Some upheld, recommendations

Summary

Ms C complained to us about the care and treatment she received from the board when she was diagnosed with lung cancer. Ms C was told that the tumour in her lung had been visible in a CT scan she had several years earlier, which was taken to plan her radiotherapy treatment (a treatment using high-energy radiation) for breast cancer. Ms C complained that the lung tumour was not identified at that time or if it was, she was not offered any treatment. We took independent medical advice from an oncologist (cancer specialist). We found that CT scans for planning radiotherapy are not taken with enough detail to be used for diagnostic purposes. We also found Ms C's lung tumour was small and it could have easily been missed by a clinician who was not reviewing her CT scan for diagnostic purposes. We found it was reasonable that Ms C's lung lesion was not identified at that time and we did not uphold this aspect of her complaint.

Ms C also complained about the communication with her about her condition and treatment, leading up to her diagnosis of lung cancer. In particular, that Ms C was sent an appointment letter for a chest CT scan without being told the reason why she was being referred for a CT scan. We took independent medical advice from an acute medical consultant. We found that Ms C and her GP were not appropriately informed about the outcomes of investigations that had been carried out; and why there was a need to carry out further investigations into her condition. We upheld this aspect of Ms C's complaint.

Ms C also complained about the board's complaints handling. We found that the board did not keep Ms C appropriately updated during their investigation. We found that the board had failed to identify and respond to all aspects of Ms C's complaint; it was unclear what the conclusions of their complaints investigation had been; and they did not apologise to Ms C for failings they had identified. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in their communication with her; and for failing to handle her complaint in a reasonable manner. 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 and their GPs should be appropriately informed about the outcomes of investigations and the need to carry out any further investigations.

In relation to complaints handling, we recommended:

• In line with the NHS complaints handling procedure, complaint responses should address all the issues raised and demonstrate that each element has been fully and fairly investigated; include the conclusions of the investigation; and include an apology where things have gone wrong. 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

Mr C complained about the care and treatment he received from Aberdeen Royal Infirmary. Mr C had a nerve sheath tumour (a type of tumour of the nervous system) in his neck in an area known as the brachial plexus (a group of nerves that come from the spinal cord in the neck and travel down the arm. These nerves control the muscles of the shoulder, elbow, wrist and hand, as well as provide feeling in the arm). Mr C had surgery to remove the tumour. During the operation three nerves were found to be running through the tumour. All three nerves were stimulated electrically. One nerve made the deltoid muscle twitch and this nerve was preserved. The other two nerves produced no apparent muscle movement and were cut and removed with the tumour. This resulted in Mr C losing the use of large muscles in his arm.

We took advice from an otolaryngology (the study of diseases of the ear and throat) and head and neck surgeon and from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). We found that:

advice should have been sought from the Scottish Brachial Plexus Team prior to Mr C's operation

intraoperative neurophysiological nerve monitoring (IONM – where fine needles are placed in the target muscles and spontaneous muscle fibre electrical activity is continuously displayed on a screen as waves) should have been used during Mr C's operation

Mr C's nerves should not have been cut during the operation

Mr C was not referred to the Scottish Brachial Plexus Team within a reasonable amount of time following his surgery

the board failed to consider at an earlier stage whether an Adverse Event Review should have been carried out.

We upheld Mr C's complaint that the board did not provide him with reasonable care and treatment.

Mr C also complained that the board did not inform him of the risks of the surgery. We found that the board did communicate reasonably with Mr C about the risks of the surgery and therefore we did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board failed to handle his complaint reasonably. We found that:

the board's own complaint investigation did not identify the serious failings in the care provided to Mr C

there was a delay in responding to Mr C's complaint and he was not kept updated on the progress of his complaint or provided with a revised timescale for the response

the board's complaint response said that Mr C's reparative surgery took place on an incorrect date.

Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to seek advice from the Scottish Brachial Plexus Team prior to his operation; the failure to use IONM; cutting his nerves during the operation; the length of time taken to refer him to the Scottish Brachial Plexus Team after the operation; the delay in responding to his complaint and that he was not kept updated and; that the complaint response did not accurately state the date his reparative surgery took place. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance .

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

• The board should consider carrying out an Adverse Event Review where an event has occurred that could have resulted in harm (a near miss) or did result in harm to a patient.

