Some upheld, recommendations

Summary

Ms C complained about the care and treatment she received during and after an operation to correct a squint at the Princess Alexandra Eye Pavilion. She raised concerns that she was not fully informed of what to expect, and that doctors performed additional procedures on her eyes that she had not consented to and which were not necessary. She also raised concerns about the use of experimental medications. Ms C attended the hospital for a follow-up consultation a month later, and was concerned about the attitude and thoroughness of the consultant during this consultation.

We sought independent advice from an ophthalmology adviser and an anaesthetic adviser. The ophthalmology adviser was satisfied that the surgery was of a reasonable standard, and there were no concerns raised about the surgical treatment Ms C received. However, they noted that significant elements of the consent process took place on the morning of surgery, and that this did not give Ms C the time she needed to assimilate the information. This was compounded by the stress she felt at being called in for the operation earlier than anticipated.

The anaesthetic adviser was satisfied that the care and treatment provided were appropriate, but noted that Ms C's recall of events may have been affected by the anaesthetic, and this, combined with confusion and potential delirium, could account for her concerns about what happened during and after surgery.

We were satisfied that the care and treatment Ms C received were reasonable, and we did not uphold this aspect of Ms C's complaint. However, we found that she was not given sufficient time to consider the information provided during the consent process. We were also critical of the poor level of record-keeping in relation to consent, which meant that the board could not verify what had been discussed and when. We upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• share the findings of this investigation with the appropriate ophthalmic surgical staff to ensure that patients give properly informed consent, and that discussions are appropriately documented;
• consider developing a leaflet informing patients of what is involved in squint surgery, including the risks or side effects and the likelihood of these; and
• apologise to Ms C for the failures identified and for the distress this caused her, and provide assurances that she still has full access to NHS ophthalmology services.

Summary

Mr C complained about the medical and dental care and treatment he received from the prison health centre. He suffered from severe pain, particularly head and face pain, due to historic injuries and he raised concerns that adequate pain relief was not provided to him and that nursing staff regularly refused his requests to see a doctor. He also complained about delays in getting dental appointments and about the standard of treatment received, including that the dentist favoured extraction of his teeth over treating them.

We took independent advice from a GP adviser, who advised that the prison health centre were using a recognised system whereby nursing staff triage patient requests before making appointments. The adviser did not consider that Mr C was unreasonably prevented from seeing a doctor and said that, overall, healthcare staff reacted to his requests and treated his symptoms appropriately. We did not uphold these aspects of his complaint. However, we identified that some of Mr C's records were missing and we made a recommendation relating to record-keeping.

We also took independent advice from a dental adviser, who identified that Mr C initially submitted a routine appointment request, which he subsequently re-submitted indicating that his need for treatment had become urgent. He was seen within 12 weeks of his initial request and within a week of his urgent request. When he later submitted a further urgent request, he was not seen for two months, and apparently only after he had complained. We were advised that patients in the community could expect to be seen within six to eight weeks for routine appointments and within 24 hours for urgent appointments. We concluded that Mr C's wait for treatment was unreasonable and we upheld this aspect of his complaint. We were advised that, when Mr C was seen by a dentist, he was given appropriate advice and treatment and we did not uphold this aspect of his complaint.

Mr C also raised concerns about the way in which his complaints were handled by the board. We reviewed the board's investigation processes and replies to Mr C and did not consider that his complaints were responded to in a timely, accurate and comprehensive manner. We, therefore, upheld this aspect of his complaint, however, we were satisfied that appropriate action had since been taken by the board to improve their complaints handling.

Recommendations

We recommended that the board:

• ask prison healthcare staff to reflect on the identified record-keeping failure and seek to ensure compliance with the relevant professional guidance at all times;
• apologise to Mr C for the identified delays in arranging dental appointments for him;
• review the process for prioritising dental appointments in the relevant prison and inform us of the steps they have taken to avoid similar future delays; and
• apologise to Mr C for the identified failings in the handling of his complaints.

