Some upheld, recommendations

Summary
Mr and Ms C complained about the care and treatment provided to Ms C's mother (Mrs A) by her medical practice.

They complained that the practice failed to adequately investigate the decline in Mrs A's mental health; properly monitor her repeat prescription medication; fully investigate her incontinence problems; or arrange for Mrs A to have an influenza vaccination without being prompted by the family. They also complained that the practice failed to provide treatment in line with the Adults with Incapacity legislation and that there were unreasonable delays in responding to their complaints.

Turning first to the complaint that the practice failed to provide treatment in line with the Adults with Incapacity legislation, we found that they acted within their procedures, but that there were communication failures. These were contrary to the principles underpinning the legislation and also contributed to the delay in arranging the influenza vaccination. We found that there were shortcomings by the practice in the way they handled the complaint in that there were delays and that the practice failed to tell Mr and Ms C of their right to approach the SPSO at the beginning of the complaints process. We also found that the practice did not closely monitor Mrs A's repeat prescription. We made recommendations to address the failings that we found. However, we did not find any failures by the practice in the provision of care and treatment in relation to Mrs A's mental health and incontinence problems.
 

Recommendations
We recommended that the practice:
• review their systems to monitor repeat prescriptions;
• ensure effective communication takes place between practitioners and all the key people involved in a patient's care;
• review their complaints handling to ensure it complies with the NHS complaints procedure, with particular reference to timescales; and
• apologise for the failures identified.

Summary
Mrs C complained about the treatment her mother (Mrs A) received at the Victoria Infirmary. Mrs A was admitted to hospital by emergency referral from her GP with a history of recurrent falls, drowsiness and reduced mobility. Mrs A was initially treated for a presumed infection based on abnormalities in her bloods and her presenting condition. However, no clear source of infection was identified. She was identified as being at risk of blood clots and was put on anticoagulant medication.

Nursing staff observed that Mrs A's right leg was swollen. A doctor reviewed the swelling and did not consider it to be significant. Mrs A's leg was found to be swollen again eight days later. A Doppler ultrasound (a type of ultrasound for monitoring blood flow) was carried out, which showed no signs of thrombosis. A CT scan showed that Mrs A had a mass in her pelvis. Biopsies were ordered, but because of the location of the mass and the quality of the material gathered, it took some time to obtain the eventual diagnosis of cancer of the B-cells. This diagnosis was made around a month later and three days after Mrs A's death. A post-mortem was carried out which concluded that Mrs A's death was the result of a pulmonary blood clot, caused by Deep Vein Thrombosis (DVT) in the right calf, due to a large tumour.

Mrs C complained that the board failed to take prompt or effective action to investigate the cause of her mother's swollen leg. She considered that this led to a failure to identify DVT. She also complained that delays to the biopsy results meant that there was no opportunity to treat her mother's cancer. Mrs C raised further concerns about delays to providing family members with test results and poor administration of medication.

Whilst we found that the board did not regularly assess Mrs A's risk of blood clots during her admission, we were satisfied that this would not have had a detrimental impact on her treatment. We considered that there were opportunities for further Doppler ultrasounds to be carried out, but were ultimately satisfied that it was reasonable for the board not to undertake these tests in the circumstances.

There was no evidence of DVT following the Doppler ultrasound and we found that Mrs A's mass (which was likely to cause leg swelling) and the fact that she was already receiving anticoagulant medication indicated that there were alternative causes for her swelling other than DVT. We did not find that the board unduly delayed providing family members with test results.

Similarly, the evidence presented to us showed that it was difficult to obtain biopsy samples from Mrs A's mass and, once obtained, the diagnosis of cancer of the B-cells was complex, requiring specialist opinion. We were satisfied that the biopsies were ordered, and their results reported, as quickly as possible. With regard to the provision of medication, we found that cough medicine prescribed for Mrs A was taken to a different patient in error. We also established that Mrs A was prescribed the wrong dose of anticoagulant medication and that doses may have been missed on more than one occasion. Whilst we were unable to confirm that doses were definitely missed, we considered that the lower dose provided would have increased Mrs A's risk of developing blood clots.