In relation to complaints handling, we recommended:

• Complaint responses should contain accurate information.
• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here www.spso.org.uk/the-model-complaints-handling-procedures .
• The board's complaints handling system should ensure that failings (and good practice) are identified, and that it is using the learning from complaints to inform service development and improvement (where appropriate).

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

Miss C, an advocacy worker, complained on behalf of Ms B that the board failed to provide her late mother (Mrs A) with reasonable care and treatment at Aberdeen Royal Infirmary and that staff at the hospital failed to communicate adequately with Mrs A's family about her care and treatment.

Mrs A had been admitted to the hospital's intensive care unit with respiratory failure where she died. Mrs A had suffered from a number of chronic illnesses. We took independent advice from a consultant in emergency medicine. We found that the care Mrs A received was reasonable and in line with current guidelines and good clinical practice. The evidence available showed that, ultimately, Mrs A's failure to respond to the treatment was because of the seriousness of her condition, and not the treatment itself. We did not uphold this aspect of the complaint.

In relation to communication with Mrs A's family, we found that it was clearly recorded in the clinical notes that on Mrs A's admission there had been a discussion with her family. It had been explained that there was a very real risk that Mrs A would not survive the admission and why performing cardiopulmonary resuscitation (CPR, where the heart and/or breathing is restarted if it stops) would not be in her best interest. However, other than this initial conversation, in general, communication with Mrs A's family was very poor. In particular, the decision to extubate Mrs A (to remove a breathing tube) should have been discussed with her family prior to this taking place. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B and her family for the communication failures 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:

• Patients and their families should be involved in the decision-making process where appropriate and should receive regular updates. This should be recorded in the clinical records.

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 that the board failed to communicate reasonably with him and his wife (Mrs C) about his child's (Child A) care and treatment. Mr C raised concerns about the timeliness and accuracy of medical advice; the failure to engage with Mr and Mrs C in a meaningful way; and a failure to obtain proper consent on a number of occasions.

We took independent advice from a paediatrician, and a paediatric surgeon with an interest in gastroenterology (the branch of medicine that deals with disorders of the stomach and intestines). We found that many aspects of communication had been reasonable, however, there was a lack of documentation regarding information given to Mrs C both prior to and following a endoscopy procedure (a medical procedure where a tube-like instrument is put into the body to look inside) carried out on Child A. The documentation was not in line with General Medical Council guidance on consent and protecting children and young people. We therefore upheld this aspect of Mr C's complaint.

Mr C also complained about the care and treatment provided to Child A. We found that the care and treatment provided was reasonable and did not uphold this aspect of the complaint.

Finally, Mr C complained about the board's handling of his complaints. Whilst we acknowledged that there was a significant volume of correspondence for the board to consider and respond to, we considered it clear that there were multiple occasions on which Mr and Mrs C's complaints were not handled in line with the appropriate complaint handling procedures. We considered that the volume of complaints made by Mr and Mrs C was partially as a result of complaints not being managed and responded to in an effective and timely manner; and that the board's failure to address correspondence correctly contributed to the breakdown in the complaints procedure. We also noted that the board had agreed at one point to issue a formal written apology about Child A being removed from the hospital without consent, but this apology had never been sent. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for the lack of documentation regarding information given to Mrs C both prior to and following the endoscopy procedure; the failure to handle the complaints in a reasonable and timely manner; Child A being removed from the hospital without consent; and the failure to issue an apology for this at the time. 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:

• Discussions with family members should be documented.

In relation to complaints handling, we recommended:

• Complaints should be handled in a reasonable and timely manner, and in line with the complaint handling procedure.

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

Mrs C complained that the association unreasonably communicated with her regarding her rent and rent arrears. We considered that, while the association was clear in the amount and frequency of payments, an element of their communication had been unreasonable and we upheld this aspect of Mrs C's complaint.

Mrs C also complained that her request for joint tenancy was unreasonably refused. We note that legislation states that a landlord must consent to the alteration of the tenancy unless they have reasonable grounds for not doing so. The association explained that they had refused the joint tenancy request as they had served a notice which warned that they may seek eviction and explained that the rent account was currently in arrears. The notice referred to was valid at the time and the association offered a reasonable explanation to explain their grounds for refusal. Therefore, we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to reasonably communicate with her in relation to her rent and rent arrears. 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.

Amendment

When originally published (20/11/2019), this summary included the line: "We considered that, while the association was clear in the amount and frequency of payments, elements of the communication had been unreasonable and we upheld this aspect of Mrs C's complaint."

