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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.

Related reading

  • Report no:
    201806286
  • Date:
    August 2020
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health

Mr C complained about the care and treatment that he received from Greater Glasgow & Clyde NHS - Acute Services Division (the Board) after he sustained a navicular fracture to his left foot (a fracture of the navicular bone on the top of the midfoot). Mr C also complained that the Board failed to respond reasonably to his complaint.

In March 2017, Mr C attended the Emergency Department (ED) of the Queen Elizabeth University Hospital, Glasgow (the Hospital). Mr C was assessed by a junior doctor and found to have pain on touching some of the bones in his foot. An xray was ordered, which the junior doctor interpreted as showing an un-displaced fracture (a fracture where the bone fragments do not separate) of one of the metatarsal bones (the 'forefoot' bones linking the toes to the middle part of the foot). Mr C was given a walking boot, advice and discharged. Two days later, the x-ray was reported by a radiologist as showing no acute joint or bony injury.

At the start of May 2017, Mr C attended again at the ED following a referral from the GP out-of-hours service as his foot was swollen and he was still in pain. Further xrays were taken. Mr C was reviewed by the on call orthopaedic doctor. The doctor's diagnosis was that there was possibly a hairline fracture (a very fine fracture) of the fourth metatarsal. Mr C said he was advised nothing further could be done and was sent home. The following day, Mr C attended the orthopaedic out-patients department at the Hospital following a call asking him to attend. He was advised by an orthopaedic doctor that the third and fourth metatarsal were broken, in addition, the navicular bone was broken in three parts with a 5mm gap.

Subsequently, Mr C underwent surgery to address the fracture. However, he continued to experience problems with his foot. Mr C had a major limb amputation of the lower part of his left leg in October 2019.

We took independent advice from a consultant in emergency medicine, a consultant orthopaedic surgeon and a consultant radiologist.

We found that it was not unreasonable that the ED junior doctor did not identify Mr C's fracture in March 2017 as it was uncommon to see a patient present at the ED with a navicular fracture and a junior doctor will rarely see a patient present with this type of fracture and often not at all. In addition, the fracture was subtle on the x-ray. On account of this, the junior doctor who saw Mr C made an understandable, reasonable, mistake in not diagnosing that he had sustained a navicular fracture.

Notwithstanding this, Mr C's fracture should have been identified in the radiology report of the x-ray taken in March 2017 and although the fracture of the navicular on the x-ray was subtle; it was unreasonable that the radiologist did not report this fracture.

Mr C was diabetic. We found that the clinical history supplied on the request for the radiograph did not include this information. While we did not consider the failure to identify and include this information in Mr C's clinical history amounted to an unreasonable standard of treatment, had the information about Mr C's diabetes been supplied it may have further alerted the reporting radiologist to the possibility of a stress fracture.

We found that when Mr C re-attended the Hospital in May 2017 after being referred by the out-of-hours service, a further opportunity to identify the navicular fracture was missed.

In conclusion, we found that overall the Board failed to provide Mr C with a reasonable standard of care and treatment and that it was likely that the failure to identify Mr C's fracture in March 2017 had a detrimental impact on his outcome. In light of the failings identified, we upheld this aspect of Mr C's complaint. 

Finally, we found that the Board failed to handle Mr C's complaint reasonably and upheld this aspect of his complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

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

Complaint number

What we found

What the organisation should do

What we need to see
(a) and (b)

The Board failed to provide Mr C with a reasonable standard of care and treatment

The Board's own complaint investigation did not identify or address the failings in Mr C's medical care

 

Apologise to Mr C for the failings in care and treatment identified in the report.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

 

 

A copy or record of the apology.

By: 19 September 2020

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

Complaint number

What we found

What should change

What we need to see
(a)

The Board unreasonably failed to identify Mr C's navicular fracture

 

 

X-rays of patients attending hospital with a possible fracture should be appropriately reported.

Patients re-attending should have their presenting symptoms fully assessed and investigated

 

 

 

Evidence that the case has been discussed at a radiology Learning from Discrepancies meeting.

Evidence that the Board have reflected on the failings identified in Mr C's case and given consideration to any required changes to processes and guidance.

Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 19 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 own complaint investigation did not identify or address the failings in Mr C's medical care

 

 

The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement.

 

 

 

 

Evidence that the Board have reviewed why its own investigation into this complaint did not identify or acknowledge the failings highlighted here, what learning they identified, and what action has been taken as a result.

My findings have been shared with relevant staff in a supportive way for reflection and learning.

By: 19 November 2020

 

 

 

Feedback

Points to note 
  • While it was not unreasonable that the junior doctor did not identify the navicular fracture when Mr C first attended the ED in March 2017, the Board may wish to consider raising awareness of a navicular fracture with junior doctors joining the ED on placement.
  • When a patient attends with a fracture at the ED, the Board may wish to give consideration to recording past clinical history as this can provide a potential alert for subsequent care and treatment.
  • Adviser 2 commented that the subsequent management of Mr C's case by the Board's consultant orthopaedic surgeon after the navicular fracture had been identified should be commended.

Related reading

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