Recommendations
We recommended that the board:
• apologise to Mrs A's family for the failure to properly prescribe and record certain anticoagulant drugs;
• remind staff of the importance of recording and signing for all administered medication; and
• draw clinical staff's attention to the guidance in the Therapeutics Handbook for Thromboprophylaxis for Medical Patients (guidance on the administration of anticoagulant drugs to patients with an increased risk of blood clots).

Summary
Mrs C was a patient of a consultant gynaecologist for about five years, during
which time she had gynaecological surgery, including a hysterectomy. At the
time of this surgery, the consultant noted signs of endometriosis (a condition in
which cells from the lining of the uterus appear outside the uterus). Five years
after the surgery, Mrs C was suffering intermittent pelvic pain and her GP
referred her to the board's gynaecology department.

Mrs C was unhappy with the care and treatment she received after the referral.
In particular, she was unhappy with the information that was provided to her
before surgery to remove her ovary. She felt that information was an
insufficient basis for her to give fully informed consent before surgery. She was
also unhappy about the removal of a stent, and complained that her ureter was
damaged during the ovary surgery. She also said that, due to failures in care
and treatment, she developed preventable infections, including MRSA.

We could not say with certainty what was said to Mrs C in advance of the two
procedures. From looking at the evidence, we found that Mrs C signed consent
forms for each procedure. Both forms stated that the nature and purpose of the
procedures had been explained to her, and that she consented to further
alternative operative measures that might be found necessary during the course
of the operation. In addition, the consent form for the ovary surgery had been
annotated and showed that the potential for bowel and bladder damage were
discussed. We were satisfied from the evidence that consent was properly
obtained and Mrs C was provided with sufficient information, and therefore, we
did not uphold this complaint.

We took advice from three of our medical advisers. One adviser said it was not
possible to say exactly how, or at what stage of, the ovary surgery Mrs C's left
ureter was damaged. The adviser was critical of the sparse record of the
operation and was also of the view, based on the available information, that the
damage to Mrs C's ureter could have been avoided. Given the deficiency in
record-keeping, and taking into account the views of the adviser, we upheld this
complaint.

In terms of Mrs C's treatment in hospital, two of our advisers found no evidence
of failures in care and treatment leading to Mrs C developing preventable
infections. However, based on the medical notes provided by the board, one
adviser was of the view that Mrs C should have been seen by a consultant
gynaecologist more urgently in another hospital, especially when she was still
unwell on the two days following her readmission after ovary surgery. In
addition, the adviser was critical of the wait for a CT urogram (a scan of the
urinary tract) before her move to another hospital. Given these failings in care
and treatment, we upheld this complaint.

Recommendations
We recommended that the board:
• apologise to Mrs C for the damage to her ureter during surgery;
• ensure operation notes include appropriate details, taking account of
Royal College of Obstetrics and Gynaecology guidelines and the
comments made in our decision; and
• draw the failings in care and treatment to the attention of medical staff in
the gynaecology department.

Summary
Mrs C is an owner/occupier in a tenement building which is partially private but in which the council still has an interest. She was dissatisfied with the cost of mutual repairs (stair entry door) which the council arranged and she claimed that all the works she was billed for had not been undertaken. When Mrs C received a reduced bill, she claimed that the council failed to explain the reason for the reduction.

Mrs C complained that the council's handling of the matter, particularly that they took an excessively long time to investigate. Our investigation established that the council had arranged for the repairs to be undertaken without consulting with the other owners because it was deemed to be emergency work, necessitating immediate action in the interests of residents' safety.

The council informed us that visits were undertaken but it was clear that there had been a delay in responding to Mrs C's complaint, and it was not handled appropriately under the terms of their complaints procedure. We upheld the complaint about failings in the council's complaints handling. We did not uphold Mrs C's complaint that the council had not explained the reason for the reduction in the repairs bill because the evidence confirmed that a satisfactory explanation was given.

Recommendation
We recommended that the council:
• issue a formal apology from the Chief Executive to the complainant in recognition of the council's shortcomings in the handling of her complaint under their complaints procedure.
 

Summary
Mr C complained that the council had breached National Care Standards by amending their policy in relation to foster carers’ ability to claim for travel expenses, and in relation to providing child care at training and consultation days. He also complained about the way the council had handled his complaints.

