Some upheld, recommendations

Summary

Mrs C complained about the in-patient care she received at Ninewells Hospital. In particular, that there was a delay in diagnosing diverticulitis (where small pouches from the wall of the gut become inflamed or infected). She also complained that a consultant surgeon had not examined her when she attended an out-patient clinic appointment at Perth Royal Infirmary and that the care that she received from the out-of-hours service was unreasonable.

We took independent advice from a consultant colorectal surgeon (a specialist in the medical and surgical treatment of conditions that affect the lower digestive tract) in relation to Mrs C's concerns about a delay in diagnosing diverticulitis. We found that a computer tomography (CT) scan should have been carried out rather than an magnetic resonance imaging (MRI) scan because it would have provided a more complete examination of Mrs C's abdomen and pelvis. In addition, we considered that a CT scan should have been performed within a few days after Mrs C's discharge from Ninewells Hospital. We were also critical of the length of time it took for staff at Ninewells Hospital to contact the consultant surgeon at Perth Royal Infirmary to inform them about the results of the MRI scan. We also found that the letter to the consultant surgeon had not referred to Mrs  C's earlier hospital admission. In terms of the clinic appointment at Perth Royal Infirmary, we considered that the consultant surgeon should have examined Mrs  C given there was no evidence of her symptoms having settled. We considered that the time taken to diagnose diverticulitis was unreasonable and upheld this aspect of Mrs C's complaint.

In relation to Mrs C's out-of-hours appointment, we considered that the treatment she received was reasonable and appropriate. 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 the unreasonable delay in performing the MRI scan, for not ensuring that an urgent CT scan was performed, the unreasonable delay in the consultant surgeon being informed about Mrs C's hospital admission and MRI results, and for not conducting a physical examination at Mrs C's clinical appointment. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should ensure that urgent CT scanning is performed when recommended.
• Staff should ensure timely and appropriate communication with other specialities where relevant.
• Staff should ensure that relevant information is clearly recorded and physical examinations carried out where appropriate.

Summary

Ms C, who works for an advice and support agency, complained on behalf of Miss  A about the medical and nursing care and treatment Miss A received at Stracathro Hospital following hip replacement surgery. Ms C raised a number of concerns, including that Miss A suffered a stroke after surgery which was not picked up on by staff, despite her repeatedly reporting visual disturbance and blurred vision.

We took independent advice from a consultant physician and cardiologist (a  doctor who specialises in disorders of the heart), a consultant orthopaedic surgeon (a surgeon who diagnoses and treats a wide range of conditions of the musculoskeletal system) and a nursing adviser. We found that there were no case note entries by the junior medical staff at any time in Miss A's post-operative notes (including in relation to the complaint of visual blurring) and that the board failed to assess Miss A's complaint of post-operative visual blurring in an appropriate manner. The failing was not that they did not diagnose a stroke as the cause of her visual blurring, but rather that they did not assess it at all. We also found that the medical staff failed to take Miss A's medical history or carry out a simple bedside assessment of her eyes. We noted that the board appropriately prescribed aspirin to Miss A on discharge. However, prescribing aspirin alone does not follow the board's protocol and there was no reason recorded in Miss A's notes to explain why this decision was taken. There was also no evidence of a 'venous thromboembolism (VTE - condition where a blood clot forms in a vein) risk assessment tool' being completed. We considered that the medical treatment provided to Ms A was unreasonable and upheld this aspect of Ms C's complaint.

In terms of the nursing care and treatment, we found that the nurses acted reasonably by informing the medical staff about Miss A's complaints of visual blurring and ensuring Miss A was seen by a doctor. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for failing to respond appropriately to reported visual blurring, the lack of record-keeping and for not giving her appropriate blood thinning medication. 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:

• Medical staff should take a patient's medical history and respond to complaints of postoperative visual blurring in a timely and appropriate manner.
• Staff should complete patients' 'VTE risk assessment tool' forms in cases of this type, prescribe blood thinning medication following hip replacement surgery in line with national guidance, and give patients blood thinning medication in accordance with the board's protocol and, if the board consider it appropriate to deviate from the protocol, to record the reason for this in patients' records.

Summary

Mr C complained about the care and treatment his late father (Mr A) received during his two admission to Wishaw General Hospital. Mr A was diagnosed with bowel cancer and Mr C complained that the board failed to provide Mr A with appropriate medical and nursing care and treatment.

