Some upheld, recommendations

Summary

C complained on behalf of their parent (A). A was diagnosed with oesophageal cancer (tumour in the tube which connects from throat to the stomach) and later underwent chemotherapy and radiotherapy. Over a year later, A had a CT scan but the results were not reported for around three weeks. The CT scan found evidence that the cancer had spread to the liver. It was no longer possible to cure the cancer and A's care became palliative (managing pain or related symptoms, but not treating the underlying disease or condition). A was admitted to the Queen Elizabeth University Hospital where they later died.

C complained that there was an unreasonable delay in reporting and communicating the results of A's scan. We took independent advice from a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer). The board had accepted there was a delay in formally reporting the CT scan and acknowledged it was a significant failure to report a life changing progression of disease. We upheld the complaint but as the board had already apologised for this error, we did not make any further recommendations. We also noted that the delay in issuing the report did not change the situation for A as the disease was already advanced.

C complained that the board failed to communicate reasonably with A's family during their admission to hospital. We found that there were annotations about discussions with the family in the records and it was routinely noted when family were present. However, there was little in the notes to show what was said or what individuals' concerns were. Therefore, we upheld this complaint.

C also raised a number of concerns about care provided to A during their admission. We found that there were elements of the care provided to A which were not best practice, some of which the board had already acknowledged in the complaints process. However, there were also many elements of A's treatment which were reasonable. On balance, we did not uphold this complaint.

Recommendations

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

• For staff to have the opportunity to reflect on the findings of this investigation.

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, an advocate, complained on behalf of their client (B). B's partner (A) was diagnosed and treated for a frozen shoulder (a condition affecting the shoulder, making it painful and stiff with loss of mobility) by the board after attending the emergency department. A's pain and symptoms did not improve so they continued to attend health services. B considered it was unreasonable for A to have been diagnosed with a frozen shoulder based on their level of pain and the board failed to provide reasonable treatment. A's health deteriorated and they were diagnosed with cancer. B said this diagnosis and A's prognosis were not appropriately communicated.

We took independent advice in relation to the complaints.

C complained that the board unreasonably administered a steroid injection to A. We found that A's symptoms were atypical for a frozen shoulder and there were red flag symptoms present. Therefore, the case should have been discussed with the responsible consultant at the clinic and further investigations carried out, prior to a decision on whether the injection should be administered. Therefore, we upheld the complaint.

C also complained that the board failed to diagnose A's cancer in a reasonable timescale. We found that there was a short but unreasonable delay in diagnosing A's cancer. We considered that the actions during most of A's attendances were reasonable. However, they raised concerns regarding no consultant opinion being sought when A attended the emergency department and that there was a missed opportunity to investigate A's atypical symptoms during one of the appointments. We found that there was a lack of clinical ownership for A's case. Therefore, we upheld the complaint.

C also complained the board failed to communicate A's cancer diagnosis in a reasonable manner. There was limited information to consider as the records were not a verbatim account of conversations. We found that there was no evidence to suggest the doctor communicated with A and B in a cold or uncaring manner. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for administering the steroid injection to A and for the delay in diagnosing A with cancer. 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:

• Cases involving multiple specialties should be appropriately managed and atypical signs of frozen shoulder appropriately investigated.
• Registrars should consult with senior clinicians prior to administering steroid injections where there are atypical signs for frozen shoulder.
• Relevant records should be available to clinicians.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all key points raised by the complainant.

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 actions of the board in respect of their late parent (A). After being examined by their GP due to stomach pains and an irregular heartbeat, A was admitted to hospital. A was initially admitted to the hospital's Initial Assessment Unit (IAU). C stated that, when A was examined in the IAU, the family informed the doctor about A's history of having an abdominal aortic aneurysm (AAA, a bulge or swelling in the aorta, which is the main blood vessel that runs from the heart down through the chest and stomach).

A was transferred to a ward for further investigation. During this time, A's stomach pain increased. Clinical staff initially considered this as the result of constipation. On speaking with C, a doctor stated they were not aware of A's history of AAA. After further investigation, the doctor told the family that complications with the AAA could be ruled out. Shortly afterwards, A's condition deteriorated and a CT scan showed a leaking AAA. It was decided that it was not appropriate to operate and A died later that day.

C complained about the treatment A received and, in particular, that clinical staff unreasonably delayed diagnosing a leaking or ruptured AAA despite being informed of A's history. In addition to this, C complained that the doctor they spoke with after A's death did not report the matter to the Procurator Fiscal despite giving the impression they had done so. Finally, C complained about the fact that the same doctor did not write to them following A's death, after telling them this would happen.

