NHS Forth Valley has apologised over three separate cases raised with the Public Services Ombudsman, including one involving a cancer patient and another involving the treatment of a patient with Alzheimer’s.
The first case lodged with the Scottish Public Services Ombudsman (SPSO) saw a complainer (C) refer to the care and treatment provided to their late parent (A).
Following a diagnosis of bladder cancer, NHS Forth Valley identified that A would require heart surgery before they would be fit enough for bladder surgery. They referred A to another health board to provide that surgery - but this took a number of months to arrange and carry out.
C told the ombudsman that, by the time the heart surgery was completed, A’s cancer had progressed to a point where treatment was no longer possible.
In their decision, the SPSO said: “We found that the board failed to identify radiotherapy as a possible alternative treatment, despite this advice being given by their oncology team. In addition, we found that the board had mishandled the referral to the other health board for heart surgery, failing to ensure that the other board were made aware of the urgency required.
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“Then, when there were inevitable delays in surgery as a result, the board failed to identify that the window for treatment was closing.
“For these reasons, we upheld C’s complaints.”
In a separate case, a complainer (C) complained about the care and treatment provided to their parent (A). A had Alzheimer’s disease and C had a full power of attorney (POA) in place that was active at the time, enabling C to make decisions about A’s welfare.
The SPSO report stated: “A was admitted to Forth Valley Royal Hospital via the acute assessment unit, and was later transferred to a ward. C said that when admitted to hospital A was continent, could walk with a stick, slept through the night, and was eating and drinking.
“C said that the board made inappropriate changes to A’s medication during their admission, and that, when later discharged, A had lost weight, was not eating and drinking, was very frail and could not stand up, and was doubly incontinent.
“C also had concerns about the way A was treated and spoken to by nursing staff, and that they were discharged with a very large pressure ulcer.
“The board apologised for the way in which A was spoken to and treated by nursing staff and that the staff involved have received training and would be monitored going forward. The board also said communication with family members was not documented as it should have been.
“We found that the medical care and treatment provided by the board, including changes in medication, was reasonable.
“However, the overall nursing care, and particularly the record-keeping, was unreasonable. We also found that the board did not communicate reasonably with C about A’s care, discharge, or their ongoing needs. We, therefore, upheld C’s complaints.”
In the third case, a complainer felt the care and treatment they received during an in-patient stay at Forth Valley Royal Hospital was substandard.
They had been admitted to the hospital while in the early stages of labour, giving birth a few days later before being discharged home the following day.
After discharge, her health began to deteriorate and she was later admitted to a different hospital, where they received a blood transfusion and treatment for an infection.
The complainer said the board had failed to inform them she had a yeast infection and failed to provide them with any treatment for this, and also that a clinician knowingly recorded an inaccurate pulse rate on their records and that the board failed to appropriately treat their post-natal high blood pressure and/or blood loss.
The Ombudsman upheld the complaint over failure to inform the patient of the yeast infection, but found insufficient evidence to establish that an inaccurate pulse rate had been recorded given blood pressure and/or blood loss were within normal limits when they were discharged from hospital.
They added, however: “We did find that clinicians failed to reasonably respond to the complainer’s high pulse rates at one point during their admission. While this issue was not raised by C in their complaint, we considered that it was reasonable to make recommendations to the board in relation to this matter.”
The SPSO told NHS Forth Valley to apologise to the three complainers and made a number of recommendations in each case aimed at rectifying any issues raised.
An NHS Forth Valley spokesperson said: “We have apologised to the individuals and families involved and work is underway to ensure all of the recommendations are addressed within the timescales set by the Scottish Public Services Ombudsman.
“We will also share the findings with local staff and services to ensure we learn from these reports and use them to inform future service developments and improvements.”
