• Report no:
    201605960
  • Date:
    August 2018
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector(s):
    Health

Summary

Ms C complained on behalf of her nephew (Mr A) about the care and treatment Mr A received from the Greater Glasgow and Clyde NHS Board (Board 1).  Ms C’s complaint concerned the delays in treatment for Mr A’s dural arteriovenous fistula (DAVF – where there are rarer, abnormal connections between arteries and veins in a protective membrane on the outer layer of the brain and spine, called the dura. Symptoms can include an unusual ringing or humming in the ears, particularly when the DAVF is near the ear, and some patients can hear a pulsating noise caused by the blood flow through the fistula) and the poor communication with him about this.  The original complaint we received concerned the treatment of Mr A’s arteriovenous malformation in the brain (AVM - where a tangle of blood vessels in the brain or on its surface bypasses normal brain tissue and directly diverts blood from the arteries to the veins). During the course of our investigation, it was identified that there were different types of AVM and that Mr A had one type, known as DAVF.

We obtained independent advice on the case from a consultant neurosurgeon, a consultant interventional neuroradiologist and a consultant in public health medicine.

We found that that Board 1 unreasonably failed to provide Mr A with treatment for his DAVF and we upheld this part of the complaint. We also found that, having advised Mr A that a hospital in another board’s area was willing to provide treatment for his condition, Board 1 then failed to make arrangements for this within a reasonable time and we upheld this part of the complaint. We found that Board 1 failed to keep Mr A updated on his proposed treatment and that Mr A and his family had to contact Board 1 repeatedly to find out what was happening and that Board 1 also failed to respond to Mr A’s email detailing his concerns about Board 1’s response to his complaint. We, therefore, upheld this part of the complaint. We made a number of recommendations to address the failings in this case.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking Board 1 to do for Ms C and Mr A:

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline

Board 1 failed to:

1. provide Mr A with appropriate treatment for his  dural arteriovenous fistula;

2. make arrangements for Mr A to receive treatment for his condition at Hospital 2 within in a reasonable time; and

3. communicate with Mr A about treatment for his condition

Apologise to Mr A and his family for the failings identified in Mr A’s care and treatment and the communication with him about this

 

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

A copy of the record of apology

 

By:  21 September 2018

 

We are asking Board 1 to improve the way they do things:

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

Mr A’s angiogram in December 2015 was incomplete, the image quality was poor and the technical report for the imaging was inadequate to inform MDT discussion and treatment planning

Consultant 2 did not have a clear treatment plan for Mr A and it took eight months before Board 1 decided what Mr A’s treatment would be and advised him of this

There was a lack of documentation of the MDT process and a poor standard of out-patient clinic discussions between Consultant 2 and Mr A, including discussion of risks of the embolisation procedure

 

 

Angiogram images should be complete and the image quality of a reasonable standard. The technical report for the imaging should be adequate to inform MDT discussion and treatment planning

Consultants should ensure patients have a clear treatment plan, setting out the treatment required.  Patients should be made aware of the plan within a reasonable time

MDT process documentation and out-patient clinic discussions, including between a consultant and a patient, should be of a standard that provides a reasonable record of the discussion.  Clinic discussions should include discussion of risks of procedures

Evidence that this case has been used as a learning tool for radiology and interventional neuroradiology staff

This should demonstrate how, in a supportive way, the Board has learned to ensure that angiograms and technical reports are completed appropriately;  that staff understand the risks involved in having to repeat angiograms; and that the MDT process documentation and out-patient clinic discussions should be of a reasonable standard

By:  22 November 2018

 

 

 

It was unreasonable of the Board to cancel and reschedule Mr A’s surgery repeatedly

Patients should receive appropriate treatment in a reasonable time from the appropriate organisation, in line with adequate contingency arrangements

Evidence that this case has been used in a supportive way as a learning tool for interventional neuroradiology staff, to ensure that in future patients receive treatment in a reasonable time, in line with adequate contingency arrangements

 

By:  22 November 2018

 

 

Board 1 did not make sufficient arrangements for Mr A to receive cross border treatment in a reasonable time

 

Board 1 failed to follow their own Policy and Scottish Government Guidance when dealing with Mr A’s referral to Hospital 2

 

There was a lack of clear documentation or audit trail of the decision making process and the communication with the parties involved, including a lack of  documentary evidence of Board 1’s contact with Board 2 on Mr A’s case

Board 1 should follow their own Policy and Scottish Government Guidance when making or considering cross border referrals. 

 

Treatment should be arranged within a reasonable time.

 

 

Decisions should be clearly documented and communicated promptly to all parties involved

Evidence that all Board staff involved in cross border referrals are aware of Board 1’s Policy and Scottish Government Guidance and the need for clear documentation and communication of  the decision making process

 

By:  22 November 2018

Board 1 failed to take reasonable steps to keep Mr A updated on his referral to/treatment at Hospital 2 

Patients should be kept updated on their referrals to/treatment at other boards

Evidence that this matter has been discussed with the staff involved in a supportive way that encourages learning

 

By:  22 November 2018

Board 1 failed to provide Mr A with a response to his email of 19 October 2016, either directly or via his MSP

Staff should respond to patients’ complaints in a reasonable time

Evidence that this matter has been discussed with the staff involved in a supportive way that encourages learning

 

By:  22 November 2018

 

Feedback

Response to SPSO investigation

Board 1 failed to respond to my enquiries by the deadlines set and failed to provide full and complete responses, which delayed our investigation of Ms C’s complaint.