Some upheld, recommendations

Summary

Mrs C, who works for a voluntary agency, complained about the care and treatment that her client (Mrs A) had received during admissions to the Southern General Hospital, the Victoria Infirmary and the New Victoria Infirmary. Mrs A was initially admitted after a fall where she broke her arm and leg. Whilst Mrs A was in hospital, she suffered a series of falls, some of which resulted in further injury.

After taking independent advice from a nursing adviser, we did not uphold Mrs C's complaint that a fall Mrs A had while using the toilet at the Southern General Hospital was caused by unreasonable circumstances. The advice we received was that it was appropriate for Mrs A to have been allowed privacy to use the facilities after being assisted there by nursing staff. Although we did not uphold this aspect of the complaint, we did make a recommendation about this.

We also took independent advice from a consultant physician and geriatrician who considered whether it was reasonable that staff at the New Victoria Infirmary had not identified a hip fracture following a fall there. We did not uphold this complaint as the advice we received was that there was no indication that, following the fall, Mrs A had sustained a fracture. The adviser also said that an appropriate medical assessment had taken place. We also did not uphold Mrs C's complaint that Mrs A had to wait too long for surgery following admission to the Victoria Infirmary. We found that surgery had taken place within the recognised standard of 48 hours.

We did, however, uphold a complaint about Mrs A's premature discharge from the New Victoria Infirmary. We found that records, including National Early Warning Scores (NEWS), were unavailable and it was not clear whether there had been a failure to complete these or if they had been lost. These records, had they been available, would have enabled the adviser to confirm whether the decision to discharge was reasonable.

We also found that nursing staff caring for Mrs A should have requested a medical review before she was discharged due to her recent falls history and the level of pain she was experiencing.

Recommendations

We recommended that the board:

• ensure that the relevant staff are made aware of the nursing adviser's comments on toilet supervision requirements and facilities checks;
• issue an apology for the failing to request a medical review prior to discharge;
• make the relevant staff aware of the nursing adviser's comments on requesting a medical review; and
• take steps to ensure NEWS scores are appropriately taken and recorded on the ward and that medical records are appropriately stored.

Summary

Ms C complained to us about the medical and nursing care her mother (Mrs A) received at the Royal Alexandra Hospital before her death from heart failure. We took independent advice on Ms C's complaints from a nursing adviser and from a medical adviser who is a consultant physician and geriatrician. We found that the medical and nursing care provided to Mrs A had been reasonable and appropriate. It had been reasonable to catheterise Mrs A, as medication that she had been receiving for her heart failure made her pass urine continuously to try to reduce her excess fluid. It was also important to measure her urine output accurately during this treatment. We also found that the nursing care she received for pain and hydration was reasonable, as was the decision to give her oral and not intravenous antibiotics. In addition, the end of life care provided was consistent both with usual clinical practice and with the relevant guidance. We did not uphold these complaints.

Ms C also complained that staff in the hospital had not discussed a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form with her, before this was put in place for Mrs A. The records said that this had been discussed with Mrs A's daughter. Although it was not clear whether this was Ms C or her sister, we were satisfied that the board had acted in line with the relevant procedure on this. We did not uphold this complaint either.

Finally, Ms C complained that the board had not communicated with her properly. We found that the communication with Ms C at this distressing time for her, just before her mother's death, had not met her needs. We upheld this aspect of Ms C's complaint, although we were satisfied that the board had apologised to her for this and had shared their findings with relevant staff.

Recommendations

We recommended that the board:

• provide us with a copy of their action plan to address the failings they had identified.

Summary

Mr C was suffering from hoarseness and was referred to hospital by the medical practice for an out-patient appointment at the ear, nose and throat (ENT) department. He was seen by a consultant who identified no suspicious findings and he was discharged back into the care of the practice. Mr C continued to have the same symptoms and was re-referred some time later. He was later seen by a speech and language therapist who identified possible malignancy in the voice box and thereafter, Mr C was diagnosed with cancer. Mr C complained that there had been unreasonable delays in referring him for a further ENT appointment and that the practice's communication with the hospital had not been adequate.

After taking independent advice on this case from an adviser, who is a general practitioner, we did not uphold Mr C's complaint about delay in referral. We found no evidence that there had been unreasonable delay in making referrals and the adviser explained that it was reasonable for doctors at the practice to have been reassured when the initial ENT consultation revealed no sinister findings. Although the adviser considered the majority of the practice's communication with the hospital to have been reasonable, we upheld Mr C's complaint about communication as we found that the initial referral to ENT was categorised as routine, rather than urgent in line with the relevant guidance. The advice we received, however, was that this had no impact on Mr C as the subsequent ENT consultation had not identified any sinister findings. We made a recommendation to the practice to ensure they are aware of the issue.

Recommendations

We recommended that the practice:

• review both the Scottish Intercollegiate Guidelines Network (SIGN) and Greater Glasgow and Clyde guidance to ensure staff are familiar with the referral criteria and confirm to us that the review has taken place.

Summary

Mrs C raised a number of issues about the care and treatment her late mother (Mrs A) received during a number of admissions to Glasgow Royal Infirmary during 2013 and 2014.

