• Report no:
  • Date:
    January 2018
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector(s):

Mrs C complained about the care and treatment she received from Queen Elizabeth University Hospital Glasgow (the hospital).  Mrs C was concerned about delays in the time taken for her to receive spinal surgery to address her medical condition (incomplete cauda equina syndrome).  In addition, Mrs C complained about the level of care provided during her two admissions by physiotherapy and nursing staff.  Mrs C also raised concerns about the aftercare arrangements made at the time of her discharge from the hospital.

We took independent advice from three clinical specialists:  a consultant neurosurgeon, a physiotherapist and a nurse.

We found that the board failed to provide neurosurgery to Mrs C within a reasonable time.  We noted that there had been unexpected repair works at the hospital that impacted on theatre availability; however, there is clear guidance on the need for surgery to be performed on an emergency basis in cases of incomplete cauda equina syndrome to minimise the risks associated with this condition.  In these circumstances, we considered it was unreasonable for the board not to have provided the surgery, or arranged for this to take place at an alternative hospital site.  We considered that it was likely that the delay would have impacted on Mrs C's poor outcome following the surgery.  Our investigation also highlighted that there was no evidence of communication with Mrs C about the risks of the delays while she was on the neurosurgery ward, and that documentation in the relevant medical records was of a very poor standard.

Our investigation identified failings in the care and treatment provided to Mrs C during her admissions.  We found that Mrs C's care while in hospital and on discharge did not appear to have been planned in a co-ordinated and multi-disciplinary way.  We found that Mrs C did not receive an adequate level of physiotherapy care.  We also had concerns about the level of continence care provided to Mrs C, the management of her pain and wound care based on the evidence in the nursing records.

We found that there were failings in discharge planning and aftercare arrangements for Mrs C.  We considered this was not planned in a co-ordinated and multi-disciplinary way.  Our investigation also found there was inadequate patient information provided to Mrs C on discharge, and referrals for aftercare were not made.  We noted that this likely contributed to Mrs C's difficult and distressing experience returning to her home.

We upheld Mrs C's three complaints and made a number of recommendations to address the issues identified.  The board have accepted these recommendations and we will follow-up on these recommendations.  The board are asked to inform us of the steps that have been taken to implement these recommendations by the dates specified.  We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm the recommendations have been implemented.

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

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

Complaint number

What we found

What the organisation should do

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

(a), (b) and (c)

There was an unreasonable delay in providing neurosurgery to Mrs C.  There were also failings in the physiotherapy and nursing care offered to Mrs C and failings in the multi-disciplinary and discharge planning processes

Apologise to Mrs C for the delay in providing neurosurgery; the failings in physiotherapy and nursing care and in the multi-disciplinary and discharge planning processes.

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 or record of the apology

By:  24 February 2018


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

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline


There was an unreasonable delay in providing surgery to Mrs C, who was suffering incomplete cauda equina syndrome

Surgery for cauda equina should be performed within recommended timescales (in this case 24 to 48 hours), or the patient considered for transfer to an alternative hospital site

The Board should demonstrate that they have systems in place to ensure patients with incomplete cauda equina are operated on as an emergency, or transferred to an alternative hospital site for surgery

By:  24 April 2018

(a) and (b)

There were significant failings in record-keeping.  The ward review documentation was very poor in this case.  There were gaps in nursing records (including assessments and fluid balance charts)

The Board should ensure staff complete adequate and contemporaneous medical documentation

The Board should demonstrate how this issue has been raised with relevant staff in a supportive way for reflection and learning and that learning has taken place and/ or relevant future training and development identified

By:  24 April 2018

(a), (b) and (c)

There were unacceptable failings in communication.  There is no evidence that information was given about the risks of delays to the surgery.  Mrs C was not given an appropriate level of information on discharge

Patients should receive relevant and understandable information about cauda equina syndrome

The Board should demonstrate how they will provide patients presenting with cauda equina syndrome with such information and in what way:  for example, through discussions and an information leaflet

By:  24 April 2018


There were failings in the physiotherapy care.  Despite the record of Mrs C's anxiety, only one pre-discharge supervised trial of stairs was undertaken by physiotherapy

The Board should ensure an adequate level of physiotherapy assistance for patients in Mrs C's position

The steps the Board will take to ensure adequate physiotherapy support is provided to patients following surgery for cauda equina syndrome.

