably failed to undertake a Significant Adverse Event Review. We found it was unreasonable for the board not to have undertaken a Significant Adverse Event Review. This was a missed opportunity to reflect on A’s care and treatment, and identify learning from these events. We upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment to A, the failure to communicate to a reasonable standard and the failure to undertake a Significant Adverse Event Review. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Plans for investigations, especially of an invasive nature, should be adequately discussed with the patient, including where there is a suspicion of malignancy.
• Relevant clinical teams should be involved, especially where investigations were initiated prior to admission. Sepsis should be appropriately considered as a reason for deterioration, and wherever possible, antibiotics be administered within an hour of deterioration. Appropriate treatment should be given based on clinical signs and symptoms.
• Significant Adverse Event Review’s should be completed in line with the national framework and the board’s own protocols.

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

C complained about the post-operative care and treatment that they received from the board after they suffered a leg and ankle fracture. C said that unreasonable post-operative care led to a poor recovery and the requirement for an additional operation.

We took independent advice from a consultant orthopaedic surgeon (specialists in the treatment of diseases and injuries of the musculoskeletal system). We found that the board failed to report some x-rays and to reasonably explain why further x-rays were taken and who had reviewed them. We also found that there had been an unreasonable delay in carrying out a CT scan and in discussing C’s case at a Morbidity and Mortality meeting. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board handled C’s complaint reasonably and did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• A patient’s medical records should document the reasons why a scan(s) has been taken and who has reviewed them. The results should be recorded on the hospital’s clinical portal system.
• There should be processes and guidance in place to ensure when it is appropriate to carry out a CT scan.
• Where a patient’s case is appropriate for discussion at a Morbidity and Mortality meeting, this should take place as soon as possible.

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

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A became acutely unwell with uncontrollable diarrhoea, severe abdominal pain and vomiting. After visits from both a community nurse and out-of-hours GP, C called for an ambulance. The ambulance crew called ahead to the hospital to have A admitted, as per the board’s alternative admission pathway. As agreed during the call, A was taken to the Acute Medical Unit (AMU) but there was no bed for A on arrival. Initial observations and ECG/bloods were taken but A was found unresponsive a short time later and died of a cardiac arrest.

The board apologised that no bed was available for A. They reviewed A’s case and concluded that the appropriate referral pathway was followed. However, they acknowledged that patients with undifferentiated (undiagnosed) abdominal pain should not be admitted to the AMU.

We took independent advice from a consultant physician in acute and general medicine. We found that the board failed to obtain key information to determine which pathway should be followed. This resulted in A not entering the correct pathway. We found that the board failed to escalate A’s care and treatment in line with relevant guidance and with their own policy. We found that A’s care was compromised by the board’s alternative admission pathway. It is possible that the outcome may have been different had the correct pathway been accessed. We upheld this part of C’s complaint.

C complained that the board unreasonably failed to carry out a Significant Adverse Event Review (SAER) following A’s death. After being notified of our investigation, the board commissioned a SAER. Although we welcomed this, the board did not provide assurance that they have adequate systems in place to identify, investigate and learn from adverse events. The board’s failure to commission a SAER following A’s death did not meet the standards outlined in the relevant guidance, and was unreasonable. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a SAER. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failings our investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be admitted to the correct care pathway on the basis of their presenting symptoms. When accepting patients with undifferentiated gastrointestinal symptoms, local teams should be aware of the presence or absence of abdominal pain. Teams should ensure that they ask this specific question when accepting patients.
• Patients should be managed in line with their presenting symptoms. Observations should be carried out in line with the board’s escalation policy.
• There should be a robust process in place for reviewing all unexpected deaths, and, where appropriate, prompt commissioning of SAERs. Learning from these events should be disseminated and shared across teams in line with national guidance.

In relation to complaints handling, we recommended:

• Complaint investigations and case reviews should respond to all of the main points raised, identify failings where appropriate and take learning from what happened. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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

C complained about the care and treatment provided to their late parent (A). Scans revealed findings that were suggestive of bladder cancer. Over a number of further admissions, A received treatment to resect (remove) a bladder tumour, fit and remove catheters, treat infection and generally manage A’s condition. Eventually, it was decided that A’s condition should be managed palliatively, and A was discharged home.

C complained that the medical and nursing care and treatment A received from the board was unreasonable and that the communication with A and their family was unreasonable.

The board said that A was not medically or psychologically fit for further management of their condition and they were not a candidate for chemotherapy or radiotherapy. A was referred to palliative care once it was identified that they were also not a candidate for surgery. The board said A chose not to share their diagnosis for a number of weeks and were unwilling for discussions to take place with their family.