Mr C stated he was disadvantaged by the amendment to the foster carer’s allowance, which meant he could no longer claim for journeys of less than 50 miles. He felt that this expenditure should not come out of an allowance for an individual child, and that he was discriminated against as an individual who lived in a more remote location than other foster carers receiving the same allowance. He also explained the council had failed to provide child care at some training events, which made it more difficult for foster carers such as him to attend.

We did not uphold this complaint, although we criticised the council’s consultation process in relation to changing its policy about foster carers’ allowances. We found that the change did not breach the Standards and were within the council’s discretion. We also found that the council had apologised for failing to provide child care at training events, and did so at subsequent events.

We upheld Mr C’s complaint about the complaints handling process. We found there were lengthy delays in him receiving responses at some stages of the process, and that at one stage the complaint went back to someone who had dealt with it at an earlier stage. Mr C also had to request twice that his complaint be responded to by the Chief Executive as per the council’s procedure.

Recommendations
We recommend that the council:
• provide an apology to Mr C for failing to follow its complaints procedure adequately in relation to your complaints; and
• provide evidence of the new complaints handling process, and of staff training in relation to complaints handling.
 

Summary
Mr C's 86-year-old mother (Mrs A) was admitted to The Golden Jubilee National Hospital for hip surgery. Following surgery, she was returned to the ward for bed rest and was noted to be a little confused. The hospital said that they explained to Mrs A that she should not mobilise and to use her call bell if she needed assistance. They said that she seemed to understand this advice.

During the night, Mrs A fell out of bed and dislocated her hip which then required further surgery. Within half an hour, she fell out of bed again and was then placed in an alarmed bed. Since her falls and surgeries, Mrs A’s recovery has been protracted and her long term prognosis is poor.

Mr C complained that his mother was not properly monitored following her surgery. Our investigation confirmed that although Mrs A's first fall could not have been anticipated, the hospital did not take appropriate action after a second fall. We found that the hospital also failed to send Mr C a copy of the appropriate incident report after he requested it.

Recommendation
We recommended that the hospital:
• apologise for failing to send Mr C a copy of the appropriate incident report and that they provide one.
 

Summary
Mr C's mother (Mrs A) required ankle replacement surgery. Around one week after her surgery, Mrs A was discharged home. Mr C complained that his mother was not properly cared for by the district nursing service to the extent that her ankle became severely infected, and she was disorientated and malnourished. Mr C said that when Mrs A was admitted to Ninewells Hospital around three weeks later, her condition was life-threatening.

Mr C said that the infection in his mother's ankle had also spread to her spine but that despite her pain and the concerns expressed by her family, it took a month to determine and treat the extent of the problem.

We investigated Mr C’s complaint and obtained advice from our medical adviser. The adviser found that the care and treatment given to Mr C's mother was satisfactory and that hospital staff had correctly concentrated on the severity of Mrs A's infection before addressing the pain in her back.

Although Mr C's complaints about his mother's care and treatment were not upheld, we did uphold his complaint about the board's complaints handling. We found that the board took too long to handle and investigate Mr C’s complaint and that they did not comply with their own stated timescales.

Recommendation
We recommended that the board:
• remind all staff involved in this complaint (particularly those who have been asked to respond to the complaints department) of their responsibility to support the NHS complaints procedure by replying in a timely way.

Summary
Mrs C was treated for a vaginal prolapse. She underwent surgery to correct the condition but had complications following the procedure which left her with bladder dysfunction. As a result of this, she required a permanent catheter.

Mrs C was initially taught to intermittently self-catheterise. She was uncomfortable with this procedure and found that it had a detrimental impact on her life. She raised her concerns with the board but it was some time before an alternative form of catheterisation was provided. Mrs C complained that avoidable surgical failures resulted in her losing bladder sensation and that the board failed to warn her in advance that her surgery could permanently damage her bladder. She also felt that the board took too long to investigate alternatives to self-catheterisation.

We found that the board did not warn Mrs C of the possibility of permanent bladder damage prior to her surgery. Whilst we were satisfied that the surgery was carried out correctly and the subsequent complications were unavoidable, we considered that there was an unreasonable delay to providing Mrs C with an alternative to self-catheterisation.

