Some upheld, recommendations

Summary

Mr C complained that the housing association delayed in dealing with water ingress to his home, which he said caused damage to his flooring, but the association would not pay for the damage. Mr C also complained that the association failed to complete repairs to the loft and ceiling in his home.

We found that there was no unreasonable delay in the association dealing with the water ingress and, given this, we could not say it was unreasonable that the association would not pay for the damage to Mr C's flooring. We also found, and the association acknowledged, that they should have completed the repairs to Mr C's loft and ceiling much sooner. Given the inconvenience of being left with an incomplete repair and a large hole in the ceiling for an unreasonable period of time over the autumn and winter months, in the specific circumstances of this case, we recommended that the association consider making an ex gratia payment to Mr C.

Recommendations

We recommended that the association:

• consider making an ex gratia payment to Mr C.

Summary

Mrs C complained about ongoing issues with damp in her property and how long the repairs for this had taken. Mrs C also complained that the housing association had failed to communicate with her appropriately, and had refused to provide adequate information about the works going on inside her property.

The association accepted it had taken a long time to diagnose the damp problems in the property. They said that this was not unreasonable as the problem had been complex. The association accepted the works had taken too long to complete, but said lessons had been learnt from Mrs C's experience.

We found that the association had taken too long to identify the source of the damp problem in Mrs C's house. This was in part because a new bathroom had been fitted before the source of the problem was identified, and prior to the completion of the bathroom works, Mrs C had provided a privately-obtained surveyor's report to the association recommending more extensive works were required. The association had failed to act on this, which had led to some of the delay. We also found that the length of time taken to complete the works was excessive. Although the association had had difficulties with contractors and their insurance company, there was no evidence of any learning being identified to prevent a recurrence of this problem. We upheld this part of Mrs C's complaint.

We found that the association had, however, communicated appropriately with Mrs C, and we did not uphold this part of her complaint. There was evidence of regular contact with staff at the association and reasonable attempts to manage Mrs C's expectations in terms of the length of time the works were taking.

Recommendations

We recommended that the association:

• provide us with evidence that the installation of Mrs C's bathroom has been reviewed and that any lessons identified are being put into practice;
• apologise for the decision to install the bathroom;
• provide evidence that they have reviewed this case and that any learning has been identified and actioned; and
• provide evidence of the actions they have taken to avoid a recurrence of the delays experienced in this case.

Summary

Ms C raised concerns that the there was a failure to reasonably inform her of her treatment options prior to having a laparotomy (a surgical procedure that involves an incision being made into the abdominal wall) at Western Isles Hospital. Two ultrasound scans of Ms C's pelvis, carried out six weeks apart, showed she had a cyst on her right ovary. Ms C said she initially understood that she was to have a laparoscopy (a surgical procedure to access the abdomen and pelvis) to treat the cyst and only learned at a pre-operative appointment that she was to have a laparotomy. The board accepted that more explanatory detail could have been provided to Ms C.

We took independent advice from a medical adviser who said that the entries in Ms C's medical records indicated that she was always to have a laparotomy, and as she thought she was having a laparoscopy, she evidently had not been given enough information to make an informed choice about her treatment options. Also, it was unclear if the risks of surgery had been explained to Ms C. Therefore, we upheld this part of the complaint.

Ms C also complained she had not been provided with reasonable care and treatment. When Ms C had the laparotomy, no cyst was found on her right ovary and she questioned this. The adviser agreed with the board that the most likely explanation was the cyst had ruptured before surgery. The adviser also said that overall, the care and treatment Ms C received was reasonable. We agreed with this and did not uphold this part of the complaint.

Ms C further complained that she was not provided with reasonable post-operative care. She said that following the laparotomy she suffered continuing abdominal pain and tenderness. The advice we received was that the symptoms Ms C was experiencing post-operatively were not unusual and would be expected. There was also no evidence she had a post-operative infection. While we did not identify any failings in Ms C's clinical care we considered there were failings in communication with Ms C and for this reason we upheld this part of the complaint.

Recommendations

We recommended that the board:

• apologise to Ms C for the failure to ensure that she understood the surgical procedure she was to undergo;
• provide evidence that clinicians have been advised to confirm with patients that they understand the procedure they are to undergo and that this information and any comments made by the patient will be recorded in the patient's case records;
• ensure that where the risks of surgery are explained to a patient, this information is clearly recorded in the patient's medical records;
• provide an update on the review and development of their obstetric and gynaecological protocols;
• consider investing in appropriate training to improve the communication skills of their medical staff; and
• feed back the outcome of this investigation to the relevant clinicians.

