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Forth Valley NHS Board

  • Report no:
    202202065
  • Date:
    August 2023
  • Body:
    Forth Valley NHS Board
  • Sector:
    Health

The complainant (C) complained to my office about the care and treatment provided by the Board. C was admitted to hospital in August 2021 with severe abdominal pain, nausea and vomiting. C underwent a CT scan of the abdomen, which showed localised perforation of the bowel. They were diagnosed with complicated diverticulitis and treated with intravenous (IV) antibiotics and discharged four days after being admitted. C was re-admitted to hospital within a few days and underwent an emergency Hartmann’s procedure in which most of their bowel was removed and a stoma created. C complained that the original decision to discharge them was unreasonable.

At the time of discharge home following their surgery, C was told they would have consultant follow-up in six to eight weeks. They complained that did not happen and they had to chase the Board for an appointment. They developed hernias at the surgery site and complained about the length of time taken to provide them with further treatment. C’s consultant follow-up appointment took place in April 2022, seven months after their discharge. They were advised they may require further surgery in relation to the hernias that had developed. C faced further wait times for scans, and in January 2023 they underwent hernia surgery.

In their complaint, C explained that, following their surgery on 25 August 2021, they were advised that most of their bowel had been removed and that they had been left with a permanent stoma. During my investigation, I sought independent advice from a Consultant Colorectal and General Surgeon (the Adviser). The Adviser explained that, in their experience, it is almost always technically possible to reverse a stoma created during a Hartmann’s procedure such as C had. The Adviser commented that there was no indication of a discussion having taken place with C regarding their stoma being temporary. With C’s agreement, we expanded our investigation to include the complaint that communication with C was unreasonable in relation to the permanence of the stoma.

In responding to the complaint, the Board considered that the decision to discharge C had been reasonable. They acknowledged there had been an unreasonable delay in providing C with a follow-up appointment with a consultant, which they explained had been due to human error. The Board considered that C had been prioritised correctly for their hernia surgery. After we expanded our investigation to include the complaint about communication in relation to the permanence of the stoma, the Board arranged a consultation with C during which the possibility of stoma reversal was discussed.

Having considered the advice received, I found that:

  • The decision to discharge C from hospital in August 2021 was unreasonable and was not supported by evidence of repeat tests and appropriate clinical review.
  • There was an unreasonable delay to C being offered a follow-up appointment post- surgery and a subsequent delay in them receiving hernia repair surgery.
  • The Board failed to communicate reasonably with C regarding the possibility of their stoma being reversible.
  • The Board’s complaint response was unreasonable.

As such, I upheld C's complaints

 

Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C:

Rec number

What we found

What the organisation should do

What we need to see

1

The decision to discharge C from hospital in August 2021 was unreasonable and not supported by evidence of repeat tests and appropriate clinical review, in particular before switching to oral antibiotics.

There was a failure to document the rationale for discharge and complete the safety checklist which could have prompted a better assessment of C’s suitability for discharge.

The discharge summary documentation was not completed timeously, including to C’s GP and there is no evidence that C was provided with appropriate advice on discharge.

There was an unreasonable delay to C being offered a follow-up appointment post-surgery and a subsequent delay in them receiving hernia repair surgery.

The Board failed to communicate reasonably with C regarding the possibility of their stoma being reversible.

The Board’s complaint response was unreasonable

Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

Given the delays C has experienced the Board should, as a matter of urgency, provide them with a clear treatment plan and timeline for the follow up assessments required including any future surgical treatment that is decided on following assessment.

A copy of the apology letter.

A copy of the treatment plan.

By: 15 September 2023 

                                                                                                                                                                                             

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

2

The decision to discharge C from hospital in August 2021 was unreasonable and not supported by evidence of repeat tests and appropriate clinical review, in particular before switching to oral antibiotics.

There was a failure to document the rationale for discharge and complete the safety checklist which could have prompted a better assessment of C’s suitability for discharge.

The discharge summary documentation was not completed timeously, including to C’s GP and there is no evidence that C was provided with appropriate advice on discharge.

Patients’ suitability for discharge should be appropriately assessed and their condition appropriately reviewed, including where appropriate antibiotic therapy regimes, prior to discharge.

The rationale for discharge should be properly documented and any relevant documentation completed (for example, safety checklist) timeously.

Immediate discharge letters should be issued at the time of discharge and patients should receive appropriate advice on discharge which should be documented.

Evidence that the Board have reviewed their management of complicated diverticular disease with specific reference to:

(i) the assessment and clinical review of patients prior to discharge (including decision-making in relation to antibiotic therapy)

(ii) ensuring the rationale for discharge is clearly documented and, where appropriate, the safety checklist is completed, and

(iii) the provision of discharge information to the patient and their GP on discharge. Confirmation of the action taken and details of any resulting action points or procedural changes.

Evidence that this decision and findings have been fed back to relevant staff, in a supportive manner, for reflection and learning.

By: 16 October 2023

3 There was an unreasonable delay to C receiving a follow-up appointment post-surgery and a subsequent delay in them receiving hernia repair surgery.

Patients should receive timely follow up and any subsequent surgery that may be required without delay.

Evidence the Board has in place a robust system to arrange follow-up appointments for emergency admissions that ensures appointments are made and are on the system in a timely manner Evidence that the Board have reviewed their processes for listing patients requiring hernia repair to ensure that cases are expedited appropriately Confirmation of the outcome of the Board’s consideration including any resulting action points.

By: 16 October 2023

4 The Board failed to communicate reasonably with C regarding the possibility of their stoma being reversible. Patients should be fully advised of any potential future treatment options to enable them to make an informed choice without delay.

Evidence that this decision and findings have been fed back to relevant staff, in a supportive manner, for reflection and learning.

By: 16 October 2023

We are asking the Board to improve their complaints handling:

Complaint number

What we found

Outcome needed

What we need to see

5

The Board’s complaint response was unreasonable.

There was a failure to investigate and respond to all the concerns raised by C and provide an appropriate response that recognised the significance of the events for C.

The Board’s complaint handling monitoring, and governance system should ensure that

(i) complaints are properly investigated and responded to in line with the NHS Scotland Model Complaints Handling Procedure.

(ii) failings and good practice are identified, and learning from complaints is used to drive service development and improvement. 

(iii) complaint responses recognise and acknowledge the significance and human impact of the events complained about.

Evidence that the findings on the Board’s complaint handling have been fed back in a supportive manner to relevant staff and that they have reflected on the findings of this investigation. (For example, a copy of a meeting note of summary of a discussion.)

By: 16 October 2023

 

 

Updated: August 16, 2023