Health

Summary

C complained about the care and treatment provided to their spouse (A). A had been diagnosed with lung cancer and were due to start treatment. A had become unwell overnight and attended the A&E twice in 24 hours. At the first attendance A had been examined but sent home. A’s condition had worsened, and they had been taken back to the A&E by paramedics. A had been examined and then admitted to hospital but died shortly after.

C believed that A’s first assessment was inadequate, and that their concerns about pneumonia were dismissed unreasonably. They felt strongly that had A been given antibiotics and admitted, they might have had a better outcome. C believed that on A’s second attendance, A’s cancer specialists should have been contacted sooner.

We took independent advice from an emergency medicine adviser. We found that A’s assessments were reasonable and that it was unlikely that the outcome would have been different had A been prescribed antibiotics or admitted sooner. We did not uphold the complaint.

Summary

C complained that the dentist failed to provide them with a reasonable standard of dental care and treatment, resulting in significant deterioration. C had concerns about x-rays and the dentist's complaint response. Following contact from our office, the dentist offered a resolution which C accepted. Therefore, we closed the complaint as resolved.

Summary

C complained on behalf of a relative (B), about the care and treatment provided by the board to B's late spouse (A).

When A first felt unwell, they visited their GP on three occasions where they were prescribed antibiotics and told they had a chest infection. Following an x-ray, A was prescribed medication to increase the amount of urine produced, with a plan to carry out a follow up x-ray. A visited the GP again with breathlessness and was referred to the hospital where they were admitted and diagnosed with COVID-19. Blood tests showed that A had an infection and a chest x-ray reported fluid on the right side of A’s chest. A was initially treated for infection with COVID-19 and a suspected bacterial infection. A was discharged from hospital with a plan to repeat the x-ray as an outpatient. A few days later, A was readmitted and diagnosed with lung cancer and was showing signs of spinal cancer.

A was further told that there was a cancerous tumour pressing on their lungs. A’s breathing worsened, they had severe weight loss and they were not eating. Only one family member at a time was permitted to visit A. Staff said that more of A's family would be able to visit if their condition deteriorated. A remained in hospital until their death a week later.

In considering C’s complaint, we took independent advice from a consultant in general and respiratory medicine and a senior nurse. We found that the decision to discharge A from hospital was reasonable and did not uphold this aspect of C's complaint. However, we found that it was unreasonable that A's pleural effusion (fluid build up) was not treated on or shortly after admission. Therefore we upheld the complaint that the board unreasonably failed to carry out further investigations whilst A was on the ward.

We also found that A was unreasonably left sitting and sleeping in a chair during their admission, that A’s family were not given any additional time to visit when A was at end of life and that there was a failure by the board to notify A’s family that their condition was rapidly deteriorating. We upheld these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of these 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:

• Further investigations should be carried out in line with the expected standards for management of pleural effusions in the context of acute admissions.
• In such circumstances, staff should contact the family promptly to inform them of a patient’s deterioration.
• Relevant staff should be aware of changes to guidance.
• The person-centred care plan should be fully completed for each patient and updated with a changing deteriorating picture. When a patient is nursed in a chair it should be clearly documented that this is an informed choice to ensure person centred decision making and regular skin checks completed. Recliner chairs should be obtained promptly where required.

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

The complainant (C) had a right top hip replacement. Some years later, C began to experience back pain and left ankle pain for which they attended physiotherapists and podiatrists. C told us that two years after their hip replacement, a podiatrist identified that C had a leg length discrepancy. C complained that they now have a leg length discrepancy of approximately 17 mm which they considered to be unacceptable.

The board said that leg length discrepancy is a recognised risk following hip replacement surgery. This was confirmed on a form signed by C prior to the procedure.

We took independent advice from a consultant orthopaedic surgeon. We found that the risk of leg length discrepancy was reasonably discussed before the procedure and that the true discrepancy was 5mm which was reasonable. We noted that the operation was carried out to a reasonable standard.

As such, we found that the care and treatment provided by the board was reasonable and we did not uphold the complaint.

Summary

C complained about the care and treatment provided to their late parent (A) by the board. A was living independently but fell and injured their knee. A was admitted to hospital and underwent surgery. C believed that A did not receive adequate food or drink and that A was not provided with antibiotics timeously. A died in hospital and C complained about the way that A’s end of life care was managed, as well as a delay in providing C with a death certificate.