Recommendations
We recommended that the board:
• include information about the potential for permanent bladder problems, and any other significant detrimental outcomes, in their pre-operative counselling for vaginal repair surgery;
• draw their staff's attention to the NICE guidance on surgical repair of vaginal wall prolapse using mesh to ensure that patients are provided with full information regarding the risks and benefits of this procedure prior to giving consent; and
• apologise to Mrs C for the issues highlighted.
 

Summary
Mr C had been experiencing abdominal pain since around 05:00 on a day in June 2010. He became unwell and his pain increased in severity around 22:00. He telephoned the Scottish Ambulance Service (SAS). They did not consider his case to be an emergency and transferred his call to NHS 24. Mr C’s conversation with NHS 24 lasted around 40 minutes, during which time he repeatedly asked for an ambulance to be dispatched to his home. The NHS 24 call handler sought details of his symptoms and ultimately decided to arrange for a duty doctor to call him back within one hour. Mr C was not satisfied with this outcome and arranged for a neighbour to assist him to phone the SAS again. Following this call, a paramedic was dispatched and, following an examination, an ambulance was called. Mr C was found to have a burst appendix.

Mr C complained that NHS 24 should have dispatched an ambulance given the nature of his symptoms. He felt that the number and nature of the questions put to him by the call handler was repetitive, unreasonable and inappropriate. He also complained that it was inappropriate and unreasonable for NHS 24 to suggest that a doctor phone him ‘within an hour’ for further assessment when he was clearly in considerable pain and distress.

We were satisfied with the nature of the questions asked by NHS 24 and found that, whilst there was some duplication, this was kept to a minimum. The evidence that we were presented with showed that there were some communication issues between Mr C and the call-handler and we considered that these contributed to the length of the call more than the NHS 24 call procedure. Our professional medical adviser shared an opinion expressed by NHS 24 that Mr C’s symptoms indicated a need for a physical examination. Mr C had advised the call-handler that he was unable to make his own way to hospital, so we considered it unreasonable for the physical examination to be delayed further by arranging for a doctor to telephone him. We considered that NHS 24 should have made arrangements for a physical examination and, given the symptoms described by Mr C, we found that the most appropriate outcome would have been for an ambulance to be dispatched.

Recommendations
We recommended that NHS 24:
• reflect on their handling of Category C calls and the assessment criteria for transferring cases back to the Scottish Ambulance Service; and
• consider reviewing their criteria for assessing cases of acute abdominal pain to ensure that where rapid escalation of symptoms occurs, this is given due emphasis.
 

Summary
Mr C attended his GP with regard to a lesion below his right eye. His GP referred him to a clinic at the hospital for further examination of the lesion. He was reviewed by a registrar initially in November 2010, and attended for the procedure around one month later. When Mr C left the clinic, he found the lesion he was concerned about remained on his face, and a lesion on his nose had been removed instead. Mr C complained to the board.

We found that the notes for the initial clinical appointment contained inaccurate details, and that the lesion for which Mr C’s GP had referred him was not the lesion subsequently identified by the registrar for removal. On this basis, we upheld Mr C’s complaint that the board failed to remove the lesion which he had been concerned about. Mr C had several lesions on his face, and it may also have been helpful if the original GP referral had included details of the other lesions to prevent this confusion arising.

However, we did not uphold Mr C’s second complaint that it was inappropriate to remove the lesion from the side of his nose. Examination of this lesion established that it was a benign tumour and, therefore, it was of clinical concern and certainly the most high risk lesion on Mr C’s face. We also found Mr C had signed a consent form prior to the procedure which stated he consented to any additional procedure which was in his best interests and justifiable for medical reasons.

We did not uphold Mr C’s third complaint that he had been provided with conflicting information regarding the necessity of removing the lesion he had been concerned about. The board had referred Mr C on to a dermatology specialist who had established this lesion was a mole which could be treated satisfactorily with cryotherapy. We did not find this to be conflicting, but in fact appropriate medical advice on the best way in which to proceed.

Recommendation
We recommended that the board:
• apologise Mr C for removing a different lesion on his face to the one he and his GP were concerned about.