In respect of the first complaint, we took independent advice from a specialist in acute medicine. We found that, given A's presentation at the time, the actions and decision-making of clinical staff was reasonable. The records showed that the possibility of a ruptured AAA was considered after A was transferred to the ward. However, given the outcomes of examinations and investigations carried out, this diagnosis was considered unlikely. Instead, an alternative diagnosis of pneumonia was initially pursued, with a secondary complaint of abdominal pain attributed to known constipation. We found that these conclusions were reasonable and justified by the recorded evidence. We also found that there was not sufficient evidence to reach a conclusive view on whether the IAU doctor was aware of A's history of AAA. We, therefore, did not uphold this complaint.

In respect of the second complaint, we noted that The Crown Office & Procurator Fiscal Service has produced guidance called Reporting Deaths to the Procurator Fiscal: Information and Guidance for Medical Practitioners. One situation where deaths should be reported is where the nearest relatives of the deceased raise concerns that the medical treatment given to the deceased may have contributed to their death. Given the evidence available about the conversation between C and the doctor following A's death, we could not reach a conclusive view on whether the Procurator Fiscal should have been informed at this point. However, another situation where deaths should be reported to the Procurator Fiscal is where a death certificate has already been issued and a complaint is later received which suggests an act or omission by medical staff caused or contributed to the death. This did not happen in this case and, therefore, we upheld this complaint.

The final complaint related to the doctor who spoke with C following A's death and their failing to contact C about the outcome of a meeting that was to take place. We noted that the doctor had acknowledged there was an unacceptable delay in writing to C. However, we did not consider the board's stage 2 response to contain an explanation for such a delay or indicate that any reflection had taken place about what went wrong. We reviewed the statement provided by the doctor as part of the board's complaint investigation and considered this to provide far more context about what happened. If the board had provided a fuller response that reflected the doctor's statement, C may have had a better understanding of what happened and considered this aspect of the complaint closed. We upheld this complaint because there was a clear failing, which had already been acknowledged by the board. We also provided feedback to the board about the importance of providing open and transparent explanations when acknowledging failings in complaint responses.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform the Procurator Fiscal of A's death, following the complaint made by C. 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:

• In line with the guidance issued by the Procurator Fiscal, deaths should be reported where, at any time, a death certificate has been issued and a complaint is later received by a doctor or by the health board, which suggests that an act or omission by medical staff caused or contributed to the death.

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 on behalf of their parent (A). A had a fall at home and was admitted to hospital due to a fractured hip. C was concerned that A was discharged from hospital only a few days after they had surgery. We took independent advice from an orthopaedic surgeon (specialist in diagnosing and treating conditions involving the musculoskeletal system) and an occupational therapist. We found that a comprehensive occupational therapy assessment was carried out prior to A's discharge which fully considered A's home environment and that the decision to discharge A four days after surgery was reasonable and met the targets set out in the Scottish Standards of Care for Hip Fracture Patients. We also found that the discharge and medications were discussed with A.

We, therefore, did not uphold C's complaint about A's discharge from hospital.

C also complained about the way the board handled their complaint. We found that the board did not always proactively update C or provide a revised timescale when they could expect to receive the response to their complaint. Therefore, we upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not always proactively updating them or providing a revised timescale for when they could expect to receive a response to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Where the 20 working day timescale for a response cannot be met, the complainant must be kept updated on the reason for the delay and given a revised timescale for completion.

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 to us on behalf of their late parent (A). A was admitted to Forth Valley Royal Hospital after falling at home. A few days into their admission, A was diagnosed with pneumonia (a chest infection) and then later developed sepsis (a severe complication of infection). A's condition deteriorated and they died.

C complained about A's medical treatment; in particular, that there was a delay in recognising and treating A's sepsis. We took independent advice from a geriatric (medicine of the elderly) adviser. We found that A's medical care and treatment was reasonable. We did not uphold this complaint.

C also complained about A's nursing care. C said that A was not given enough help with personal care and that their conversations with nursing staff had not been recorded adequately. We took independent advice from an acute nursing adviser. We found that the standard and frequency of the communication recorded appeared reasonable. However, we found that there was a lack of evidence of regular and appropriate care rounding to meet A's personal care needs. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care. 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:

• Patients should be given timely and appropriate nursing care.