We took independent advice from a consultant in acute medicine, a consultant in colorectal surgery (a specialist in disorders of the rectum, anus and colon) and a nurse. In respect of Mr A's first admission, we considered that Mr A's underlying issues were all reasonably investigated, treated and resolved. In respect of Mr  A's second admission, we found that all appropriate investigations were carried out and that, overall, Mr A received appropriate medical treatment. However, we noted that there was an unreasonable delay before Mr A was seen by the speech and language therapy service (SALT) given that there was concerns regarding his ability to swallow. Therefore, we upheld this aspect of Mr  C's complaint.

In relation to the nursing care, we found that there was no evidence to indicate any failings in nursing care and that the nursing records were of a reasonable standard. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the board failed to communicate appropriately with Mr  A's family regarding his condition at a meeting. In particular, that only two family members were allowed to attend the meeting when there were twice as many hospital staff in attendance and that he was not allowed to record the meeting. We considered it was unreasonable that Mr C had been restricted to two family members while double the number of hospital staff attended the meeting. Mr C also appeared to have been open with hospital staff that he wanted to record the meeting and the reason for this. Therefore, we considered it would have been reasonable to have allowed him to record the meeting. We upheld this aspect of Mr C's complaint. We also noted that that these issues could have been avoided if the board had a policy that ensured both parties were aware of the ground rules for such meetings in advance. We made a recommendation to the board in light of this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay by hospital staff in referring Mr A to SALT, for restricting the number of family members who were permitted to attend the meeting and not allowing the meeting to be recorded. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Patients with impaired ability to swallow should receive an appropriate and timely referral to SALT.
• Both staff and patients and/or their families should be clear about what to expect in advance of a meeting.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's late husband (Mr A) at Belford Hospital. Mr A was admitted to hospital on a number of occasions over a short period of time for breathlessness and chest pain. Ms C complained about the clinical care and nursing treatment provided to Mr A, the board's communication with Mrs B about her husband's deterioration, and the post-mortem care (care after death) provided to Mr A.

We took independent advice from a consultant physician and from a nursing adviser. We found that there were a number of failings with regards to the clinical treatment provided to Mr A, and we upheld this aspect of the complaint. However, we found that the nursing care had been reasonable and so we did not uphold this part of the complaint.

Regarding communication, we found that there was a failure to discuss Mr A's deterioration with Mrs B in a timely manner, and so we upheld this part of the complaint.

We found that the post-mortem care provided to Mr A was reasonable, and we did not uphold this aspect of the complaint. However, we found that the board had not addressed Ms C's concerns around post-mortem care in their original complaint repsonse. We, therefore, made a recommendation regarding this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for the failure to provide Mr A with reasonable clinical treatment, and for the failure to communicate reasonably with her about Mr  A's deterioration. 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:

• Patient care should be in line with the Scottish Intercollegiate Guidelines Network guideline 139: Care of the Deteriorating Patient, and Healthcare Improvement Scotland guidance on Structured Response to the Deteriorating Patient.

In relation to complaints handling, we recommended:

• All issues raised in complaints letters should be addressed.

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs  A) by the practice. Mrs A reported hip and back pain to her GP, and was later found to have breast cancer which had spread to her stomach and bones. Ms C complained that the practice failed to identify that Mrs A's back and hip pain was due to cancer in her bones.

We took independent advice from a GP adviser. We found that, when Mrs A presented with back pain she was directed to physiotherapy, which was reasonable, and that there were no signs or symptoms of cancer at this point. We found that the practice provided reasonable care and treatment to Mrs A for her back and hip pain, and we did not uphold the complaint.

Ms C also complained about the way the practice handled her complaint. We found that the practice had not handled her complaint in line with the model complaints handling procedure and, therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to respond to 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/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Ms C complained about the care and treatment she received at Queen Elizabeth University Hospital. Ms C attended a follow-up orthopaedic (the branch of medicine involving the musculoskeletal system) clinic at the hospital after hip surgery and explained she was experiencing discomfort in her ankle. She was found to have deep vein thrombosis (DVT, a blood clot in a vein) in her calf. However, other tests also showed that she may have secondary liver cancer. It was later found that she had primary breast cancer which had spread to her liver. Ms C complained about the way she was told about her diagnosis and that she was given inconsistent information about her illness. She also complained that her care was not appropriately personalised for her.

