Some upheld, recommendations

Summary

C complained on behalf of their spouse (A) about the treatment A received in hospital after they fell at home and injured their back. A had previously suffered a stroke and, as a result, a computerised tomography (CT) scan of their brain was carried out. This showed no change from the previous CT scan that was carried out. Following an assessment in A&E, it was concluded that A’s back pain was muscular and that they were also suffering from an infection. A remained in hospital for treatment and observation. Twelve days after being admitted to hospital, MRI scans of A’s brain and lumbar spine were arranged. These scans showed that A had suffered a new stroke and had spinal compression fractures. C felt that A should have had an MRI scan when they were admitted to hospital or soon after. In C’s view, this would have confirmed the issues earlier and resulted in more appropriate care being delivered.

We took independent advice from an appropriately qualified adviser. In respect of whether the board unreasonably delayed in diagnosing and treating A’s stroke, we found that there was not sufficient evidence of a fresh stroke to justify an MRI scan at the time of admission. Based on A’s presentation at the time and the need to prioritise their treatment, there was not an unreasonable delay in the board diagnosing and treating A’s fresh stroke. As such, we did not uphold this complaint.

In respect of whether the board unreasonably delayed in diagnosing and treating A’s spinal compression fractures, we found that, given A’s symptoms, an earlier MRI scan of the spine was not indicated. However, we highlighted one clinician’s entry in the medical records that indicated a need for further investigation of A’s back injury that was identified on the date of admission. This entry also suggested that an x-ray was to be arranged. However, this specific entry in the medical records did not appear to have been followed up or acted on, with no narrative in the records to explain why. For this reason, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for unreasonably delaying in carrying out further investigation into A’s back injury despite a clinician recording this as being indicated. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should review the circumstances surrounding this with the aim of establishing why the clinician’s findings do not appear to have been followed up and why an x-ray was not carried out when the medical records suggest that it was to be.
• The possibility of osteoporotic fractures should be considered in all older patients presenting with new-onset back pain (particularly where trauma could be involved), unless a clear alternative diagnosis is evident. Under these circumstances, imaging should be undertaken to investigate the possibility further.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C was dissatisfied with the treatment received from the board following an urgent referral to the gastroenterology department (specialists in the diagnosis and treatment of disorders of the stomach and intestines) from their GP after experiencing back pain and rectal bleeding. The referral was triaged by the board and a colonoscopy (examination of the bowel with a camera on a flexible tube) was arranged.

Following the colonoscopy, C was advised there was a probable tumour in their lower bowel. C’s treatment was discussed at a multi-disciplinary team meeting (MDT) and C was advised that a referral to a hospital within another board had been made for a Transanal Endoscopic Mucosal Surgery (TEMS, a minimally invasive surgery) procedure.

C was examined by a colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) at the other board and the TEMS procedure was scheduled. Further MDTs took place where the question of an anterior resection (a surgical procedure to remove the diseased portion of the bowel and rectum) being a more appropriate treatment was considered. C had a meeting with a consultant surgeon at Borders General Hospital and their understanding following this meeting was that clinicians would further consider and reach a decision on what the most appropriate treatment for C was. The consultant surgeon’s letter to C’s GP indicated that their understanding of the outcome of the meeting was that C had expressed a preference for TEMS with further steps, such as an anterior resection, afterwards if needs be, and had made arrangements for C to be seen by the TEMS team.

C attended an appointment at the other board where the colorectal surgeon said that C had refused an anterior resection. C denied this. It was also decided that a further biopsy would be undertaken. Whilst awaiting the results of the biopsy, C complained to the board and had further correspondence with them whilst also approaching this office about their concerns.

We took independent advice from an oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that it was reasonable that C was not referred to an oncologist and that investigations of a tumour reported following their colonoscopy were reasonable. However, we found that the board had unreasonably downgraded C’s referral and that the board’s failure to treat C’s condition as cancer was unreasonable. We noted that the board did not meet the treatment time guarantee and that there were significant delays in decisions on C’s treatment that were reached jointly with another board. We considered that the likelihood of delays should have been made clear to C to allow them the opportunity to properly consider all of the options available. We upheld C’s complaint about the treatment they had received.

C also complained about the board’s response to a complaint they submitted. We found that it was unreasonable that the board did not directly address some matters that C raised and upheld this aspect of C’s complaint. However, we considered it was reasonable that the board took a different position to C about what had been said at a particular consultation.

