SPSO Individual Decisions

Mr C, who is a prisoner, complained to the board about the medication decisions taken by his prison health centre. Mr C was not satisfied with their reply, which he felt had not addressed his concerns, and so he sent them a follow-up letter. However, the board sent it back to the health centre, unanswered, and the health centre gave it to him, with a note that advised him to follow the correct complaints process. Mr C contacted us for help in getting a reply to his follow-up letter as he thought he had been following the process and did not know what to do. Although initial complaints to health boards should go through the health centre, it is our view that follow-up letters may go direct to a board. If a board wish to ensure that the health centre knows what is happening, the board may tell the health centre about it themselves. But we take the view that it is not for a complainant to have to try to navigate a complaints system this way. We, therefore, sent Mr C's follow-up letter back to the board and asked them to reply to Mr C. We told Mr C that we had closed his complaint while he and the board were dealing with it but that he could come back to this office after that if he thought the complaint should be investigated further. Related reading View Decision Report 201202059 as a PDF (11.23 KB) Updated: March 13, 2018

Mr C complained about the board's decision to relocate the pain management clinic at a hospital. He said that the previous location for the clinic was more accessible for him and because of the relocation he now faced a journey time of over eight hours for a 15 minute appointment. In response to Mr C’s complaint, the board suggested alternative means by which he could attend the clinic but he did not feel they were appropriate. He felt the board had not taken into account his health needs when making the decision to relocate the clinic and complained to us. We explained that health boards have the authority to take decisions about where to site services within their area. We found that in an effort to address Mr C's concerns, the board had offered Mr C reasonable solutions in order that he could access the clinic where his condition could be assessed. This included information about public transport links and the availability of patient transport services. In addition, the board also offered to pay for a taxi fare for his next appointment but said that the matter would be kept under review. The board also suggested that to avoid the need for travelling, Mr C could have a telephone consultation. We concluded that the board had taken appropriate action to assist Mr C and did not uphold the complaint. Related reading View Decision Report 201103887 as a PDF (11.37 KB) Updated: March 13, 2018

Mr C had a history of mental health problems. In 2011 he started to become increasingly anxious with strong violent urges. He was able to control the urges but found it difficult and was concerned that he might harm friends or family members if he did not receive effective treatment. Mr C complained that his medical practice did not do enough to progress his treatment. He was unhappy with how they managed his condition, saying that they adopted a 'wait and see' approach. The medical records showed that therapists and the practice had made a number of referrals. We were satisfied that there was a pattern of reasonable care, and that the referrals made were detailed and appropriate and responsive to Mr C's circumstances. Mr C had also asked the medical practice to prescribe medication to help with his unwanted thoughts, but this was refused. Our medical adviser considered Mr C's case and said that medication should not be used to treat personality disorders. We, therefore, found that the decision not to prescribe medication was appropriate, as Mr C had been diagnosed with a personality disorder rather than a psychiatric disorder. Mr C is receiving ongoing treatment from a psychologist and we considered this to be the appropriate treatment for his condition. Related reading View Decision Report 201103386 as a PDF (11.36 KB) Updated: March 13, 2018

Mrs C complained that a doctor in a hospital's accident and emergency department did not order an x-ray despite her prior history of osteopenia (a condition affecting bone density). Mrs C said that the doctor had examined her and advised that nothing was broken but that there was some bruising to her ribs that was likely to last two months or so. She also said that the doctor had told her to take 500 milligrams of paracetamol four times a day for pain relief. Mrs C said that the doctor planned to do a rectal examination but she left before it was carried out. This was because of the time it was taking to arrange a chaperone, and because she was unable to get into the required position due to the level of pain she experienced. As the pain had not improved, Mrs C visited her GP some two weeks later. An x-ray was arranged and showed a fracture to her spine. In their response to the complaint, the board advised Mrs C that it was not possible to make a judgement on whether it would have been appropriate for the doctor to have requested an x-ray, as she had left the department before the clinical assessment could be completed. Following advice from our medical adviser, we concluded that, although Mrs C had left the department before the rectal examination was done, the doctor should have considered an x-ray based on the risk factors Mrs C presented with and her previous medical history. We also noted that most protocols suggest that, in women over fifty years of age, back pain caused by trauma requires x-ray investigation. We also identified that the doctor had not documented the partial examination he had carried out on Mrs C, nor had he noted the plan to carry out a rectal examination. The doctor has said that he will learn from the incident and ensure that relevant information is recorded if a similar situation were to arise in future.