Summary

Ms C was pregnant with twins when she was taken to Raigmore Maternity Unit by paramedics. She was found to be in premature labour and despite attempts to stop her contractions, her twins were delivered prematurely with very low birth weights. Ms C was 20 weeks pregnant at the time of the delivery and her twins did not survive. Ms C complained about the care and treatment that was provided to her and the twins. She also complained about the information and advice provided by the board on taking the babies away from the hospital. Ms C was concerned about the board's final response to her complaints as she felt this took a long time to be issued and contained a lot of mistakes.

After taking independent advice on this case from a midwife, an obstetrician, a neonatologist and a consultant physician, we did not uphold Ms C's complaints about the care and treatment. The advice we received was that the care was appropriate and no failings were identified in this regard. We also did not uphold her complaint about the information or advice that was given on taking the babies away from the hospital as this was considered to be reasonable in the circumstances. We did, however, make recommendations in this respect.

We upheld Ms C's complaint about the board's final response to her concerns. We found that while the response was issued within a reasonable timescale, there were a number of factual errors with details such as dates.

Recommendations

We recommended that the board:

• consider the introduction of a booklet for bereaved parents to assist staff in providing information;
• provide a specific apology for the error in the times of death noted on the removal forms;
• apologise for the issues identified with their final response; and
• review their process for fact-checking decisions before issue.

Summary

Mr C complained that a prison health centre nurse refused to give him a replacement asthma inhaler because he could not return the empty inhaler. Mr C said he was not told of this policy, and he complained about the board's handling of his complaint.

We could not determine whether the nurse's actions at the time were reasonable, as, other than the two differing accounts of what happened, there was no evidence to prove what actually happened. We also found that the board's handling of Mr C's complaint was adequate. We did not uphold either aspect of Mr C's complaint. However, we were concerned about the nurse's written record of the incident, and we made a recommendation to address this point.

There was no evidence that the board had informed Mr C of the inhaler exchange policy or protocol, and the board were unable to provide us with a copy of the protocol, as it was no longer available because the staff who had developed it had left the board. We upheld this aspect of Mr C's complaint, and we made recommendations to address the board's failings.

Recommendations

We recommended that the board:

• ensure that the nurse involved is reminded of the importance of complying with Section 10 of the Nursing and Midwifery Council code in relation to record-keeping;
• ensure that if prisoners are to continue returning empty inhalers, a replacement protocol is written without delay and is stored so it can be accessed and will not be lost due to staff changes; and
• ensure that prisoners are made aware of the replacement protocol, and provide us with evidence of this.

Summary

Mrs C raised concerns about the care and treatment she received at Aberdeen Royal Infirmary. She complained that she was provided with inappropriate gynaecological treatment for her reported symptoms, that her operation was cancelled on the day of the proposed surgery, and that she was discharged despite having received pre-medication. She complained that there was poor communication about her medication and about the rescheduled operation. She also complained that the length of time she would have to wait for the rescheduled operation was unreasonable.

We took independent advice from a consultant gynaecologist and a consultant physician. We were advised that both the treatment suggested and the management of Mrs C's medication were reasonable. We were also advised that the date given for the rescheduled operation meant that the board had failed to meet the target guarantee time in line with The Patient Rights (Scotland) Act 2011 and that, as such, the delay was unreasonable. However, the medical records demonstrated that alternative options had been discussed with Mrs C's GP. We were advised that Mrs C's operation would not be classed as medically urgent.

We were concerned that the board was unable to provide copies of Mrs C's medical records from her admission to Aberdeen Royal Infirmary and that therefore the adviser was unable to comment on the care and treatment provided after Mrs C was admitted to hospital, including her discharge and the level of communication.

While the medical records demonstrated there was some communication with Mrs C and her GP following the cancellation of the operation, we were not satisfied that this was adequate.