We took independent advice from a consultant physician and a registered senior nurse. We found that A’s medical and nursing care fell below a reasonable standard. During the end-of-life period, we also found that A’s nursing care fell below a reasonable standard, although their medical care was reasonable. We also found that there was an unreasonable delay in providing C with A’s death certificate. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family 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:

• Care for patients receiving end of life care should be planned and their care plan updated to reflect their specific needs. Appropriate end of life care should be provided in particular in relation to repositioning and comfort care and this should be documented.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring, as well as appropriate and regular monitoring of their weight when requested as part of their care plan.
• Patients admitted to hospital should receive reasonable medical care including appropriate and timely medical assessments for feeding and nutrition and delirium and appropriate antibiotic treatment.
• Staff caring for a patient with diabetes should be competent in the monitoring and appropriate recording of blood sugar results and any action taken to address low or high blood sugar.
• Staff involved in wound care should be knowledgeable and competent in wound assessment; wound care and treatment.
• Reporting of deaths and issuing of a death certificate should not be delayed unnecessarily by staff absence.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning.

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, an independent advocate, complained on behalf of their client (B). B’s adult child (A) died from an overdose of dihydrocodeine (opioid prescribed for pain or severe shortness of breath). A had been prescribed a number of different medicines by their GP practice including painkillers and benzodiazepines (depressants).

B complained that the practice did not appropriately manage the risks of prescribing A such medication. B questioned why prescriptions were issued to A on a monthly basis, rather than weekly or even daily. B also complained that the practice had insufficient regard to A’s history of overdoses and that A should not have been given additional prescriptions on request, as had happened on multiple occasions. Lastly, B was concerned that A had remained with the practice despite having moved a significant distance away.

In their response to the complaint, the practice stated that weekly or dispensing does not necessarily prevent the hoarding of medication, and that A had been maintained as patient due to their local GP being staffed primarily by locum doctors lacking a familiarity with A’s situation. They said that while they were aware of A’s overdoses these were often also due to alcohol or illegal drugs. The practice said that they felt A’s requests for additional medication had been genuine and that they needed to balance the risk that A would seek illicit drugs or street medication if suffering from withdrawal. The practice also stated that following this incident they had reviewed their approach to such patients and had recently refused a number of requests to keep on patients living remotely.

We took independent advice from a GP. We found that the kinds of medication prescribed to A are implicated in many drug related deaths, often in combination with other substances such as alcohol. Taking into consideration A’s history, their mental health, alcohol misuse and history of multiple drug overdoses, early prescriptions should not have been given to A and instalment dispensing should have been used to reduce risk. We also found that the evidence did not suggest that A remaining as a patient with the practice had kept them safe, and had influenced the decision not to provide weekly dispending. While it was not possible to say whether this decision had contributed to A’s death, overall, the practice had not provided A with reasonable care and treatment with regard to their prescription medication and on this basis, we upheld B’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the failings identified in A’s care and treatment with respect to the prescription medication issued to A. The apology should meet the standards set out in the SPSO guidelines on apology available at 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’s parent (A) was admitted to the hospital and diagnosed with a urinary tract infection (UTI) and sepsis. A was transferred to the acute medical unit (AMU) that night and died later the next day. C was concerned about the care and treatment provided to A.

C raised a number of complaints with the board regarding the care and treatment that A received, including the provision of oral care. The board accepted that there had been issues with the prescription and administration of anticipatory medication and the care provided to A, and outlined steps that would be taken to prevent any recurrence. C was dissatisfied with the board’s responses and actions and raised their concerns with SPSO.

We took independent advice from a nursing adviser. We found that the investigation already carried out by the board, and the steps taken to address the areas for improvement identified were reasonable and did not require further investigation by the SPSO. However, we found that the action taken did not address the issue of the provision of oral care to A and investigated this matter further.

In responding to our enquiries, the board accepted and apologised that there had been issues with A’s oral care during their admission. Therefore, we upheld the complaint that the board did not provide A with reasonable oral care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not provide A with reasonable oral care. 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:

• Training is delivered to all relevant nursing staff in the Acute Medical Unit regarding mouthcare in palliative care. This should include structured educational or awareness sessions covering common mouth problems in such care (dry mouth, painful mouth, infections, bad breath, changes in taste and drooling).

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 on behalf of their spouse (A). A was taken into hospital with COVID-19 and low blood sugar and was discharged after two days. That night C was concerned that A’s condition had deteriorated. A was taken to ICU and died 4 days later. The cause of death was recorded as COVID-19, ketoacidosis (where a lack of insulin causes harmful substances called ketones to build up in the blood) and renal failure. C considered that A had been discharged inappropriately in the first instance.

