Health

Summary

Mrs C complained about the children's waiting arrangements in a hospital accident and emergency department (A&E). She said that when she had to go there with her grandson she was appalled that children waited together with adults and were, therefore, exposed to bad language and inappropriate behaviour. She said that despite complaining to the board's chief executive little action was taken and the board failed properly to deal with her complaint.

We carefully considered all the available information, including all the complaints correspondence, and the response to our formal enquiries to the board. Our investigation confirmed that at the time Mrs C made her complaint, the board were simply required to provide emergency care 'within a safe environment' which could have been provided in a variety of ways. Since then, new standards have been introduced which are more than mere recommendations. The board are currently exploring the feasibility of creating a children's waiting area in A&E and reviewing how this could be achieved. However, it would seem that progress is slow. Although we did not uphold this complaint, we made a recommendation in order to monitor this.

The investigation also showed that the board took too long to respond to Mrs C's complaint, so we upheld her complaint about this. We noted that the board have introduced new ways of working to avoid this in the future, and made relevant recommendations.

Recommendations

We recommended that the board:

• update the Ombudsman on the outcome of the feasibility study;
• formally apologise to Mrs C for their failure to deal with her complaint in a timely manner; and
• confirm to the Ombudsman that they are satisfied that their complaints process is robust and the resources to support it are sufficient to allow them to deal properly and efficiently with complaints made to them in accordance with the terms of the Patients Rights (Scotland) Act 2011.

Summary

Mr C, who is a prisoner, complained that his confidentiality was unreasonably breached, as he was given medication in the sight of other people. In their response to our enquiries, the board said that healthcare staff try as far as possible to issue medication in pharmacy bags. However, they said that prison officers are present when medication is given out, as they are needed to escort the prisoners to and from the dispensing hatch. They said that this is a security matter and that the prison officers are necessary as security for nursing and healthcare assistants whilst they dispense medication. The board said that there are other prisoners in the same area who are waiting for their names to be called and their movements are controlled by the prison officers. Our investigation found that there are clearly some practical issues about ensuring confidentiality in a prison setting. Staff in the prison health centre have to ensure that the correct medication is prescribed at the right time to a large number of prisoners whilst maintaining confidentiality. At the same time, prison officers have to ensure that security is maintained. In the circumstances, we considered that the board's response was reasonable.

Mr C also complained that his request for a review of his glasses was unreasonably refused. We found that the board had in fact arranged for him to see an optician but there was a delay, because the optician left without prior notice. The board then arranged for Mr C to see an optician from another prison. We found that this was reasonable.

Finally, Mr C complained that the board failed to provide chiropody treatment. There is no longer a chiropodist service in the prison. When Mr C asked to see a chiropodist, he was told that he could obtain nail clippers from officers to cut his nails. The board told us that when he complained about this, they asked a nurse to assess his feet. The nurse then ordered a pumice stone for Mr C, as he had hard skin on his feet. Again, we found that this was reasonable.

That said, we found that in their response to Mr C's complaint the board said that the first stage of the complaints process is to raise the matter directly with the healthcare team, who will do their best to resolve it. They also said that the second stage is to complete a feedback form, which the local healthcare team will respond to within seven days. The board said that only then should prisoners complete a complaint form. Although the board dealt with Mr C's letter as a complaint, they said that they would appreciate it if he would follow this process in the future. We have previously raised concerns that NHS boards are using their feedback system as an additional stage in the complaints process. There is no requirement to complete a feedback form, or to raise the issue with staff for that matter, before submitting a complaint to NHS boards. The Scottish Government have written to NHS boards to highlight our concerns about this, and in view of this, we made a recommendation.

Recommendations

We recommended that the board:

• ensure that the local process in place for the management of prison health care complaints is in line with the good practice outlined in the Scottish Government Guidance 'Can I help you?'

Summary

Mrs C had a long history of chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed) and as her condition worsened, she was admitted to hospital. After initial treatment, because of a shortage of appropriate bed spaces, she was transferred to a surgical rather than a respiratory ward through a process known as boarding. Mrs C complained that, once there, she began to react badly to the medication she was prescribed but staff on the surgical ward were unable to deal with her concerns. She maintained that she was given too high a dose and that she may have been suffering from side effects. She said no one explained this to her or addressed her concerns.

We took independent advice from one of our medical advisers, and carefully considered all the relevant information, including Mrs C's clinical records. We upheld Mrs C's complaints about the ward transfer and about staff not responding to her concerns. Our investigation found that although Mrs C was transferred to a surgical ward, throughout her stay there she was under the supervision of a specialist respiratory doctor; the nursing care she received was the same as that provided on any other ward with the exception of an intensive care ward; and her care had been reasonable. However, the board had not followed their own policy to facilitate such a change of ward. The investigation also showed that despite Mrs C's concerns that she was given an unusually high drug dosage, she had not, although she may have reacted badly to the dosage she received. However, we did find that staff failed to respond to Mrs C's concerns despite her long experience of taking this drug, nor did they address mental health concerns that had arisen.