This has since been changed to: "We considered that, while the association was clear in the amount and frequency of payments, an element of their communication had been unreasonable and we upheld this aspect of Mrs C's complaint."  We apologise for this error. 

Summary

Mrs C complained about a decision that was taken by the board to refuse out-of-area funding for a paediatric consultant for her child's (Child A) care. Mrs C said that the process leading up to the decision, how the decision was communicated to her and how the board handled her complaint was unreasonable.

We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine) and found that the board followed the correct process in reaching a decision regarding the referral and, therefore, did not uphold this part of the complaint.

However, we identified that the board had failed to provide Mrs C with a clear explanation of the process that they followed and the rationale for their decision; to give correct information to Mrs C regarding a third doctor's involvement; to correct their error when communicating with Mrs C; and to provide relevant information to SPSO in this regard in response to our enquiries. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide clear explanations, for providing her with erroneous information; failing to correct this error; and for the complaint handling failings. The apology should acknowledge the impact this has had on Mrs 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:

• Notifying clinicians and families should receive a full explanation of the outcome of funding requests, including information on the evidence used to reach that decision.
• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: http://www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by Queen Elizabeth University Hospital and by Gartnavel General Hospital. After Mrs A died, amyloidosis disease (a condition caused by the accumulation and deposition of amyloid protein in the body in various organisations) was diagnosed. Mrs C complained that, had this condition been diagnosed earlier, Mrs A would not have suffered as she did and that she would not have been subjected to unnecessary physiotherapy or to a one-night hospital transfer which she believes exacerbated Mrs A's condition. Mrs C also complained that the board wrongly discharged her mother on one occasion and failed to admit her to a high dependency unit, but sent her to a rehabilitation unit instead.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that the medical investigations, treatment, physiotherapy and nursing care provided to Mrs A were reasonable. We did not uphold these aspects of the complaint.

However, we concluded that the decision to discharge Mrs A home from hospital on one occasion was unreasonable; the decision to admit Mrs A for rehabilitation was not appropriate due to her frailty; and the decision to transfer her to a general hospital was not reasonable. Therefore, we upheld these aspects of the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to discuss other possible options for Mrs A’s discharge and for transferring her inappropriately. 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:

• Before transferring or discharging frail patients consideration should be given to all the options for discharge/ transfer; whether a patient’s condition is stable enough for any transfer and whether a patient’s condition is such that they will benefit from rehabilitation if appropriate.

Summary

Mr C’s father (Mr A) was referred by his GP to the Royal Alexandra Hospital for investigation of breathlessness. Two chest x-rays and a CT scan were performed over the following months. Mr A attended A&E seven months after his initial referral with severe pain in his side and back and a further x-ray was carried out. Mr A was admitted to hospital later that month following a fall, and a further x-ray and CT scan were carried out. Further to a biopsy (tissue sample) of an identified mass, Mr A was told he had incurable cancer. He died the following month.

Mr C complained about a failure to diagnose the cancer from the first CT scan. 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). We found that an abnormality on the CT scan was not reported. This resulted in an avoidable delay of approximately three months in the diagnosis of Mr A’s cancer. Therefore, we upheld this aspect of the complaint. The board have already apologised to Mr C for not picking up the cancer on the CT scan, and have undertook to discuss this at a learning meeting.

Mr C also complained about a delay in notifying Mr A of the results of this CT scan. We took independent advice from a consultant physician. We found that the scan result had been left on a consultant’s desk awaiting dictation, and the consultant had retired. It took Mr A’s prompting before a secretary arranged for another consultant to review and share the result. Mr A received the result ten weeks after it had been reported. We considered this delay was unreasonable and that a more robust system was required. We also noted that the board had not addressed this aspect of Mr C's complaint. Therefore, we upheld this aspect of the complaint.

Mr C also complained that there was a failure to diagnose Mr A's cancer from the x-ray taken during his admission to A&E. We found that the x-ray raised the possibility of an abnormality and suggested a repeat CT scan which was later carried out. We considered that this was appropriate and there was no unreasonable failure to diagnose the cancer directly from the x-ray. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in informing Mr A of the result of his CT scan, and for failing to address Mr C's complaint about this. 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:

• There needs to be a robust system in place for reviewing and communicating imaging results. The board should review their system and provide this office with an assurance that mechanisms are in place to avoid a repeat of the circumstances which contributed to the delay in this case.
• The board should reflect on the adviser's comments in relation to minimising any systems deficiencies which might contribute to perceptual errors when reporting imaging studies, unless such reflection occurred as part of the Learning from Discrepancies me

In relation to complaints handling, we recommended:

• The board should adhere to their Complaints Policy and Procedure, and aim ‘to establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response’.