Summary

Mrs C complained that staff at the minor injuries clinic (MIC) at the Western General Hospital failed to identify that her ankle was broken. She also complained that as part of the board's investigation, the staff member involved gave false information about the advice given to Mrs C when she attended the MIC. Mrs C stated she was advised she could travel while the board stated she was advised travel was not ideal.

We took independent advice from a consultant in emergency medicine. While we found that Mrs C's ankle fracture had been missed when she attended the MIC, the advice we received was that the fracture had not been obvious and it was understandable that it had been missed. However, we were concerned that when the radiologist's report identified the fracture, the board did not contact Mrs C in line with their procedures. We were also concerned that the board failed to explain the reason for the failure in their system in this case. We therefore upheld this part of the complaint and made several recommendations to address the failings we found.

We found no objective evidence to prove or disprove what advice about travel had been given to Mrs C when she attended the MIC. We did not uphold this part of the complaint.

Recommendations

We recommended that the board:

• provide further information on the system in place for reviewing MIC x-ray reports, correlating them to the interpretation and diagnosis by the practitioner and the system for acting on any missed injuries;
• provide further information on how any missed injuries are recorded and audited;
• bring the adviser's comments on the advice to give patients with soft tissue injuries to the attention of the relevant physiotherapy practitioner; and
• ensure that the physiotherapy practitioner involved in this case is reminded of the requirement to make accurate records of advice given to patients and specifically document any advice given with regards to fitness to travel.

Summary

Mr C complained about the delay in treatment for his wife (Mrs C) when she was diagnosed with oesophageal cancer. Chemotherapy was commenced around 12 weeks after diagnosis in an effort to shrink the tumour and make it operable. Unfortunately, Mrs C did not tolerate this well and it was discontinued, with her cancer having progressed. Mr C complained that the delay in commencing treatment allowed the cancer to spread to Mrs C's lymph nodes, meaning surgery was not possible. The board acknowledged that Mrs C's wait for treatment was outwith the national waiting target of 62 days from referral with a suspicion of cancer to the start of treatment. However, they assured Mr C that all the investigations carried out to determine the extent of the cancer were appropriate.

We obtained independent medical advice from a consultant general surgeon, specialising in upper gastro-intestinal surgery. They informed us that Mrs C's tumour was very extensive at the point of diagnosis and had already spread to her lymph nodes. They considered that appropriate tests were then carried out to determine if there were any curative treatment options, advising that the national target can be difficult to achieve when additional tests are required. However, they noted that part of the delay Mrs C experienced was caused by the absence of a particular clinician who was able to carry out one of the tests. They suggested that the board should look at staff training issues and review their management of waiting times between tests. Notwithstanding this, they did not consider that the delay Mrs C experienced had any impact on the curability of her cancer.

We found no evidence that the board failed to recognise the severity of Mrs C's cancer and we did not uphold this aspect of Mr C's complaint. However, we considered that the extent of the cancer was not made clear enough to Mr C by the board, particularly when responding to his complaint. This could have alleviated his concern that the cancer had spread to an inoperable stage during the wait for treatment. In relation to this wait, while we noted the complexities of the diagnostic pathway, we considered that some of the delay was avoidable. We, therefore, upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for failing to explain more clearly the extensive nature of the cancer from the time it was first diagnosed;
• ask relevant staff to reflect on the findings of this investigation in order to improve communication in similar future circumstances;
• apologise to Mr and Mrs C for the delay in starting Mrs C's treatment; and
• review their oesophago-gastric cancer pathway, including staff training issues and the management of waiting times between tests/discussions, with a view to reducing future incidences of avoidable delay.

Summary

Mr C complained that he sustained damage around his knee after surgery at the Royal Infirmary of Edinburgh. He also raised a concern that, after reporting pain and clicking in his knee some years later, a neurophysiologist (a medical professional specialised in the function of the nervous system) at the Western General Hospital should have referred him for nerve conduction tests (studies to check for abnormalities in the nerves). Mr C also complained that an orthopaedic surgeon at St John's Hospital did not refer him in a timely manner to physiotherapy and to the orthopaedic surgeon who had carried out his original surgery. Mr C was dissatisfied with the lack of communication in relation to his care and with the board's handling of his complaint.

