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  • Report no:
    201901343
  • Date:
    August 2020
  • Body:
    Highland NHS Board
  • Sector:
    Health

Ms C complained about the care and treatment her late father (Mr A) received at Raigmore Hospital after he died unexpectedly following elective knee surgery. Ms C also complained about Highland NHS Board's investigation of her complaint.

The Board's investigation of Ms C's complaint did not identify any failings in Mr A's care. We took independent advice from a consultant trauma and orthopaedic surgeon. We found that Mr A's symptoms prior to discharge were not appropriately acted on. Had they been, there is a possibility that other specialities could have been called in to assess and assist. However, we could not say whether this would have affected Mr A's outcome. We concluded that Mr A's postoperative care and treatment was of an unreasonable standard and upheld the complaint.

In terms of the consent process for Mr A's surgery, we were also critical that there was no record to demonstrate that all the specific recognised risks of a total knee replacement surgery were covered sufficiently during a clinic consultation. We concluded that this is contrary to national guidance on consent and was unreasonable.

We also found that the Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care. The letter concentrated mainly on the opinion as to the cause of Mr A's death rather than systematically addressing the points Ms C had written in her complaints form. We concluded that the response to Ms C's complaint was not compliant with the NHS Complaints Handling Procedure (NHS CHP) because the investigation and response should have been more comprehensive, clearer and easier to understand. We upheld the complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Ms C:

Complaint number

What we found

What the organisation should do

What we need to see
(a)

There was an unreasonable failure to act upon Mr A's acute kidney injury and episodes of vomiting;

there was an unreasonable failure to demonstrate that all the recognised risks of total knee replacement surgery were covered sufficiently during the consultation on 30 January 2018; and

the Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care

 

Apologise to Ms C and the family for failing to:

  • act upon Mr A's acute kidney injury and episodes of vomiting;
  • demonstrate that all the recognised risks of total knee replacement surgery had been fully explained to Mr A; and
  • provide accurate information in their complaint response to Ms C, address all the concerns Ms C raised, and identify and address the failings in Mr A's care

 

 

A copy or record of the apology.

By: 16 September 2020

 

We are asking the Board to improve the way they do things:

Complaint number

What we found

Outcome needed

What we need to see
(a)

The fluid balance chart was discontinued despite there being a significant fluid imbalance and an acute kidney injury having been identified;

the acute kidney injury was not acted upon (no intravenous infusion was given and no repeat blood testing carried out); and

no physical examination was performed prior to discharge

 

 

Patients with acute kidney injury should have their symptoms acted on and managed in line with relevant standards and guidance, where appropriate

Evidence that:

  • these findings have been shared with all relevant staff involved in Mr A's care in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions); and
  • there is a standard operating procedure for the management of acute kidney injury and ensure it is included in junior doctor induction.

By: 11 November 2020

 

 
(a) The orthopaedic team did not seek assistance regarding the acute kidney injury from other specialities Patients should receive appropriate medical review for their symptoms

Evidence to:

  • demonstrate that these findings have been shared with the surgical staff involved in Mr A's care in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions); and
  • demonstrate how junior doctors are supported on the surgical ward.

By: 11 November 2020
(a) There was an unreasonable failure to demonstrate that all the recognised risks of total knee replacement surgery were covered sufficiently during the consultation on 30 January 2018 Patients should be fully advised of all material risks of total knee replacement surgery and the discussion should be clearly recorded, in accordance with the Royal College of Surgeons standard

Evidence that:

  • surgical staff undertaking total knee replacement surgery have been reminded of the requirement to obtain informed consent in line with relevant standards and guidance; and
  • the consent form has been reviewed to ensure there is a section on the template to clearly capture material risks of the proposed procedure.

The SPSO thematic report on informed consent may assist in encouraging learning for staff in this area:

https://www.spso.org.uk/thematicreports

By: 11 November 2020

We are asking the Board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see
(b)

The Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care

The Board's complaint handling and governance systems should ensure that complaints are investigated and responded to in accordance with the NHS CHP. They should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement

Evidence that:

  • these findings have been shared with complaint handling staff (both clinical and non-clinical) in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-toone sessions); and
  • the Board have reviewed why its own investigation into the complaint did not identify or acknowledge all the failings highlighted here and any learning they have identified.

By: 11 November 2020

Feedback

Points to note 

As well as the recommendation above to ensure there is a standard operating procedure for the management of acute kidney injury and to include this in junior doctor induction, the Board may wish to consider the placement of ward posters informing others about the issue.

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