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Tayside NHS Board

  • Report no:
    201802594
  • Date:
    July 2019
  • Body:
    Tayside NHS Board
  • Sector:
    Health

Summary

Mrs C, an advocacy worker, complained to me, on behalf of Ms A, about the care and treatment that Tayside NHS Board (the Board) provided to Ms A.

From early 2012 onwards, Ms A experienced severe hip pain following her right hip replacement surgery. It affected her ability to walk and to carry out everyday tasks. Despite various orthopaedic reviews and investigations over the following five years, no underlying cause was identified for her pain. In mid-2017, Ms A's symptoms suddenly worsened and she experienced total right hip replacement failure. Ms A was referred for further surgery and a deep-seated infection was found in her right hip joint. Mrs C complained about an unreasonable delay in diagnosing Ms A's hip infection.

We took independent advice from a consultant orthopaedic surgeon, which we accepted. We found that there was a failure to properly investigate Ms A for a hip infection over a period of five years, in light of her symptoms. We found that concerning and obvious changes were apparent to Ms A's hip in her x-rays taken in 2015, 2016 and 2017. However, these changes were missed in her orthopaedic reviews. We found that when the changes in her 2017 x-rays were subsequently identified, there was an unreasonable delay in offering her an orthopaedics review as she waited over three months to be seen. We were critical that the Board's investigation did not identify and/or acknowledge the significant failings in the care provided to Ms A.

We upheld Mrs C's complaint. We made a number of recommendations to address the issues identified. The Board have accepted the recommendations and will act on them accordingly. 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 date specified. We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that 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 Ms A:

What we found

What the organisation should do

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

There was a failure to properly investigate Ms A for a hip infection over a period of five years in light of her presentation; to appropriately report on and review her x-rays over this period; and an unreasonable delay in offering Ms A an orthopaedics review after her May 2017 x-rays showed concerning changes to her hip replacement

Apologise to Ms A for the failings in diagnosing and treating her right hip infection; and the unreasonable delay in offering her an orthopaedics review

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

 

By:  26 August 2019

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

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline

There was a failure to properly investigate Ms A for an underlying right hip infection over a period of five years in light of her presentation

Patients, who have symptoms suggestive of an underlying joint infection, should be fully and appropriately investigated, in line with  recognised guidelines

 

Evidence that the findings of this case have been used as a training tool for staff and that this decision has been shared and discussed with relevant staff in a supportive manner.   This could include minutes of discussions at a staff meeting or copies of internal memos/emails.

Evidence that the Board have prepared a local guidance policy, which is in line with recognised guidelines for investigating hip replacement infections

 

By:  24 September 2019

There was a failure to appropriately report on x-rays taken in 2015 and 2016

Orthopaedic x-rays should be appropriately reported

Evidence that a review of the Board’s system for reporting orthopaedic x-rays has been carried out, in light of the findings of this investigation and details of the action taken on any areas identified for improvement

By:  24 September 2019

There were concerning and obvious changes in Ms A's x-rays in 2015,  2016 and 2017, which were missed in her orthopaedic reviews

The results of hospital tests and investigations should be carefully reviewed

Evidence that the findings of this investigation have been fed back to the clinicians involved in a supportive way that promotes learning, including reference to what that learning is.

Confirmation that the relevant clinicians will discuss this case at their next appraisal

 

By:  24 September 2019

When the changes in Ms A’s May 2017 x-rays were subsequently identified, there was an unreasonable delay in offering her an orthopaedics review as she waited over three months to be seen In similar circumstances, patients should receive an orthopaedics review in a timely manner

Evidence of the steps being taken to ensure that patients are given a timely orthopaedics review in similar circumstances

 

By:  24 September 2019

We are asking the Board to improve their complaints handling:

What we found Outcome needed What we need to see

The Board's investigation did not identify and/or acknowledge the significant failings in the care provided to Ms A

The Board's complaints handling system should ensure that failings (and good practice) are identified, where appropriate remedied, and that it is using the learning from complaints to inform service development and improvement (where needed)

 

 

Evidence that the Board have demonstrated learning from this case and complaints in general

 

By:  24 September 2019

Feedback

Points to note:

Included in the advice I received and accepted were the following points from the Adviser:

  • a clinical audit facilitator regularly reviewed Ms A and checked her blood metal ion levels.  This was appropriate and it was in line with the relevant Medicines and Healthcare Products Regulatory Agency (MHRA) guidance on metal-on-metal hip replacements.
  • an MRI scan in 2012 was not a helpful investigation if a metal artefact reduction sequence (MARS) type of MRI scan was not available.
  • after Ms A's hip replacement failed in August 2017, she was given entirely reasonable treatment by the Board.

Updated: July 24, 2019