By:  24 April 2018


Mrs C's nursing assessment, both on admission to and during her stay in hospital, did not include sufficient detail on her symptoms of both pain and incontinence and wound management. Neither did it include the psychosocial impact of her diagnosis and symptoms on her health

Registered nurses should have the knowledge to carry out comprehensive assessments and to develop clear care plans which facilitate consistent and person-centred care.

The Board should ensure that registered nurses can assess the psychosocial impact of illness for patients admitted to hospital and can plan care to ameliorate its effects as much as possible

The Board should demonstrate that they have:

  • reviewed their approach to both incontinence and pain management in in-patient settings;
  • that learning has taken place; and
  • put in place steps to implement any actions identified within definitive timescales

By:  24 April 2018

(b) and (c)

Mrs C's care while in hospital and on discharge does not appear to have been planned in a co-ordinated and multi-disciplinary way.  Her nursing and physiotherapy records have little evidence of input from other professionals.  The records did not suggest Mrs C was involved in discharge planning, or her perception of needs or anxieties considered

A supportive multi-disciplinary approach should be in place for patients with cauda equina syndrome

The Board should demonstrate they have reviewed their approach to multi-disciplinary working in in-patient settings to ensure that care is person centred and co-ordinated to optimise recovery for patients while in hospital.  Consideration should be given to the use of multi-disciplinary records which facilitate better person-centred assessment and care planning

By:  24 April 2018

(c) There were failings in the discharge planning and arrangements made for Mrs C Discharge should be planned in a co-ordinated way.  A personalised aftercare plan should be undertaken prior to discharge in cases of this type and include prompt referral to appropriate services.  The Board should ensure that patients returning home from hospital have the appropriate referrals made to community based services to support their care on discharge from hospital.  This should include the transfer of care plans with the patient, where appropriate, to ensure continuity and consistency of care

An explanation with supporting documentation of the steps the Board will take to ensure appropriate discharge planning

By:  24 April 2018


Complaints handling
I agree with Adviser 3's comment about the Board's handling of this complaint.  The Board did not investigate this complaint in a sufficiently detailed and analytical manner.  They appeared defensive of, and failed to take account of the gaps in, nursing practice as evidenced in the nursing notes.  While printed nursing records are lengthy, and consideration has been given to how they might facilitate assessment and care planning, it was nonetheless difficult (on the basis of this investigation) to understand the priorities for Mrs C's care. This must cause difficulty in personalising the care to meet individual patient need and for nurses, working different shifts, to be clear about the care plan.

Points to note on best practice
In line with the views of Adviser 2, I would ask the Board to consider the following points about delivering best practice in the care of patients presenting with cauda equina syndrome:

  • patient representation on the Cauda Equina Forum;
  • patient information developed for people who are at risk of developing cauda equina syndrome and for those with incomplete cauda equina syndrome for issue at the time of diagnosis;
  • to ensure that the diagnosis of cauda equina syndrome is recorded, explained to the patient and communicated clearly across the multi-disciplinary team;
  • training arranged for all members of the clinical team to ensure that; the diagnosis of cauda equina syndrome, the prognosis and the importance of personalised co-ordinated postoperative management are understood;
  • a clear pathway to urology;
  • a clear pathway to pain services; and
  • a governance reporting system for cases who have poor post-operative outcomes related to cauda equina syndrome.

Points to note on the development of the information leaflet
The Board is asked to consider the following suggestions from Adviser 2 for further improvement:

  • page 2:  It is important to treat cauda equina syndrome as an emergency not urgently;
  • page 3:  the symptoms of cauda equina syndrome can also occur gradually, often related to spinal stenosis;
  • page 4:  women may also have sexual dysfunction related to vaginal numbness;
  • page 7:  links to patient support groups such as; www.caudaequina.org,  www.ihavecaudaequina.com or www.caudaequinauk.com might be included; and
  • the inclusion of guidance on when and where to seek help should symptoms deteriorate.