C also complained about a subsequent response the board provided to them. We found that the board’s response was generally reasonable. Therefore, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. The apology should make clear mention of each of the failings identified and meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• In similar cases, referrals and test results should be assessed reasonably and patients should receive treatment within 62 days of the referral and within 31 days from the decision to treat, as per Scottish Government treatment time targets. Our findings should be brought to the attention of relevant clinicians in a supportive manner and they should consider identifying these as learning point for their annual appraisals.
• A mechanism should be in place to ensure patients are informed when delays to treatment are likely.
• The pathway for the treatment of patients from Borders NHS board to another board area should be appropriate and efficient; including that clinician availability does not delay treatment decisions and that it is clear where responsibility for ongoing management and treatment lies at all times.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes responding to all aspects of complaints.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the standard of medical care and treatment provided to their parent (A). A received a likely diagnosis of metastatic lung and liver cancer. They were placed on palliative care, however, after approximately a year, A remained in good health. C sought a further review, A received subsequent scans, and it was ultimately established that they did not have cancer (approximately two years after the original diagnosis).

C raised concerns about the basis for the initial diagnosis that A had cancer. They also complained about the subsequent management of A. C said there was no appropriate follow-up or subsequent communication after the diagnosis. Ultimately, C requested a review, but said it took significant time for the board to establish there was no cancer.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the diagnosis that A likely had cancer was reasonable. It was based on a reasonable radiological opinion given the findings on A’s CT scan. We did not uphold C’s complaint in that regard.

In relation to A’s subsequent management, we found that there were unreasonable failings. The standard of care and attention the board provided to A following discharge was not reasonable, and we found evidence that follow-up was proposed for A and then not acted on. We also found that there was a failure to respond within a reasonable time to the referral for an oncology review. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified in this investigation and include recognition of the impact the failings have had on them. The apology should meet the standards set out in the SPSO guidelines on apology at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Ensure effective systems are in place for review on hospital discharge and communication is effective especially where there is diagnostic uncertainty.

In relation to complaints handling, we recommended:

• Ensure board investigations identify and address incidents covered by the Duty of Candour with the relevant Scottish Government guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment their late parent (A) received at Queen Elizabeth University Hospital. A was admitted to hospital with a diagnosis of pancreatitis (inflammation of the pancreas). They were treated with fluids and antibiotics and their fluid balance was measured. They recovered and were discharged later that month. A was readmitted with various symptoms including abdominal pain, vomiting, loose stools and not eating or drinking on two further occasions and was discharged both times. A was later readmitted to the hospital in cardiac arrest and died shortly after arrival at the hospital.

We took independent advice from an appropriately qualified adviser. We found that the board failed to provide A with a reasonable standard of care and treatment. During one admission, there was a lack of comment on A’s hernia, a lack of investigation of low blood pressure and no evidence of a cardiology (specialists in diseases and abnormalities of the heart) input. On another admission, we found that the care and the management plan concerning A’s hernia was below standard and that there appeared to be a delay in the involvement of other specialists. We also found issues relating to the planning of surgery for A. Therefore, we upheld this aspect of C's complaint.

C also complained that A's final discharge from hospital was unreasonable. We found A's discharge to be reasonable and did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not making a timely assessment of risk for surgery, the failure to address A’s low blood pressure, the standard of monitoring and examination of A’s hernia, the delay in the involvement of clinical specialists, the standard of the management plan for A's hernia repair, the standard of planning of A's urgent surgery and for delays in surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should have a policy in place on the management of emergency cases and prioritisation to ensure delays and recurrent cancellations of cases are minimised.
• The board should review how deteriorating patients are managed to ensure timely involvement of relevant specialties in care when there are complex patients.
• Ward round documentation needs to reflect concerns and management plans clearly.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C had enrolled on two short courses run by Queen Margaret University. They made a number of complaints to us about the action taken by the university in relation to adjustments that they requested for disabilities that affected the way they worked.

C complained that the university did not initially provide them with reasonable support for the courses. We were satisfied that the university sought to make reasonable adjustments for C and that they demonstrably took account of C’s input when preparing an Individual Learning Plan (ILP). We did not uphold this complaint.

C also complained that the university then unreasonably failed to provide the support that was agreed. We found that there had been a delay in providing C with a USB stick that the university had committed to provide them with and we upheld this complaint.