Mrs A, who was elderly and disabled, was admitted to hospital. While in hospital she fell. Mrs A was seen by a doctor, who did not suspect any broken bones. Later, it was determined that she had broken her hip. Her solicitor (Mr C) complained that although her mobility problems were recorded, she was not given enough assistance. He said that as the fracture was not diagnosed at the time, Mrs A was caused additional pain. We carefully considered all the available information provided by Mr C, Mrs A's son and the board. Our investigation found that the board failed to carry out an adequate mobility assessment when Mrs A was admitted to hospital. However, we found no evidence that she was not offered appropriate assistance. We also found that the board's care and treatment of Mrs A was satisfactory. We upheld Mr C's complaint that the board unreasonably failed to respond when he questioned the outcome of their investigation.

Ms C was diagnosed for a second time with cancer in the left breast and a lumpectomy (operation to remove a lump) was carried out. Ms C complained that the board failed to carry out the consultant's agreed monitoring programme of six monthly clinic reviews and annual mammograms. She said that when attending her second six monthly clinic review she was advised by one of the doctors that her next clinic review would be in one year's time due to the volume of patients. Ms C was also dissatisfied that a mammogram appointment was supposed to have been arranged but that she had to raise it with the doctor and arrange it herself. She also complained that the board's response to her complaint contained inaccurate information, in that they said she had undergone a mastectomy (opertation to remove a breast) and reconstructive surgery, which was incorrect. The board had advised Ms C that she was being reviewed in accordance with the agreed monitoring plan of two six monthly clinic reviews, followed by yearly reviews and yearly mammograms. The board also told her that the doctor had not said that the yearly clinic reviews were due to the volume of patients, but that they were based on patient need. We did not uphold the complaint about the monitoring programme. Although we considered that the wording of the consultant's monitoring plan was open to interpretation, our medical adviser said that the frequency of clinic reviews was appropriate and in line with the Scottish Intercollegiate Guidelines Network for the management of breast cancer in women. We could find no objective evidence to support Ms C's concern that she had been told that her next clinic review would be in one year's time due to the volume of patients. Our medical adviser also considered that it was not unusual or inappropriate for a mammogram appointment not to have been made prior to Ms C's last six monthly clinic review. This was because it is safer to book appointments from the clinical assessment than to hav

Mr C made several complaints about the care and treatment he received in hospital, most of which we did not uphold. He said that a communication failure meant that staff were not expecting him when he arrived. However, we found that the staff nurse had been told that he was coming in and that, although there was a delay in providing him with a bed, this was not unreasonable in the circumstances. Mr C also said that he asked for a doctor when he felt that he was developing a urinary tract infection, but no doctor attended. We found that nursing staff had contacted the night team, which included medical staff, and the team had said that the staff should wait for the results of tests on a urine sample that had been taken. We found that staff acted reasonably in response to Mr C's requests and noted that a consultant saw him the next day. Mr C asked to see a doctor again the next evening. Nursing staff again contacted the night team, who said that they would see him after they had seen some other patients. However, Mr C then decided to discharge himself and was ready to leave when the team arrived. Mr C also told us that some nursing staff displayed hostility towards him. We found no evidence of this, but noted that Mr C felt very frustrated by what he saw as staff failure to respond to his requests and wishes. We took the view that staff might have been able to prevent the situation escalating if they had more expertise in listening and responding to feedback. We noted that Mr C's complaint resulted in the board deciding that staff should have additional training in relevant techniques. We did uphold Mr C's complaint that the board delayed in responding when he complained to them. We found the response itself to be satisfactory, although we thought the board could have provided Mr C with more information about the training they had arranged for staff in response to his complaint. Recommendation We recommended that the board: • provide us with further information about

Mr C complained on behalf of his mother about a cancer diagnosis that was delayed due to 'human error' by a radiologist (a medical specialist that uses imaging to diagnose and treat disease) in interpreting a scan. He also complained about the board's complaints handling and what he regarded as confusing and/or contradictory information. We upheld Mr C's complaint about the misinterpreted scan. We found that the board had already acknowledged this and apologised to him. When looking at the complaint, we took account of the action already taken by the board. We also looked at the remedial action they took to minimise the likelihood of a recurrence and took advice from our medical adviser, who compared the board's action to national standards set by the Royal College of Radiographers. We found that the remedial action either matched or exceeded the national standards and we were satisfied that appropriate and timely action had been taken to address the failings identified. We, therefore, did not make any recommendations. On the issue of the complaints handling, we found that the information provided to Mr C was clear and was not contradictory. Related reading View Decision Report 201103024 as a PDF (17.01 KB) Updated: March 13, 2018