We took independent advice from two consultant medical advisers, one specialised in orthopaedic surgery and the other in neurophysiology. We found no evidence that Mr C's surgery at the Royal Infirmary of Edinburgh was unreasonable although the consent procedure fell below a reasonable standard. We agreed that nerve conduction tests would not have provided anything further in the management of Mr C's care some years after the surgery and that this was evident when such tests were carried out and no abnormality was found. We did not consider that the orthopaedic surgeon had delayed unreasonably in referring Mr C to physiotherapy or to the surgeon who had carried out the knee surgery. Whilst we concluded that communication with Mr C about his care appeared reasonable overall, we upheld Mr C's complaint that the board failed to adhere to his request for electronic communication during their investigation of his complaint, and we made recommendations to the board.

Recommendations

We recommended that the board:

• ensure that their current consent forms prompt the clinician to record that the advantages and risks of surgery have been discussed with the patient;
• apologise to Mr C for failing to adhere to his request for electronic communication;
• review the wording of their electronic information consent form to ensure that it is not contradictory; and
• take steps to ensure that patients' requests for electronic communication are properly logged and acted upon.

Summary

Mrs C was recovering from breast cancer and had previously been diagnosed with truncal lymphedema (fluid affecting the trunk and/or breast following breast cancer treatment). Mrs C had therefore understood that she should be treated urgently if she became unwell. As she was experiencing pain between the shoulder blades, Mrs C was taken by ambulance to A&E at Monklands Hospital, where she was assessed by a registrar and a consultant, and then discharged with a prescription for pain medication.

Mrs C complained there was a failure to carry out an adequate clinical assessment, a failure to provide adequate nursing care and an unreasonable delay in assessing and treating her. Mrs C was also unhappy about the attitude of staff towards her. The board said that Mrs C had behaved unreasonably towards members of A&E staff.

We took independent advice from a medical adviser and a nursing adviser. We found that while the majority of Mrs C's care and treatment was reasonable and she suffered no adverse outcome, the doctors who treated Mrs C should have sought information on truncal lymphedema, and there was no evidence they did so. In addition, the registrar had failed to record their consultation with Mrs C in her medical records. Therefore, we upheld Mrs C's complaint that there was a failure to carry out an adequate clinical assessment. However, we did not find evidence that there had been a failure to provide Mrs C with adequate nursing care or that there had been an unreasonable delay in assessing and treating her, and we did not uphold this part of Mrs C's complaint.

Mrs C attended the out-of-hours service at Monklands Hospital approximately two weeks later because she was concerned about having truncal lymphedema and that she possibly had shingles. Mrs C complained about the care and treatment she received and about staff attitude towards her. The advice we received from both advisers was that the care and treatment Mrs C received was appropriate, and we were unable to reach a conclusion on her complaint about staff attitude due to conflicting accounts. We did not uphold this part of Mrs C's complaint.

Recommendations

We recommended that the board:

• consider organising a consultation between A&E and the oncology department at Monklands Hospital and Mrs C's GP with a view to putting a care plan in place and to sharing the plan with her;
• remind relevant staff of the importance of ensuring that consultations and discussions with a patient are recorded in the patient's medical records; and
• provide evidence that nursing staff in A&E have been reminded of the need to routinely record a patient's pain score.

Summary

Miss C's mother (Mrs A) was diagnosed with diverticular disease (disease of the colon) a number of years ago, but did not experience any symptoms from this and was not on medication.

Mrs A was admitted to Monklands Hospital with symptoms of abdominal pain, vomiting and weight loss and was treated for a urinary tract infection. A possible diagnosis of diverticulitis (a condition related to diverticular disease, where the abnormalities in the large intestine become inflamed or infected) was made but she was discharged for follow-up as an out-patient.

Mrs A was then admitted to Hairmyres Hospital a few days later and diagnosed with diverticulitis. Staff had planned to treat her conservatively (without surgery) for a few days, but to consider surgery if she did not improve. Mrs A suffered a heart attack during this time, and the cardiac team advised that surgery should be avoided if possible. While Mrs A initially improved, her health then deteriorated and became critical due to septicaemia (blood poisoning). Emergency surgery was carried out, but Mrs A passed away a few hours after the surgery.

Miss C complained about Mrs A's discharge from Monklands Hospital and the delay in offering surgery. She also raised concerns about nursing care, including pain management. The board met with Miss C and her family and apologised for some aspects of Mrs A's care. They also conducted a Significant Adverse Event Review (SAER) which identified a number of failings in care, including pain management and record-keeping, as well as a delay in carrying out the emergency surgery. However, Miss C was not satisfied with this response and she brought her complaint to us.