Recommendations

We recommended that the board:

• review the decision to board Mrs C to a surgical ward in circumstances that were not in line with their own policy;
• assure Mrs C that she will not be boarded during future admissions unless this is in line with their policy, and her care needs, including potential side effects from treatment, can be met on the ward she is transferred to;
• formally apologise to Mrs C for their shortcomings in this matter; and
• review Mrs C's case notes and consider providing her with a letter so that if she is admitted as an emergency in future, clinicians are aware of the circumstances surrounding the prescription of salbutamol and her assessment of how the increased dose affected her.

Summary

Miss C complained about the care and treatment that her late mother (Mrs A) received in two hospitals. She said the board failed to appropriately manage her mother's intake of food and fluids; failed to adequately communicate with her mother and her family; handled her mother's transfer to the second hospital inappropriately; and unreasonably refused to discharge her mother from that hospital despite her wish to go home and her family's willingness to care for her.

We took independent advice from one of our medical advisers, a consultant geriatrician, and upheld most of Miss C's complaints. The adviser explained that in many respects the board managed Mrs A's intake of food and fluids appropriately. However, he was critical of the first hospital's failure to assess Mrs A's nutritional needs using a malnutrition universal screening tool, a universally recognised nursing standard used to identify adults who are at risk of malnutrition.

The adviser said that overall the level of communication by staff in this case was relatively good. However, he was critical of the board's timing of a 'do not resuscitate' decision (a decision that a doctor is not required to resuscitate the patient if their heart stops) and their failure to speak to Miss C face-to-face about that decision, once it had been made, or to discuss the issue of Mrs A not returning home. We also noted that the tone of one of the consultant's comments was rather insensitive.

Our investigation found significant failings by the board in their handling of Mrs A's transfer to the second hospital. These included the assessment for transfer, the transfer decision, the documentation transferred, speech and language therapy assessments before and after transfer, and engagement with Mrs A's family. We were also critical of the board for failing to advise Miss C, in their response to her complaint, about failings in her mother's transfer that were identified in the internal correspondence between the consultants at the time of the transfer.

We did not uphold the complaint about Mrs A's discharge from the second hospital, as we took the view that the board's actions were reasonable in the circumstances.

Recommendations

We recommended that the board:

• apologise to Miss C for each of the failings identified;
• feed back our decisions on these complaints to the staff involved to try to ensure that similar situations do not happen again; and
• review their transfer arrangements, including assessment for transfer, to try to ensure that such failings do not occur in future.

Summary

Miss C complained that the care and treatment provided to her late mother (Mrs A) was inappropriate after she suffered a third heart attack. Mrs A also had a history of lung cancer and breathing problems. She was admitted to hospital on the Wednesday before a bank holiday weekend and told she would be transferred to another hospital for further investigations and treatment. However, as services were not available over the holiday weekend, Miss C was also told that Mrs A would not be transferred until the following week. Mrs A was treated with blood thinning medication and her condition was monitored. She complained of dizziness and was diagnosed with postural hypotension (where the blood pressure drops on standing) and some of her medication was stopped. On the Monday she developed severe pain in her head and neck which was not relieved by painkillers. When she was examined by a doctor and had a CT scan (a special type of computerised x-ray), it was found that she was bleeding from the brain. Her doctors consulted with a neurosurgeon (brain specialist) who advised that nothing could be done. Mrs A died later that day.

Miss C complained that, given her past medical history, her mother should have been treated as an emergency case for transfer. Miss C also complained that record-keeping was not to an acceptable standard and that while her mother was in hospital she was not properly cared for, including that her pain was not monitored and managed appropriately.

Our investigation, which included taking independent advice from a medical adviser and a nursing adviser, found that the care and treatment provided to Mrs A was reasonable, appropriate and in line with current NHS guidance. The observations and test results in the clinical records showed that Mrs A's condition was clinically stable and there was no indication to treat her as requiring emergency transfer. Mrs A suffered a recognised risk factor of the treatment she was undergoing, but the medical adviser was of the view that the treatment was reasonable, appropriate and timely. There was evidence that Mrs A's condition, including her pain level, was being regularly monitored and addressed. Neither adviser found any deficiency in the medical or nursing records.