Recommendations

We recommended that the board:

• provide a plan detailing the changes which have been made to prevent a recurrence in relation to the failure to store medical records securely;
• apologise to Mrs C for the failings identified in this investigation; and
• remind relevant staff involved in this case of the importance of maintaining comprehensive records in line with General Medical Council guidance.

Summary

Mr C complained about his treatment at Victoria Hospital. Mr C had injured his shoulder and felt the care and treatment provided by A&E was not reasonable. Mr C said his examination had been inadequate and inappropriately carried out and that he had been referred first for physiotherapy, rather than orthopaedic examination.

Mr C's physiotherapist diagnosed a serious injury and Mr C was referred to an orthopaedic specialist. He underwent a scan and was told he was not suitable for surgery as he was too old and the joint had suffered too much wear and tear. Mr C received a further examination as part of a second opinion offered by the board. This examination found Mr C to be a suitable candidate for surgery and he underwent a successful operation.

Mr C complained that the delay in diagnosing his shoulder injury had affected his treatment and chances of making a full recovery. We took independent advice from a consultant in emergency medicine and from a consultant orthopaedic surgeon. We were advised that Mr C had been treated appropriately in A&E and that it was normal practice to refer patients for physiotherapy in such cases. However, we were advised that Mr C's orthopaedic treatment had fallen below a reasonable standard as Mr C was within an appropriate age range for treatment. We therefore found that Mr C's orthopaedic treatment had been unreasonable.

Mr C also complained that the board had not responded reasonably to his complaints. Although the board's responses had on occasion been delayed, we found that their responses to Mr C's complaints were reasonable and so we did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• provide evidence that the orthopaedic specialist has reflected on the case and in particular the assessment of the adviser on Mr C's suitability for surgery; and
• apologise to Mr C for the failings identified in this report.

Summary

Mrs C complained about the practice's handling of her cervical screening (commonly known as a smear test), and also about their response to her complaint.

Mrs C received a positive result from her smear test, and over the following year underwent investigations for suspected cancer. No cancer was detected and in looking into the matter, the board decided to look again at the original smear test result.

The board convened a Problem Assessment Group (PAG) with input from a public health specialist and investigated the circumstances. As part of the investigation they tested the DNA on the original smear test and identified two sets of DNA, Mrs C's and another, unidentified sample. The PAG was unable to say definitively how or when the test was contaminated with another DNA sample. The laboratory that tested the sample was confident contamination could not have occurred there.

The PAG concluded that the correct procedure in handling and processing smear tests had not been followed. All tests should be sent to the laboratory on the day taken or the next working day if done in the afternoon. The practice instead was sending batches of tests over a number of days or weeks. Women who had had smears around the same time as Mrs C were re-tested and none were found to have cancer.

We were not able to establish for certain how the DNA and that of another person ended up in the same sample. Clearly, an error had occurred, and the independent advice we took from a nursing adviser confirmed that the nurse who took the smear test had not followed best practice guidance. The adviser also noted that Mrs C's appointment was not recorded in her medical records; only the date the test was sent was noted, which had led to confusion about the date of Mrs C's test. We made a recommendation to address this.

We confirmed with the board that the nurse in question had discussed the incident at the time with senior staff at the practice and was now processing smear tests in the correct manner. We also noted that the practice had updated its cervical screening protocol in light of the incident. We therefore had no further recommendations to make.

While we noted that Mrs C had found the practice's approach to her complaint to be lacking in empathy, we did not find evidence to support this and so did not uphold this aspect of her complaint.

Recommendations

We recommended that the practice:

• provide reassurance that action has been taken to ensure that both the date of the appointment for the smear test and the date the test is sent to the laboratory are noted.

Summary

Miss C complained to us following two admissions to University Hospital Crosshouse with severe abdominal pain and persistent vomiting. She was transferred between several different wards, and was due to have a scan of her abdomen. However, she discharged herself prior to this scan taking place. She was re-admitted five days later for an investigative procedure, but chose to be discharged the following day. She complained that the care and treatment was inadequate, and that she was not given the treatment she needed to resolve her symptoms. She also complained that there was a delay in giving her a scan and she was left in pain by poor practices in relation to the insertion of a cannula and a catheter. She said staff were dismissive of her pain and did not identify her as being at risk of falls. She also said hygiene standards were poor, and medical staff failed to diagnose and treat her appropriately.