The board explained that A was frail. They came into hospital with chest pains from COVID-19 and were checked for pulmonary embolism. A was discharged appropriately but unfortunately deteriorated rapidly at home. Every effort was made to treat A on readmission.

We took independent advice from a consultant physician, specialising in acute medicine. We found that A had a poor state of health prior to admission, that their discharge on the first occasion was reasonable and that there was no way the discharging team could have predicted A’s subsequent deterioration. Upon A’s second admission, medical teams and intensive care teams provided a reasonable standard of management and care. Overall, we considered that the care and treatment had been reasonable and that there was no requirement for a Severe Adverse Event Review or Duty of Candour to be initiated. Therefore, we did not uphold the complaints.

Summary

C complained about the care and treatment that they received from the dentist during a period of eight months. C is a bariatric patient and is unable to recline due to their medical condition. C attended for an examination with the dentist and complained of a broken front tooth and decay on the upper left second molar. Treatment options were discussed and it was agreed that at the next visit, the dentist would apply fillings to both teeth.

C attended for treatment to both teeth 11 weeks later. The dentist explained to C that a referral to the Public Dental Service (for individuals who cannot access an independent dentist) would likely be the best option going forward as they were unable to gain proper access to treat C. C agreed to a referral and the next examination was scheduled for six months’ time. C attended for an emergency appointment six weeks later, complaining of pain. The tooth was filled and the dentist made a referral to the Public Dental Service, resending it six weeks later.

C emailed complaints to the practice on two occasions but did not receive a response to either.

C attended for a further examination complaining of ongoing pain. Treatment options were discussed and the dentist booked C in for an appointment for treatment.

C emailed the practice to ask for a response to their previous two complaint emails. C was advised by the practice to speak with the dentist during their appointment the following day. However, C decided to cancel future treatment as they had lost faith in the dentist.

C received a complaint response from the dentist and contacted the practice the following day to express their dissatisfaction with the response. The dentist issued a further response in an undated letter. C wrote to the practice again and the dentist subsequently issued a further letter to C saying that they believed they had already addressed all of C’s concerns.

In considering C’s complaint, we took independent advice from a dentist. We found that overall, the care and treatment provided to C by the dentist was reasonable and that there was no unreasonable delay in referring C for treatment. We did however find that C’s complaints were not appropriately identified and responded to in line with the complaint handling procedure and upheld this complaint. We also provided feedback to the dentist in relation to communication.

Recommendations

What we asked the organisation to do in this case:

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

In relation to complaints handling, we recommended:

• The dentist should ensure complaint investigations conform to the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. They should review their handling of this complaint with a view to identifying areas for learning and improvement.

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 that they received from the board. C underwent a left total hip replacement but returned to the consultant orthopaedic surgeon for follow-up three months later as they were continuing to experience pain and mobility problems. C complained that they were told there was nothing the surgeon could do for them. C sought a second opinion and learned that they had impingement (pinching or rubbing together inside a joint) which would require further surgery. C said that they had been significantly impacted by the initial surgery, both mentally and physically.

In their original complaint response, the board acknowledged the poor outcome of the surgery. Following our formal enquiry the board acknowledged that a different choice of acetabular (socket) implant would have been appropriate. The surgeon acknowledged that this case was one where they would have benefited from advice from a more experienced surgeon. They accepted that they had failed to discuss with C that a poor outcome from surgery was a risk, and failed to document decision making and consent discussions in C’s clinical records. They apologised for failings in communication with C during their post-operative consultation. They also apologised for record-keeping failings. The board said they should have discussed this case at a departmental Morbidity and Mortality meeting once it became clear that there were ongoing problems requiring further surgery. They considered that not doing so represented a failure of process, prompting them to review their relevant structures and processes. The board confirmed comprehensive measures to address what had gone wrong in C's case.

We took independent advice from a consultant orthopaedic surgeon (specialists in the musculoskeletal system). We concluded that the board had now appropriately acknowledged the multiple failings in this case, apologising and confirming extensive learning and improvement. Taking all of this into account, we upheld C's complaint and asked the board to apologise but did not make further recommendations for learning and improvement.

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.

In relation to complaints handling, we recommended:

• Complaints are investigated with sufficient rigour to identify failings where appropriate. Complaints handling procedure timescales are met.

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.