We took independent clinical advice from a consultant urologist (specialists in he male and female urinary tract, and the male reproductive organs) and a registered nurse. We found that the surgical care was of a reasonable standard and that the board adopted a holistic approach. However there was a failure to detect the bladder tumour when it was initially suspected and a failure to follow up with A about their nephrostomy (a thin tube inserted through the skin directly into the kidney to allow urine to drain into an external drainage bag) and JJ stents (a thin flexible tube placed to help urine flow). We also found that there was a delay in organising an inpatient CT scan, failures in relation to discharge planning and a failure to care for A’s skin and pressure damage.

In relation to communication, we found that the board failed to tell A that there was a suspicion of bladder cancer at an appropriate time and it was unreasonable for the board not to communicate with A’s family when arranging discharge.

We considered that the board failed to provide reasonable care and treatment to A and failed to communicate reasonably with A. Therefore, we upheld these parts of C’s complaint.

C complained that the board failed to handle their complaint reasonably. We found that the board’s investigation and response contained a number of factual inaccuracies, particularly with the accuracy of dates and order of events, and that important information was omitted from the response. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable care and treatment to A, failing to communicate reasonably with A and their family, and failing to provide a reasonable response to C’s complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Discharge planning should take into account the patient’s ability and motivation to complete required self-care tasks such as catheter and nephrostomy care. Patients should be issued with a copy of the discharge letter where appropriate. When a patient does not live independently family members should be informed of their discharge to ensure there is appropriate care in place.
• There should be nurse specialist support for patients with urological cancers. Nurse specialists should contact the patient within a reasonable timescale. Patients should be assessed to ensure suitability before phone consultations are carried out. Patients should be supported, where possible, when bad news is being communicated to them. Relevant updates should be given to a patient in a timely manner.
• There should be adequate trainee supervision during surgical procedures in keeping with the trainee’s experience. Patients should be informed of investigation findings if they are suspicious of a cancer diagnosis. When there is a suspicion of cancer further investigations should be carried out with due diligence. Relevant findings should be discussed with the patient and recorded in the medical notes.
• A pathway should be in place to ensure that patients with nephrostomies and/or JJ-stent are followed-up in line with best practice time frames.
• Inpatient scans should be carried out within a reasonable time frame.
• Wound charts should be in place for pressure wounds and there should be subsequent weekly assessments. Care rounding should be delivered to the frequency required to prevent pressure damage. Patients should be appropriately moved position to avoid worsening pressure damage.

In relation to complaints handling, we recommended:

• Complaint responses should be factually accurate. Details such as dates and the order of events should be supported by what is recorded in the medical records, and these should be checked for accuracy before the response is issued. Complaint responses should be completed in line with the NHS Model Complaints Handling Procedure.

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

C complained that the board failed to provide reasonable physiotherapy care and treatment to their child (A) and failed to maintain reasonable clinical records.

We took independent advice from a physiotherapist. We found that some aspects of A’s care were reasonable, particularly in relation to ongoing treatment at school, and the adjusting of equipment and personal care access was in line with normal practice. However, it was unreasonable that no paediatric physiotherapy programme was provided and delegated to school staff initially to support classroom and curriculum access and that clinical notes only mentioned a programme taught to support staff in school following the change in physiotherapist. Therefore, we upheld this part of C’s complaint.

In relation to the clinical records, we found that there were omissions in the completion of documentation and poor physiotherapy clinical record keeping. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board’s actions in relation to the handling of C’s complaint were reasonable and did not uphold this part of C’s complaint. We also noted that the board had taken learning and improvement action which we welcomed.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Clinical notes should be comprehensive as set out by the Charted Society of Physiotherapy (CSP)/Health and Care Professional Council (HCPC) standards and include action plans. Senior managers should be aware of their role in relation to monitoring the quality of record keeping (in line with the Records Management Code of Practice).

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide them with appropriate orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) care and treatment following a fall. The board operated on C’s left wrist the day after the fall. Two days later, they performed revision surgery on C’s wrist and operated on their left elbow. C said that they had been advised by an orthopaedic surgeon at the board that their initial wrist surgery had not been done correctly. C said they had developed nerve compression pain issues and would require further surgery.

We took independent advice from an orthopaedic consultant. We found that C’s initial wrist surgery was reasonable. However, the tilt of the radius was slightly beyond the normal range, which carried a minor increased risk of longer term functional impairment in the wrist. We considered that, if C had not required additional surgery for the elbow, the initial wrist fixation might have been left unchanged, as any potential long-term dysfunction could still have been treated later if necessary. However, given that C was already scheduled for elbow surgery, the decision to proceed with revision surgery on the wrist was considered reasonable. We also noted that key indicators related to pain were appropriately assessed in C’s case, and there was no indication that the surgery had been performed in a manner likely to cause excessive pain. Therefore, we did not uphold C’s complaint.