We also found that there was no evidence of communication with C when their disability adviser was absent and that the Head of Student Services had failed to respond to C’s contact. We upheld C’s complaints about these matters.

We also upheld C’s complaint that the university had failed to provide a note taker for a course. Although the equality legislation recognises that there can be more than one way to address an assessed need, in this case, the alternative arrangements did not run smoothly and did not address the matter within a reasonable timescale. We also upheld a complaint that the university had failed to provide a transcript of the course as previously agreed with C.

We did not uphold C’s complaint that a lecturer had failed to respond to their contact about the course or their complaint that the university failed to deal with their complaint effectively.

Recommendations

What we asked the organisation to do in this case:

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

What we said should change to put things right in future:

• The university should ensure that any agreed adjustments are provided within reasonable timescales.
• The university should ensure that staff reasonably communicate with students who contact them.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C applied for a Collaborative Doctoral Award (CDA) programme. One of the key features of a CDA is the opportunity to work with an industry partner (IP) as well as academic staff. C complained that their supervision had been flawed and that there had been a lack of engagement with the IP. They also complained about how their complaint was handled.

We considered the information both C and Glasgow School of Art (GSA) provided in support of the complaint. We found that C had regular supervision meetings which were documented as required. There is also evidence that C’s supervisors were readily available by email and responded promptly to C’s contacts. However, according to associated guidance from the Arts and Humanities Research Council Training Grant Funding Guide and their guide on CDAs, GSA should have set out the structure of the collaboration and the expectations of those involved. They did not define what a CDA is or the expectations of the IP and student. The student did not receive an induction at the IP’s business address nor was a supervisor appointed at the IP. We upheld this complaint.

We were satisfied GSA had provided a reasonable response to C's complaint, which was about a number of different issues as well as supervision, and did not uphold that complaint.

Recommendations

What we asked the organisation to do in this case:

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C attended A&E at Perth Royal Infirmary following a knee injury. They were diagnosed with a soft tissue/tendon strain and advised to attend their GP for follow-up. C said that their knee did not settle and attended the hospital again six months later. C was then told that they had a meniscal tear (a partial or full tear in the cartilage of the knee). As their condition did not improve, C underwent an operation. C said that they experienced no relief following the operation and their GP made a further referral to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system). They were advised that further surgery would be unlikely to help and, therefore, there was no clinical reasons to operate further.

C complained about the care and treatment they were given by the board. C said that there was a delay in providing appropriate treatment and diagnosis, that their care was poor and that the board did not deal reasonably with their complaints about this.

The board said that C’s initial care and treatment had been appropriate and although they were aware of C’s view that they should have been x-rayed when they first attended the hospital, to have done so would not have shown the subsequent diagnosis they received. The board added that scans and x-rays were not routinely carried out for knee injuries and that C had been given appropriate advice.

We took independent advice from consultants in emergency medicine and in orthopaedics. We found that, overall, C’s care and treatment had been reasonable. However, there was a failure to carry out an x-ray when they first attended hospital which was contrary to accepted guidance regarding when an x-ray of a knee should be undertaken following trauma. For this reason, the complaint was upheld.

In relation to complaint handling, we found that C was kept fully apprised of the progress of their complaint and given a new target date for a response which was met. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to x-ray their knee in accordance with the Ottowa knee rules. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• When presented with knee injuries in A&E, clinicians should take into account the relevant guidance (in this case the Ottowa knee rules).

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C’s late partner (A) tested positive for COVID-19. A week after testing positive, A called 111 as they were still feeling very ill. They explained that they had had a fever for a few days and were having difficulty regulating their temperature. A was advised by a nurse practitioner to remain hydrated, continue taking paracetamol, and to continue to self-isolate until they had no fever for 48 hours. They were also advised to call back if they had any further concerns about their symptoms.

C called 111 again a few days later as they were concerned A’s breathing was becoming laboured. C had to wait around 20 minutes before the call was answered. During the call, the call handler repeatedly asked to speak to A to take information directly from them, even though C kept answering for A as A was confused. The call lasted around 30 minutes. The call handler contacted Scottish Ambulance Service and requested an ambulance on an emergency basis, but by the time paramedics arrived A had stopped breathing and could not be resuscitated. C complained about the clinical assessments of A’s condition on both instances.

We took advice from an advanced nurse practitioner with experience of assessing patients with similar presentations. We found the assessment on the first instance to be reasonable, and we therefore did not uphold this complaint.