Summary

Mr C complained about the care and treatment provided to his late mother (Mrs A) by her medical practice. He also complained that they failed to refer her to hospital for definitive diagnosis. Mrs A had been living in a care home. She was examined by a doctor from the out-of-hours service in the early hours of the morning. He recorded that there were signs that she had vomited blood and that her abdomen was soft and 'non-tender'. He recorded that his diagnosis was gastritis and that the care home should observe Mrs A. Mrs A was seen by a GP from the practice later that day. The GP considered that she had melaena (passing blood in the stool), haematemesis (vomiting blood) and an upper digestive tract bleed. He did blood tests and stopped some of her medication. He also prescribed omeprazole (medication used to reduce the amount of acid produced in the stomach). Mrs A was examined by the practice on a number of occasions over the next few weeks and was admitted to hospital three weeks after the first GP had examined her. Mrs A died of a small bowel obstruction in the hospital nine days later.

The practice GP who examined Mrs A decided to keep her at the care home and carry out non-invasive investigations, and to adapt her medication. After taking independent advice from one of our medical advisers, we considered that this was reasonable. Mrs A was bleeding from the digestive tract, and there was no evidence to suggest that she had a small bowel obstruction at that time. Our adviser said that even if she had been admitted to hospital earlier, the decision not to carry out invasive procedures would still likely have been made, given her overall frailty and general poor health. There would also have been no benefit in admitting Mrs A to hospital as an emergency, when there were nursing staff in the care home who could monitor her condition. We found that the practice's management of Mrs A's care and treatment was reasonable and there were no failings in the clinical treatment provided.

That said, Mr C was welfare power of attorney for his mother, and so her care should have been discussed with him. There was no evidence that the practice consulted him about the treatment provided to Mrs A and about her future care plans. We found that the practice had incorrectly assumed that the care home staff would have told Mr C about this. However, there was no evidence that the practice checked that this had happened or that they spoke directly to Mr C to discuss his mother's condition. In their response to Mr C's complaint, they had apologised and said that they would review their communication processes to improve on this.

Recommendations

We recommended that the practice:

• provide evidence that they have taken action to review their processes for communicating with relatives in light of Mr C's complaint.

Summary

Mrs C had a history of myeloma (a type of cancer arising from plasma cells found in the bone marrow). She began to suffer from sickness and diarrhoea and arrangements were made for her to have a gastroscopy (a medical procedure during which a thin, flexible tube called an endoscope is used to look inside the stomach) and a colonoscopy (an examination of the lining of the bowel using a long flexible tube-like camera). Before these could be done, Mrs C's condition deteriorated and she had to attend a hospital accident and emergency department (A&E). She was told that her problems could be related to her myeloma. Blood tests and an x-ray were arranged and steps were taken to hydrate her (give her more fluids).

Mrs C had the gastroscopy two days later and a hiatus hernia (a protrusion of part of the stomach) was discovered which could be controlled by medication. The colonoscopy, however, could not take place as Mrs C was feeling unwell. She attended A&E again a few days later, as her legs were swollen, and was admitted to hospital. Five days later, the hospital contacted her husband (Mr C) to tell him that doctors had found a tumour in Mrs C's bowel and that it had ruptured. Mrs C died the following week.

Mr C complained that staff failed to carry out appropriate investigations in order to arrive at an accurate diagnosis for his wife. We found that there were some failures in the care and treatment provided. In particular, there was a failure to adequately assess some of Mrs C's symptoms; to perform examinations; and to consider her blood tests in sufficient detail. Although there were only a few days for a diagnosis to be made, we found that the hospital had missed opportunities. They initially considered that she might have infectious diarrhoea, possible clostridium difficile (a type of bacterial infection that can affect the digestive system) or that there might be a cardiac cause. These were excluded and doctors concluded that it was likely she had a new acute illness. However, the blood test results did not fit with diagnosis of new acute illness, but suggested a significant period of illness, iron deficiency and malnutrition. Mrs C was already having her bowel investigated for an alternative diagnosis of iron deficiency anaemia, which was unrelated to her myeloma. We found that a more balanced view of Mrs C's symptoms, clinical signs, and blood results would have considered chronic bowel disease, including malignancy, at least as likely as acute diarrhoea and vomiting caused by infection. We found that the level of care provided to Mrs C was below acceptable standards.

Recommendations

We recommended that the board:

• consider holding a significant event analysis in order to reflect and learn from this case; and
• issue a written apology to Mr C for their failure to adequately examine Mrs C and assess her symptoms and blood tests and for the delay in making an accurate diagnosis.

Summary

Mr C (an MSP) made a complaint on behalf of his constituent (Mrs B) about the clinical treatment and nursing care provided to Mrs B's late mother (Mrs A). The complaints included a delay in undertaking a CT scan (a specialised type of x-ray using a computer); the insertion and monitoring of a drain to remove fluid from Mrs A's abdomen; and failures in communication.