Mrs C complained to the board about aspects of the care and treatment provided to her late husband (Mr C) both in hospital and by the Out of Hours Service (OOHS). Mr C had been suffering from cancer. When he became unwell with abdominal pain and diarrhoea, Mrs C contacted the OOHS and Mr C was taken to hospital. Mrs C complained that Mr C should have been taken to a different hospital, and that he was given inadequate clinical treatment and pain relief. She also complained about delays in diagnosis and treatment; poor communication and unhelpful attitudes from staff; the time taken for an OOHS doctor to arrive at the house and that the doctor was uncaring. We did not uphold the majority of Mrs C's complaints. We established that, as an emergency ambulance was called, it was appropriate for Mr C to be taken to the hospital where he was treated. After taking advice from one of our medical advisers, we also found that while Mr C was in hospital he received appropriate clinical treatment, staff carried out appropriate investigations, and the general level of communication was adequate. We upheld two of Mrs C's complaints as we found that for a period Mr C's pain was not managed appropriately; and that there had been a fifteen minute delay by the OOHS doctor in arriving for the home visit. We did not make recommendations on this complaint as the board have already taken action to remedy what went wrong. The board have apologised for a breakdown in communication by the nurses in regards to pain relief and staff at the OOHS have apologised for the delay in their doctor making a house call. Related reading View Decision Report 201101242 as a PDF (17.31 KB) Updated: March 13, 2018

Mr C complained about the care and treatment he received from his medical practice. Specifically, he said that he had been prescribed the wrong drugs for his illness. He maintained that he had resisted the prescriptions but that his GP had refused to change or stop his medication. He believed that his continuing mental health problems were as a consequence of receiving the wrong drugs. The investigation found no evidence to suggest that the treatment given to Mr C was incorrect. We also did not find any evidence to suggest that Mr C had asked for his prescriptions to be changed or stopped or that his requests had been refused. We found that all the drugs prescribed to Mr C were appropriate for his presenting condition, and we did not uphold his complaint. Related reading View Decision Report 201101237 as a PDF (13.67 KB) Updated: March 13, 2018

Ms C has been undergoing psychiatric treatment for a number of years and had been diagnosed with 'Bi-Polar Type II Rapid Cycling Mood Disorder'. In May 2010 she attended a consultation and was told that her diagnosis had been changed to 'Complex Personality Disorder'. Despite advice that the team would gradually reduce her medication, Ms C stopped taking her medication right away. She reported that this has made her feel considerably worse. She was also concerned that the board told her she needed a chaperone when attending any consultation where there would be discussion of her condition and treatment. Finally, she also complained that some of the copy clinical notes she was provided with were hand-written and illegible. The complaint was investigated and independent psychiatric advice was obtained. At this point the difficulties of psychiatric advice were explained (that it was rarely that objective investigations, like blood tests, could be relied upon) and that changes in diagnosis were perhaps more probable in this area of medicine. It was confirmed that as an initial diagnosis had taken four years it was likely that Ms C's presentation was atypical and it was, therefore, reasonable to review her diagnosis and medication. The investigation also showed that after an alleged incident involving Ms C, there had been significant concern expressed by a senior member of staff about his personal safety. A collective decision had later been taken by board staff that a chaperone should be present with Ms C and any practitioner when her clinical care and treatment were being discussed with her. This satisfied the board's own responsibilities to their staff while not prejudicing Ms C's clinical care. After consideration, Ms C’s complaints were not upheld. However, the investigation confirmed evidence that the clinical notes given to Ms C after she requested them were, in part, difficult to read. In the circumstances, while upholding this complaint, it was recommended that