We considered it unreasonable for the second call to have lasted 30 minutes before an ambulance was called. We noted that the call handler was following the protocol correctly, but were of the view that if the protocol took 30 minutes to establish that an emergency response was required, it was not fit for purpose. We considered that rigid following of the protocol led to a delay in obtaining medical attention for A. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

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

What we said should change to put things right in future:

• Protocol is reviewed so that in patients with shortness of breath as the primary presentation there is a clear escalation route to a medically trained clinician.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about various aspects of the care and treatment their late spouse (A) received from the board.

A had a history of vascular (relating to a vessel or vessels, especially those which carry blood) surgery and was admitted to hospital for the removal of a benign tumour. The procedure took place, however, A’s condition deteriorated and they were moved to an infectious diseases unit with suspected sepsis (blood infection). A’s condition deteriorated further and they were transferred to a vascular and critical care ward in a different hospital on an emergency basis. Later that day, A underwent surgery to remove an infected synthetic artery graft (a piece of living tissue that is transplanted surgically).

A experienced an abdominal bleed and was transferred to a critical care unit. After treatment, A was reviewed by a consultant and returned to the vascular and critical care ward. A experienced a fall on the ward. A later developed a lung infection/sepsis and died.

C complained that the board failed to screen, manage or treat A’s infection. C said that A had been discharged from the critical care unit onto the ward too soon. C also complained that the board had failed to properly assess A’s fall risk or treat A properly after their fall.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a registered nurse. We found that the screening, management and treatment of A’s infection and their discharge from the critical care unit was reasonable. We did not uphold these complaints. However, we found that the board had failed to adequately complete risk assessments, including a falls risk assessment, for A. We upheld this complaint.

We also considered that the board made an error of communication while responding to C’s complaint when they referred to MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) instead of MSSA (a bacterial infection which is not resistant to certain antibiotics). We provided feedback to the board about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for wrongly referring to MRSA rather than MSSA when responding to C’s complaint and for their failure to complete A’s Falls Risk Assessment; bed rails and 4AT delirium assessments in line with organisational policy. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Falls Risk Assessments and bed rails/4ATdelirium assessments should be carried out in line with the board’s stated policy.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C was referred urgently to the gynaecology department (medicine of the female genital tract and its disorders). During the vetting procedure the board requested the referral be downgraded to routine and the GP complied with this request. Following a consultation with the first consultant, C was scheduled for an operation. During the pre-operation examination by the second consultant, a cervical tumour was found and the operation cancelled. When informed of this, C made a verbal complaint about their treatment since being referred.

Biopsy results confirmed the tumour as malignant. C lost faith in the clinicians involved and requested a second opinion. A consultant oncologist (cancer specialist) met with C to discuss this and took steps to arrange a second opinion. C also took steps to obtain the second opinion using personal contacts. The second opinions provided concurred with that of the board. C complained to the board in writing regarding their experiences. A significant clinical incident (SCI) investigation was undertaken and following this, the board responded to C’s complaints. C was dissatisfied with the board’s responses and brought their complaint to this office.

We took independent advice from a consultant gynaecological oncologist. The SCI investigation had found that the board failed to give advice, contrary to relevant guidance, to C’s GP regarding the referral submitted as urgent. We upheld C’s complaint about this and accepted advice received that the board’s revised guidance had addressed the identified failings. However, the board had not apologised to C for these.

The board concluded the time taken between C’s referral by their GP and a correct diagnosis being reached was unreasonable and also accepted the time taken to respond to C’s complaint was unreasonable. We upheld C’s complaints about these and found that the board had not reasonably apologised to C for the delay in diagnosis.

We found that C’s verbal complaint had not resulted in reasonable action being taken as there was no evidence of any consideration regarding the complaint until C made a written complaint over two months later.

We accepted the advice we received that the board provided reasonable care and treatment to C following their diagnosis and that there were no concerns about how the SCI investigation had been carried out in relation to the board’s policy. We did not uphold these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. The apology should make clear mention of each of the failings identified as well as include a clear stated apology for the delay in C’s diagnosis. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should take all reasonably practicable steps in the present circumstances to ensure that they comply with the Treatment Time Guarantee.

In relation to complaints handling, we recommended:

• The second consultant should take action to ensure that all complaints are appropriately recognised, acknowledged and actioned, including verbal complaints.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.