After taking independent medical and nursing advice, we upheld most of Miss C's complaints. We found the discharge from Monklands Hospital was unreasonable in view of Mrs A's condition and, while it was appropriate not to offer Mrs A surgery until her condition deteriorated (in view of the risks), we found the delay in arranging emergency surgery at this point was not reasonable. We also found failings in communication and nursing care at Hairmyres Hospital, particularly in relation to pain management and appropriate use of the MEWS (Modified Early Warning System) - although we noted that the board had taken some action to address these issues as a result of the SAER.

Recommendations

We recommended that the board:

• feed back our findings about the inappropriate discharge of Mrs A from Monklands Hospital to the staff involved for reflection and learning;
• review their process for auditing that the MEWS is being used appropriately, including escalation where appropriate to a more senior practitioner when patients deteriorate;
• apologise to Miss C for the failings identified in our investigation; and
• feed back our findings to the medical and nursing staff involved at Hairmyres Hospital for reflection and learning.

Summary

Ms C complained about the nursing and medical care received by her brother (Mr A) over two admissions to Belford Hospital. Mr A's first admission was due to severe abdominal pain and vomiting. He was treated and discharged the same evening. Mr A's second admission was two days later after he was found disorientated in his home. He was assessed and a request was made for an out-of-hours (OOH) scan of his brain. This was refused and the scan was not carried out until the following morning. The scan showed bleeding on Mr A's brain and he was transferred to another hospital for surgery. Ms C also complained that the board had failed to respond appropriately to their complaint.

Ms C said Mr A was not properly assessed during his first admission. She said he should not have been discharged after receiving morphine and said Mr A had no memory of when he was discharged or how he got home.

Ms C said Mr A had been left in soiled clothing during his second admission, which had been distressing for his family. She said nursing staff had failed to provide personal care until the family had insisted. Ms C also said the failure to perform a brain scan sooner had put Mr A's life in danger. Ms C said the family had repeatedly told medical staff they believed Mr A was displaying symptoms of a brain injury.

We took independent medical advice from a consultant physician. The adviser said that Mr A's care and treatment during the first admission was adequate. However, the adviser said that Mr A was displaying sufficient symptoms of brain injury to justify OOH scanning earlier than he received the scan. This was unreasonable and should have been addressed in the board's complaint investigation.

We also took independent advice from a nursing adviser. They noted the records showed that staff had attempted to provide personal care to Mr A during his second admission, but that he had not been compliant.

We found the nursing care provided to Mr A was of a reasonable standard. However, we found that the medical care was not, since he should have had a brain scan sooner, although this delay did not impact on the outcome of his treatment. We also found the board's complaint response contained inaccuracies and Ms C's complaint was not investigated to a reasonable standard. We made recommendations to address the failings we identified in these different areas.

Recommendations

We recommended that the board:

• review their local protocol on the management of patients displaying abnormal brain function to ensure it is in accordance with Scottish Intercollegiate Guidance Network (SIGN) guidelines 107 and 108 which relate to the management of headache in adults and patients with strokes;
• draw the attention of the radiologist in this case to the requirement of SIGN guideline 108 for imaging for patients with suspected stroke;
• ensure the reasons for any delay in a complaint response are fully explained at the appropriate time;
• review this complaint to establish why the final response contained inaccuracies; and
• apologise in writing for the failings identified in this investigation.

Summary

Mr C, who works for an advice agency, complained to us on behalf of Mr A that the board had failed to diagnose what was causing his hypoglycaemia (low level of glucose in his blood). Mr A had been diagnosed with type 1 diabetes as a child. In his early twenties, he started to have hypoglycaemic episodes and was told to reduce his doses of insulin. He continued to have these episodes and was admitted to hospital on a number of occasions to be monitored.

We took independent advice on the complaint from a medical adviser, who is a consultant in medicine and endocrinology. We found that Mr A's recurrent hypoglycaemia had been promptly and appropriately investigated by the board and they had reasonably tried to manage this by giving him an insulin pump. We did not uphold this aspect of the complaint.

Mr C also complained that nursing staff had failed to provide reasonable treatment to Mr A when he was in Broadford Hospital. However, we found that the nursing staff had acted appropriately and we did not uphold this complaint.

Finally, Mr C complained about the board's handling of Mr A's complaint. We found that there had been an unreasonable delay by the board in responding to the complaint, although they had apologised for this delay in their response to Mr A. The board had also failed to respond to Mr A's complaint about nursing staff in Broadford Hospital. In view of these failings, we upheld this complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr A for failing to respond to all of the issues he had raised in his complaint; and
• make the staff involved in the handling of Mr A's complaint aware of our decision.