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 experienced pain and numbness in their hands over a period of years and was referred to the board for treatment. C underwent some tests and was offered repeat carpal tunnel surgery. C complained that the board failed to provide reasonable care and treatment. Unhappy with the board's response to their complaint, C brought the complaint to our office.

We took independent advice about all the complaints raised with us.

C complained that the board failed to carry out reasonable tests and investigations prior to their surgery. While we considered that the rationale provided by the surgeon in relation to what tests were carried out was reasonable, we questioned whether this was reasonably explained to C. We considered that the contemporaneous records did not evidence a thorough assessment of C's condition prior to the surgery being carried out. Therefore, we upheld this aspect of C's complaint.

C complained that the board unreasonably carried out surgery to their hands. We considered that the decision to undertake the revision surgery was reasonable, albeit that further investigations could have been carried out prior to this. C had previously had carpal tunnel surgery. We noted carpal tunnel can recur and it was reasonable for a second operation to be considered. On that basis the offer of surgery was reasonable. We did not uphold this aspect of C's complaint.

C complained that the board failed to offer a reasonable treatment plan after their surgery. We considered that after it was found the surgery had been unsuccessful, the actions recommended by the surgical team were reasonable. They offered to refer C back to the pain clinic and, after this was declined, discharged C back to the care of their GP. We concluded the board's treatment plan and actions regarding pain management were reasonable. 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 failing to reasonably evidence a thorough assessment of C prior to undertaking surgery and for the administrative error regarding the nerve conduction test results. 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:

• Clinicians should ensure the assessment of a patient is accurately recorded including the rationale behind decision-making.

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 submitted a complaint on behalf of their late sibling (A) about the treatment A had received by the board over a five-month period. A had a mass in their abdomen which led to a referral to urology (specialists in the male and female urinary tract, and the male reproductive organs) and later gynaecology (specialists in the female reproductive systems). A was initially diagnosed with pedunculated fibroids (noncancerous growths in the uterus) but it was later found by a different health board that A had cancer. C considered that the treatment provided by the board was unreasonable and led to a delay in A receiving the correct diagnosis.

C complained that the board failed to reasonably diagnose A after they were referred by their GP. We took independent advice from a specialist. We considered that the initial investigations carried out were reasonable, however, after the MRI results were received, the board failed to reasonably respond to this. The MRI result did not match with A's clinical picture and we considered that there was an unreasonable failure that this was not recognised and steps taken to investigate it further in a reasonable timescale. We considered that there was a failure in clinical judgement relating to this. Therefore, we upheld this aspect of C's complaint.

C also complained that the board failed to provide reasonable treatment when A attended A&E. We took independent advice about this complaint. We found that the investigations carried out were reasonable; we noted that further actions could have been taken, but the lack thereof was not in itself unreasonable, given the remit of A&E to only deal with emergency presentations. On balance, we did not uphold this aspect of C's complaint.

Recommendations

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

• Where radiological findings do not fit with the clinical picture a further review should be undertaken.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and respond to each main point raised.

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 provided to their late spouse (A) by the board in relation to the diagnosis, treatment, and management of A's cancer, especially regarding a delay in A receiving a Positron Emission Tomography scan (PET, a scan that produces detailed 3D images of the inside of the body). We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that A's cancer pathway took 17 months, which was significantly longer than it should have taken. We found that the most significant issue for the delay in the process was the error which resulted in the PET scan not being booked, as requested by the multi-disciplinary team (MDT). Additionally, the PET scan should have been requested on a suspected cancer pathway and we were critical that this was not the case.

We found that the delay in A's diagnosis was unreasonable and on balance, due to the increase in size of A's tumour during the delay, it is likely this negatively impacted on their outcome. We considered that the care and treatment A received from the board was unreasonable and upheld this aspect of C's complaint.

C also complained about the out-of-hours service (OOHS). A developed a postoperative wound infection, and was admitted to hospital. C complained that the OOHS, who saw A prior to admission, requested a non-life-threatening response from the Scottish Ambulance Service (SAS), rather than a life-threatening ambulance. We took independent advice from a GP. We found that the OOHS GP requested the ambulance in line with the SAS guidance, and any delays in the ambulance attending were outwith the GP's control. 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 failing to provide A with reasonable care and treatment. 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:

• MDT requests for investigations, booking of investigations, results being shared, and follow-up MDT discussions should be actioned as soon as possible in cancer pathways.
• Patients and their family should be appropriately involved in discussions regarding their condition and management and these discussions should be recorded in the patient's notes.
• Requests from MDTs should be emailed directly to the clinicians to be actioned, rather than being sent to the gastrointestinal secretaries to be passed to the consultants.
• Where cancer is being considered as a strong possibility within the differential diagnosis, a PET scan should be requested on a suspected cancer pathway.