We took independent advice from consultants in acute medicine and clinical oncology (cancer treatment). We found that the doctor who told Ms C about her diagnosis had made a conscious decision to wait overnight before giving her the details because they wanted the opportunity to discuss the matter first with the breast cancer team. While we considered that this was a reasonable approach, when Ms C was told the following day, she was alone. This does not follow Scottish Cancer guidelines and Ms C appeared not to have been appropriately supported. Therefore, we upheld this aspect of Ms C's complaint. However, we did not find that Ms C had been given inconsistent information and we found that staff had adapted her care, as far as possible, to suit her needs. Therefore, we did not uphold these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to support her properly when giving her bad news. 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:

• Patients should be adequately supported when being given bad news and discussions with patients/relatives should be fully documented in medical records.

Summary

Mr C complained about the clinical treatment he received at Inverclyde Royal Hospital. Specifically, that the treatment that he had to remove debris from his ear (known as microsuction) caused him to develop tinnitus (a ringing or buzzing noise in the ears) and that he should have had a hearing test before the treatment. Mr C also complained that questions which he raised at a follow-up clinic appointment were not fully responded to.

In response to the complaint, the board did not identify any failings in treatment or the communication that took place with Mr C about the questions he had raised at a follow-up appointment. The board also said that tinnitus is not a recognised complication of microsuction.

We took independent advice from a consultant ear, nose and throat surgeon. We found that the treatment Mr C received was of a reasonable standard and in accordance with ear care guidance issued by Health Improvement Scotland. In addition, we found that there was no requirement in terms of consent guidance issued by the General Medical Council to warn patients of the risk of tinnitus, as it is a less serious side effect that does not occur frequently with this type of procedure. We did not uphold this aspect of the complaint. However, we considered that tinnitus is a recognised risk of any noise or mechanical trauma to the ear and provided feedback to the board that they may wish to consider displaying a notice or providing a leaflet for patients in this respect.

Mr C should have received responses to the questions he had raised at his follow- up appointment. Therefore, we upheld this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not responding fully to the points he raised. 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:

• Full responses should be provided to patients regarding their care and treatment, either in writing or verbally, with documentation to demonstrate what was discussed.

Summary

Mr C made a number of complaints about an inginual hernia repair (an operation to repair a weakness in the abdominal wall) he underwent at Dr Gray's Hospital. Mr C required to have further surgery a week later to remove a testicle due to a rare but recognised complication of the surgery. Mr C complained that he had not been reasonably informed of all the recognised complications when consenting to his surgery. Mr C was also concerned that his surgery was not carried out properly, that he was discharged too soon from hospital after the inginual hernia repair, and that there was an unreasonable delay in receiving a review appointment following the operation to remove his testicle. The board apologised that they were unable to offer him a review appointment within the original planned timescale due to a high volume of patients and took action to address this problem. The board identified no other issues with Mr C's treatment. He was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant general surgeon. We considered that the board's handling of the consent process was below a reasonable standard. It was not clear to what extent the term testicular atrophy (shrinkage/wasting) was explained to Mr C at the time of his clinic appointment or whether he understood this, nor was any additional patient information on the procedure provided to Mr C for reflection at this time. In addition, the consent form Mr C signed was completed on the day of surgery instead of at the out- patient clinical consultation and it did not list the possible but rare risk of testicular complication. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the procedure, we considered that this was completed to a reasonable and appropriate standard. The adviser noted that the rare complication Mr C suffered was not a result of a failing in the surgery. However, we noted that the board incorrectly suggested in their response to Mr C's complaint that a consultant surgeon had performed the surgery when in fact they were supervising it to ensure the quality of the procedure. We did not uphold this aspect of Mr C's complaint but made a recommendation in light of this finding.

In relation to Mr C's discharge, we found no evidence to suggest that he was unreasonably discharged following the inguinal hernia repair. We did not uphold this aspect of Mr C's complaint.

Finally, we found that given the distressing complication Mr C experienced following his surgery, it was unreasonable for him to wait over 26 weeks to be reviewed following removal of his testicle rather than within the planned six to eight weeks. We upheld this aspect of Mr C's complaint but noted that the board had already taken action to address this issue.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in the consent process and the failure to provide accurate information in relation to who had performed the surgery. 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:

• Surgeons should complete the consent process in the pre-operative clinic; ensure the risks are clearly explained to the patient, checking that the patient understands the information and that this is documented; and ensure the patients take a copy of the consent form to enable reflection. Information for patients should be available concerning inguinal hernia repair in a separate booklet that details 'the risks inherent in the procedure, however small the possibility of their occurrence, side effects and complications'.

In relation to complaints handling, we recommended:

• The board should ensure transparent and open communication with patients. In particular, the board should ensure that patients are informed about who undertook their surgery.