Ms C complained on behalf of her late mother (Mrs A) about the care and treatment that she received from her GP practice. Mrs A attended the surgery for a period of two years with repeated complaints of breathlessness, pain in the back and rib cage, and a cough. She made the practice aware of a family history of lung disease and lung cancer. She was treated for numerous chest infections but received little or no relief from her symptons. Mrs A's condition deteriorated and she was admitted to hospital and diagnosed with terminal cancer of the lung, liver and upper chest. Mrs A died shortly after. Ms C complained that the practice failed to properly investigate Mrs A's symptoms within a reasonable time and that they failed to suspect her condition and refer her to hospital within a reasonable time. We found that the practice carried out reasonable investigations, but that they should have had a high index of suspicion of lung cancer given Mrs A's strong family history and that she was previously a heavy smoker. Our medical adviser said that the practice should have considered referring Mrs A to a respiratory specialist when her respiratory symptoms had persisted for more than six weeks and were unexplained. However, we also found that even if the diagnosis had been made sooner, this was unlikely to have affected the outcome because Mrs A probably had a non-curable disease at presentation. Having said that, an earlier diagnosis might have improved her quality of life because it would have allowed treatments to be explored that might have alleviated some of her symptoms.

Mrs C complained that she was removed from the practice list without warning or reasonable explanation. She also complained that the practice failed to give her advice about, or treat, a leg injury. In addition, Mrs C complained that the practice failed to refer her to appropriate specialists for treatment for ongoing health problems. We did not uphold the complaint about referral to specialists. We found from looking at the practice's records and taking advice from one of our clinical advisers, that Mrs C was referred appropriately. We also found that, as Mrs C went to hospital for her leg injury, the practice were not responsible for treating it. The practice said they gave Mrs C appropriate advice about her leg injury. However, because they did not have a record of this, we upheld the complaint. We also upheld the complaint that Mrs C was removed from the list without warning, as we felt that the practice could have given one. However, we agreed that the practice had given Mrs C a reasonable explanation when they did remove her from the list.

Mr C complained about the standard of care and treatment his late wife, Mrs C, received at Stirling Royal Infirmary. She died three weeks after being admitted to hospital. Mr C had concerns about a number of aspects of his wife's care including a belief she had had an allergic reaction to antibiotics administered, that there were not sufficient efforts made to feed Mrs C out of bed and into a chair, that Mrs C could not refuse suctioning as had been explained by the hospital and that Mrs C was not moved to another ward at the family's request. Mr C felt that his wife had received substandard care because she was elderly. Mrs C had undergone a bronchoscopy procedure (used to view a patient's lung) to clear an obstruction in her lung and she did not recover from this. Mr C felt this operation should have been performed sooner to allow Mrs C a greater chance of survival. Two of our advisers, a nursing adviser and a consultant geriatrician, considered Mrs C's medical files and the correspondence between Mr C and the hospital. They both found the care and treatment provided to Mrs C had been of a good standard. The clinical adviser found the hospital's explanation with regards to Mrs C's face and hand swelling had been rational - that she had suffered a seizure. He found no evidence of her having been given medication she was allergic to. He felt the ongoing and increasing difficulties with Mrs C's lungs had been monitored and treated to an acceptable standard. He noted radiological investigations were performed promptly. He noted the bronchoscopy, given it was a particularly invasive procedure, was performed at an appropriate stage of Mrs C's care. The nursing adviser noted the communicative difficulties between Mr C, other family members and members of staff on the ward. The hospital had already apologised for any difficulties the family had experenced with the consultant responsible for Mrs C's care. The adviser found the nursing care to have been of a good standard.

Mrs C complained that her daughter (Mrs A) received inadequate care and treatment from Surgical Services in Stirling Royal Infirmary. Mrs C said it took the hospital six weeks to diagnose Mrs A's medical condition and that this delay could have been avoided had medical staff seen her earlier. Our investigation concluded that from Mrs A's several admissions through to her in-patient care and subsequent discharges she received appropriate care and treatment from the hospital. Although the results of a Malnutrition Universal Screening Tool (MUST) test could have been recorded in more detail, our medical adviser said that Mrs A was eventually diagnosed with a rare and complex medical condition and the investigations that were carried out were appropriate. We also did not uphold the complaint that the Board failed to respond reasonably to Mrs C's complaints about this. We noted that before she brought this complaint to us the Board had already apologised for some of the issues Mrs C had raised. Recommendation We recommend that Forth Valley NHS Board ensure that a written record of every MUST test is completed and filed to comply with NHS record-keeping guidelines. Related reading View Decision Report 201002440 as a PDF (14.04 KB) Updated: March 13, 2018