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, a support and advocacy worker, complained about the standard of medical and nursing care and treatment provided to their client (A) during A's hospital admissions at Victoria Hospital and Cameron Hospital over 11 months. The concerns raised cover numerous aspects of the care and treatment provided by clinicians at A&E and the intensive care unit at Victoria Hospital, and clinical staff at Cameron Hospital. These include unreasonable failures in relation to the response to A's deterioration, medication including dosage, communication, bedsores, rehabilitation, and discharge. C also said that the board failed to handle A's complaint in a reasonable way. C told us that as a result of the failings, A developed complications which have had a profound impact on them and their spouse's life.

We took independent advice from four advisers: consultants in emergency medicine, psychiatry and anaesthesia, and a nurse specialist in tissue viability. We found that A had not been regularly reassessed as they should have been in A&E for a number of hours during which time their condition deteriorated and their transfer to the intensive care unit was delayed, and that staff in A&E failed to communicate with A's spouse in a reasonable way. We found that clinicians failed to take reasonable action to prevent hospital-acquired pressure damage to A and then failed to investigate and treat A's pressure ulcers, which led to severe and extensive pressure damage to a degree rarely seen in today's healthcare setting. We noted that this was avoidable and that the board's failure to identify these failings in their subsequent review was very concerning. We also found that the board's response to the complaint about A's condition and its cause did not reflect the evidence from the clinical records and advice obtained from specialists. We upheld five of C's complaints.

We did not find failings in relation to medications, communication from clinical staff in intensive care, transfer, handling of A by nursing staff at Cameron Hospital, rehabilitation care and treatment and discharge. We did not uphold eight of C's complaints.

Recommendations

What we asked the organisation to do in this case:

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

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

• Ensure communication by healthcare professionals is of a reasonable standard.
• Ensure patients are regularly assessed so that any deterioration is noted and respond to appropriately and within a reasonable time.
• Review the clinical failings to ascertain: how and why the failings occurred; any training needs; and what actions will be taken (or since then have been taken) to prevent a future recurrence. Before doing so, the board should consider why their previous review failed to identify the failings and ensure that the methodology of this review is robust and that whoever undertakes it is appropriately qualified, objective and impartial.

In relation to complaints handling, we recommended:

• Ensure all complaint responses are accurate and reflect the available evidence and information.

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

Mr C complained about the board's weight management service at Queen Margaret Hospital. In the course of our investigation, we took independent advice from a bariatric surgeon (a doctor who specialises in the causes, prevention and treatment of obesity).

Mr C complained that the service refused to offer him bariatric surgery after he attended a weight management programme. We found that the board provided an inadequate reason for not progressing Mr C to the next stage of the pathway, where patients are considered for surgery, and considered that this decision was unreasonable. We found that the board did not give appropriate consideration to Mr C's individual circumstances in making their decision and had failed to offer a second opinion or appeal process. We upheld Mr C's complaint and made a number of recommendations.

Mr C also complained that the board had informed him of their decision not to progress in a public setting, where other patients could overhear. We carefully considered Mr C's account and the board's account of what happened. We were unable to reconcile the differences, and we did not find evidence to conclude that clinicians had failed in their duty to maintain patient confidentiality. Therefore, we did not uphold this complaint.

Finally, Mr C was also unhappy with the way the board handled his complaint. We found that there were short delays in the board informing Mr C about the timescales for responding to the complaint. We also found that the board had not communicated accurately with Mr C about a case conference that was initially offered to him. We noted that the board had apologised for the confusion in relation to this. We upheld this complaint and provided feedback to the board about complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for deciding that he could not progress to Tier 4 of the Bariatric Surgery Pathway solely because he had not lost 5% of his body weight and for not giving reasonable consideration to his other conditions and his weight loss prior to commencing the programme. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide Mr C with an opportunity to seek a second opinion or appeal the decision in respect of his progression to Tier 4 in light of SPSO's findings and taking into account his current circumstances.

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

• Patients should be considered for Tier 4 of Bariatric Surgery Pathway in accordance with the Scottish best practice guidelines and individual circumstances should be taken into account.
• Patients should receive a letter detailing the reasons for failure to progress to Tier 4 which should be in line with Best Practice Guidelines. A second opinion or appeals process should be available to the patient if required.

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.