Summary

Ms C complained that the board failed to provide reasonable care and treatment to her friend (Mr A) at the Queen Elizabeth University Hospital, before his death. Mr A had been admitted to the hospital due to exacerbation of his asthma and flu. After a few days, his condition deteriorated. He died six days after being admitted to hospital.

We took independent advice from a consultant in acute medicine. We found that:

• more information about Mr A’s alcohol intake should have been obtained;

• if the alcohol liaison nurse’s entry had been read or actioned, his diazepam (a tranquillizingmuscle-relaxant drug used to relieve anxiety) prescription would probably have been cancelled;

• there was a failure to respond promptly to his deterioration;

• it was unreasonable that he was seen by a junior grade doctor when he was clearly very unwell;

• prescribing sedation and planning to review him four hours later was not an appropriate response to a patient who was deteriorating and showing evidence of lower oxygen levels than normal;

• he should have been seen more promptly after his initial deterioration by a more senior doctor;

• he should have had important investigations such as X-rays and blood tests as soon as he was settled enough to comply with them;

• it was unreasonable that he was not on a fluid balance chart daily from admission;

• he should have been assessed more thoroughly for potential sepsis (blood infection) when he deteriorated; and

• what was written down in the notes did not seem to be have been read by other members of the team.

Therefore, we upheld this aspect of Ms C's complaint.

Ms C also complained about the lack of communication from staff about Mr A’s deterioration. We found that staff should have contacted her earlier than they did. The failure to do so substantiated the concern that staff did not recognise or respond to Mr A’s deterioration appropriately and that they did not recognise how unwell he was. We upheld this aspect of the complaint.

Finally, Ms C complained that the board failed to accept that Mr A had sepsis. She considered that sepsis should have been recorded on his death certificate. We found that the tests that were carried out at that time showed serious infection but did not indicate sepsis. Based on the information available, it was reasonable that sepsis was not recorded on Mr A’s death certificate. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

• Clinical entries in medical notes should be read and acted on. If a decision is taken not to act on the entry, this should be noted. Caution needs to be exercised when sedating patients with respiratory failure.
• Patients who have an elevated Early Warning score should be reviewed regularly, particularly if no definitive management plan has been established. The appropriate tests and investigations should also be carried out, including the tests for sepsis.
• Medical and nursing staff responsible for the care and treatment of a patient should ensure that they read the relevant notes.

Summary

Mr C complained about the clinical and nursing care and treatment his late wife (Mrs A) received during two admissions to Vale of Leven Hospital (VOLH) and the clinical care and treatment she received during her admission to Royal Alexandra Hospital (RAH) when she was transferred there from VOLH.

We took independent advice from a consultant in acute medicine and a nursing adviser. We considered that the overall clinical care and treatment Mrs A received during her first admission to VOLH was reasonable and that appropriate assessments and investigations were carried out. However, we found that during her second admission there was a failure to carry out a medical review following an increase in Mrs A's National Early Warning Score (NEWS). NEWS is a tool used to determine the severity of a patient's condition and to highlight any deterioration. We also found that there was a failure to recheck Mrs A's NEWS within six hours. We found that, had this been done, it may have alerted staff to how unwell Mrs A was and allowed staff to speak to Mr C. We considered that the failure to respond appropriately to the elevated NEWS and the failure in relation to the communication with Mr C was unreasonable and we upheld this aspect of the complaint.

In relation to the clinical care and treatment given to Mrs A during her admission to the RAH, we found that this was reasonable and we did not uphold this aspect of the complaint.

In terms of the nursing care that Mrs A received at VOLH, we found that overall the nursing care and treatment had been reasonable. All reasonable assessments were carried out, including a falls assessmenta and the medical records were comprehensive and of a standard that met the National Midwifery Council guidance. However, we also found that there was no documentation within the medical records of the rationale for nursing staff not following NEWS guidance. In these circumstances we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide Mrs A withreasonable clinical and nursing care and treatment at VOLH. 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:

• Relevant staff should ensure they are able to recognise and respond to elevated NEWS in line with NEWS guidance.
• Relevant staff should be mindful of NEWS guidance and ensure that they document the rationale for not following the guidance.