Summary

Mrs C complained on behalf of her father-in-law (Mr A) about the care and treatment he received from Victoria Hospital and Glenrothes Hospital over a six  month admission period. Mrs C's concerns related to surgical treatment, nursing care, physiotherapy, speech and language therapy (SALT) and medical care.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), two registered nurses and a consultant geriatrician (a doctor who specialises in medicine of the elderly). In relation to Mr A's surgical treatment, Mrs C felt that a perforated ulcer should have been identified at the time Mr A underwent an emergency operation. We found that it was reasonable that the perforated ulcer was not recognised at the time of the emergency surgery given a number of relevant factors. We did not uphold this aspect of Mrs C's complaint.

In relation to the nursing care, Mrs C was concerned that Mr A developed as significant pressure ulcer, monitoring of his fluid intake/output was poor and Parkinson's medication was not administered when it should have been. We found no evidence that administration of Mr A's Parkinson's medication was unreasonable. However, we found significant failings in relation to the prevention, monitoring and management of pressure ulcers and that fluid intake/output charts were not adequately completed. We upheld this aspect of Mrs C's complaint. However, we noted that the board had identified failings in regards to pressure ulcer damage and fluid monitoring and had taken steps to address these issues.

In relation to the physiotherapy treatment Mr A received, Mrs C was concerned that there was a lack of regular visits from the physiotherapist. We found that Mr  A received regular visits from physiotherapy staff and that their care was appropriate. We did not uphold this aspect of Mrs C's complaint.

Mrs C was also concerned that there was a lack of visits from SALT and a lack of effective communication with other staff regarding Mr A's altered diet. We found that review by SALT was sporadic and not carried out in a timely manner at either hospital. We considered that Mr A's risk of aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) would have been reduced had timely SALT review taken place. We upheld this aspect of Mrs C's complaint.

In relation to Mr A's medical care, Mrs C was concerned that communication about placing a do not attempt cardio-pulmonary resuscitation (DNACPR) mandate in place was inappropriate, Mr A's usual Parkinson's medication was not prescribed causing problems with his movement and interaction, and transfer arrangements were unreasonable. We found that the conversation which took place about DNACPR were appropriate and that the changes made to Mr A's Parkinsons medication was reasonable. We also found overall that the transfer arrangements were reasonable, however, we were critical that there was no evidence to show that a formal record of discharge was documented to support a thorough hand-over. We did not uphold Mrs C's complaint but made a recommendation to the board in light of this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delays in SALT review and follow-up. 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:

• Staff should carry out pressure ulcer prevention and management in accordance with national guidance.
• SALT should ensure patients with complex needs are seen within agreed timescales.
• Complex patients should have a careful and thorough hand-over documented.

Summary

Mr C complained about his care and treatment when he attended Crosshouse Hospital after experiencing stroke-like symptoms. Mr C was taken to the emergency department (ED) and was told he would be admitted to a ward but he was discharged a few hours later. Mr C suffered a seizure later that day and was returned to hospital by ambulance. He was admitted to the high dependency unit and kept in for two days for investigations. Mr C complained that it was not reasonable for staff to discharge him when he first attended. He was concerned he was not monitored frequently and that staff did not give him a clear explanation or diagnosis.

The board acknowledged that nurses should have recorded more frequent ward rounds and apologised for this. However, they explained that Mr C was also kept under observation via electronic monitors. The board considered that the medical care and treatment was reasonable. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant in emergency medicine, a consultant in general medicine and a nurse. We found that Mr C was given prompt treatment for tonsillitis (inflammation of the tonsils) and suspected meningitis (infection of the coverings of the brain). We noted that this was investigated further but it was found that he did not have meningitis. Mr C was followed up by the neurology department (branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) after his discharge and was diagnosed with hemiplegic migraine (a rare and serious type of migraine that has symptoms similar to those of a stroke). We considered that Mr C's medical care and the decision to discharge him was reasonable. We did not uphold these aspects of Mr C's complaint.

In relation to the nursing care Mr C received, we found that nurses had not clearly recorded what action was taken when he had a high National Early Warning Score (NEWS, an indicator of a patient's overall health) or why the plan had changed from admitting him to discharging him from the ED. 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 not repeating his observations before discharge and for the gaps in record-keeping. 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:

• Nurses should record what action is taken in response to an elevated NEWS and repeat the NEWS check before discharging the patient.
• Where a plan of care changes, the nursing records should show the reasoning behind this.