We upheld Mr C's complaint and made a number of recommendations. Our investigation included taking independent advice from two of our medical advisers - an oncologist (a cancer specialist) and a senior nurse. Both advisers were critical that there was a lack of documentation about Mrs A's care and treatment, and noted that this made it difficult to know what had or had not been done for her. Our investigation also found that there were many failures in communication between staff and Mrs A and her family. This was particularly difficult for the family when Mrs A was nearing the end of her life and was placed on the Liverpool Care Pathway (a tool used to assist clinicians and nursing staff to support patients and their families as the patient is dying. The aim is to address the patient's symptoms rather than aggressively pursue a cure for the underlying terminal condition.)

We also noted that there was a delay of some four weeks before the radiology department received an urgent CT scan request made by Mrs A's GP, and then it was a further two weeks before the scan took place. The board could provide no explanation for this delay other than human error in not following it up. While the delay was unlikely to have altered the eventual outcome for Mrs A, we found it unacceptable.

Recommendations

We recommended that the board:

• remind all staff involved in processing requests for referrals and investigations of the importance of arranging appointments to meet the two-week NHS target time;
• ensure that all relevant staff are made aware of the revised medical protocol for the management of ascites (fluid)/drainage;
• ensure that all relevant staff are made aware of the requirement to seek informed consent for any invasive procedure to be undertaken, and where necessary provide appropriate training;
• conduct an audit of record-keeping in the ward concerned, and address any learning issues identified;
• remind all relevant staff of the need for effective communication with patients, relatives and/or carers, and provide refresher training where necessary; and
• apologise for all of the failings identified during our investigation.

Summary

Ms C, who was acting on behalf of Mr and Mrs A, complained about the care and treatment that their son (Master A) received after he fell from a tree and hurt his arm. He went to the accident and emergency department of a hospital, and was discharged after the wound was cleaned and glued. He later visited his GP and was referred to hospital where he had surgical treatment for the wound. However, this did not identify that two pieces of bark were lodged in it, which were only removed during a later private surgical procedure. Master A's parents felt that by not identifying the bark in the wound, the board had failed to reach the correct diagnosis.

We took independent advice from one of our medical advisers, an experienced orthopaedic surgeon. He reviewed the board's notes and all of the associated correspondence and said that, based on the evidence available at the time, the treatment was reasonable. He said that while it may seem to a member of the public that a foreign object should be identified within a wound, such objects can easily move within the body. By the time the private procedure was carried out, it was highly likely that Master C's body had been trying to expel the bark and so it may have been more evident at that point. We agreed that, without the benefit of hindsight, the board's treatment was reasonable. We also noted that the board had explained to the family that they had identified learning points from their complaint. We checked on these and, in light of this confirmation and the advice received, we were satisfied that the board had acted reasonably and that we did not need to make any recommendations.

Summary

Mrs A, who lived in a care home, became ill in the early hours of the morning. The care home contacted the out-of-hours service, and one of their doctors came and examined Mrs A. He recorded that there were signs on her teeth that she had vomited blood and that her abdomen was soft and non-tender. He diagnosed gastritis (inflammation of the stomach lining) and said that the care home should observe Mrs A, and if she vomited blood again or complained of pain in her abdomen, they should call 999. He also said she should see a GP from her own practice. One of the practice doctors visited later that day, and considered that she had an upper gastrointestinal tract bleed. She was then examined by the practice on a number of occasions and was eventually admitted to hospital three weeks after the out-of-hours doctor first examined her. Mrs A died in hospital of a small bowel obstruction nine days later.

Mrs A's son (Mr C) complained about the care and treatment provided by the out-of-hours doctor. He was of the view that the doctor had failed to diagnose that Mrs A had a small bowel obstruction and felt that he should have referred her to hospital. After taking independent advice from one of our medical advisers, however, we did not uphold his complaints. We found that the doctor's investigation, diagnosis, care and treatment of Mrs A were of a reasonable standard. Her presentation was not consistent with the symptoms or signs of bowel obstruction and we did not consider that the doctor failed to identify this. The only option the out-of-hours doctor had for referring Mrs A to hospital was as an emergency admission, and it would have been for her own GP to refer her for an out-patient assessment. We found that the medical records showed that Mrs A did not warrant emergency admission and so the doctor had arranged for her GP to see her. We also found that the doctor's clinical records were adequate and that his instructions to the care home staff were comprehensive.

Mr C was welfare power of attorney for his mother (ie he was able to take decisions about her care and welfare), and he also complained that the out-of-hours doctor failed to consult him about the treatment provided to Mrs A and about her future care plans. We found, however, that there would have been no reason for that doctor to contact Mr C in the early hours of the morning, as he made no treatment decisions when he visited Mrs A. He simply verified that she did not need to be admitted as an emergency, and referred her to her own GP the same day. There was also no requirement for him to tell Mr C that he had visited Mrs A, which we considered was the responsibility of care home staff, during normal working hours.