We obtained independent nursing and gastroenterology advice. The nursing adviser noted concerns Miss C raised in relation to her care, and also the feedback from the board, which had acknowledged some failings. The adviser considered that it was reasonable that Miss C was not assessed for her falls risk, but noted that she should have been given access to a buzzer. The adviser also acknowledged apparent problems with Miss C's cannula site and catheter, though they did not find any evidence of problems in relation to hygiene.

The gastroenterology adviser did not identify any concerns with Miss C's treatment. The adviser noted that there was no evidence to indicate Miss C had Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system), as she thought she did.

We considered the evidence available, and were satisfied that there were failings in relation to Miss C's nursing care, but not in relation to her clinical treatment. We also considered the evidence in relation to her moves between wards, and were satisfied that in each case, these were made for appropriate clinical and nursing reasons.

Recommendations

We recommended that the board:

• remind staff of the importance of full documentation in relation to the insertion of catheters, to ensure their safe removal and for infection control.

Summary

Mr C was injured in an accident in the prison workshop. He cut his arm and suffered bruising to his elbow. This was treated in the prison health centre by a nurse, who cleaned and dressed the cut. Later that day Mr C raised concerns about his tetanus immunity and that evening he received a tetanus injection.

Mr C complained to us that he should have received testing and treatment for blood borne viruses and that the treatment he was given immediately after the accident was inadequate. He also complained about two separate incidents where he believed he had been given incorrect medication by nursing staff. Mr C also complained that the board had not handled his complaints reasonably.

After taking independent advice from a nurse and a GP on the care and treatment Mr C received following the accident, we did not uphold these aspects of his complaint. The advice we received was that Mr C's nursing care was reasonable and that he was appropriately tested for blood borne viruses. Although Mr C did receive a tetanus injection after raising concerns, we have made a recommendation that nursing staff be reminded to ask patients about their tetanus status when patients have suffered cuts.

After taking independent advice from a nursing adviser, we upheld Mr C's complaint about the administration of medication. We found that the board had acknowledged that Mr C was offered the wrong type of medicine on one occasion. The adviser considered this error to be unreasonable. The board advised Mr C they had taken steps to address this and we have made a recommendation in relation to this.

We found no evidence that the board acted unreasonably with regard to the complaints handling process, therefore we did not uphold Mr C's complaint in relation to this.

Recommendations

We recommended that the board:

• report to us on the steps that have been taken to prevent dispensing errors; and
• take steps to remind nursing staff to check the tetanus status of patients with cuts.

Summary

Mrs C complained on behalf of her son (Mr A) who was a student at the college. Mr A was offered a place on a course, which he accepted. He was later withdrawn from the course after attending for two weeks because his qualifications did not meet the course entry requirements.

Mrs C told us the college had failed to properly investigate her complaint about the offer Mr A received. We found that the college had failed to take reasonable care at application stage and/or at interview to check Mr A met the course entry requirements before offering him a place. We also found that in responding to the complaint, the college had held Mr A responsible for providing inaccurate information during the application process when this was not the case. We therefore upheld this complaint.

Mrs C also said the college had not reasonably assessed and met Mr A's additional support needs during a previous academic session. We found that a needs assessment was in place and had been shared with appropriate staff. We found no evidence that Mr A had asked for support that was not provided, or at least considered by the college. We therefore did not uphold this aspect of Mrs C's complaint.

Recommendations

We recommended that the college:

• apologise to Mr A for the error in checking his qualifications, and for an error in responding to the complaint, specifically for suggesting, wrongly, that he had provided inaccurate information;
• remind staff of the importance of checking qualifications at application/ interview stage before making place offers; and
• proceed to make a goodwill payment, as discussed during the period of our investigation.