During our investigation, we took independent advice from a nursing adviser and a physician and orthogeriatrician (who specialises in the care of elderly patients with conditions involving the musculoskeletal system) who has experience in the assessment and management of a range of medical problems. While some aspects of the care and treatment Mrs A received during the various admissions was reasonable, we identified a number of concerns. In particular, in relation to her first admission to the hospital, the physician and orthogeriatrician adviser found no evidence that an appropriate multi-disciplinary assessment had been carried out to ensure a safe discharge home. The physician and orthogeriatrician adviser and the nursing adviser also had concerns about the adequacy of record-keeping by both medical and nursing staff in relation to a number of the admissions. In relation to Mrs A's second admission, we noted that the board accepted there had been a delay in diagnosing a fracture to Mrs A's wrist. We were critical of this delay.

We were also concerned that Mrs A experienced delays when she had to again attend the hospital. In addition, the advice we received and accepted from the physician and orthogeriatrician adviser was that an earlier ultrasound would have been more appropriate management, and the use of diuretics during Mrs A's fourth admission to the hospital would not generally be regarded as appropriate.

We upheld several aspects of the complaint and made a number of recommendations to address the failings.

Recommendations

We recommended that the board:

• apologise for the failings we identified;
• remind staff of the need to carry out an appropriate multi-disciplinary assessment to ensure safe discharge;
• consider the nursing adviser's comments about the standard of record-keeping and provide details as to how improvements to nursing documentation will be implemented;
• consider the suggestions made by the physician and orthogeriatrician adviser in relation to the need for attention to be given to the process of review of x-rays and report back to us on any further action taken;
• consider this case to see if any further lessons can be learned and report back to us on any action taken;
• take steps to ensure that medical staff are complying with Records Management: NHS Code of Practice (Scotland); and
• bring the physician and orthogeriatrician adviser's comments about the timing of ultrasounds and the use of diuretics to the attention of relevant staff and report back to us on any action taken.

Summary

Mrs C, who is an MSP, complained on behalf of Mr A about the board's failure to offer him robotic surgery to treat his prostate cancer. Mr A considered that there were clear benefits in having robotic rather than open or keyhole surgery. He complained that the board had failed to explore the options available to him, including the option of pursuing robotic surgery privately, after he was diagnosed with prostate cancer.

We took independent advice on the complaint from a medical adviser, who is a consultant urological surgeon with experience in the management of prostate cancer. We found that Mr A had received appropriate counselling regarding the treatment options available from the board for his prostate cancer. However, although the board did not offer robotic surgery for prostate cancer at that time, we found that for completeness, the option of having robotic surgery privately should also have been mentioned to Mr A. There was no evidence that this had been mentioned to him and he said that he had only found out about it through his own research. We upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board had failed to offer Mr A robotic surgery and that they failed to refund the cost when he had the surgery privately abroad. We found that it was reasonable that the board did not offer robotic surgery to Mr A, as they had offered him alternative surgery. The board were investigating the feasibility of purchasing a robot system and there was no requirement to offer robotic surgery at that time. We also found that it had been reasonable for the board to decline funding the surgery elsewhere. We did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr A for the failure to mention the option of pursuing robot-assisted surgery privately, when advising him of his treatment options; and
• make the relevant staff aware of our decision on this matter.

Summary

Mr C complained that the Golden Jubilee National Hospital did not carry out his knee surgery properly and that his aftercare was of a poor standard. He also had concerns about the consent he gave for the procedure as he was under the impression that his named consultant would mainly be performing it, but found out after the operation that another doctor had carried out the operation under the supervision of the consultant.

We took independent advice from a consultant orthopaedic surgeon. We considered that the need for Mr C to have revision surgery within a year was not acceptable and there were likely some failings in relation to the way in which the procedure was performed, so we upheld this part of his complaint.

We found that Mr C's consent to the procedure had been reasonably obtained by the other doctor the day before surgery, in that he had indicated that he would be involved with the procedure and had highlighted the risks. In addition, the consent form Mr C signed sets out that the procedure might not be performed by the clinician who had been treating him. In terms of Mr C's aftercare, we concluded that reasonable steps were taken in response to his ongoing symptoms of pain and difficulty walking. We did not consider that Mr C was intentionally misled in this respect and therefore we did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in relation to his surgery; and
• share the findings with the doctor for future learning.

Summary

Mr C complained that a prison health centre failed to refer him to a plastic surgery clinic for scar revision. This was in relation to scars on his abdomen which were causing him pain and discomfort. We took independent advice on the complaint from a GP. We were informed that the prison health centre had sent a referral to the plastic surgery clinic but it was subsequently decided that revision surgery was not appropriate, as Mr C was continuing to self-harm at the time. We were advised that the decision not to progress the referral in such circumstances was reasonable and in line with relevant guidelines. We accepted this advice and did not uphold this aspect of the complaint.

Mr C also complained about the way his complaints were handled by both the prison health centre and the board. He noted that he had asked specific questions in his complaints and that these had not been answered. We agreed that the prison health centre had only formally addressed one of the two points raised with them and the board's formal response omitted a reply to one of the four points raised with them. We, therefore, upheld this part of the complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for failing to fully respond to his feedback and complaint forms; and
• make the relevant complaints handling staff aware of our findings.

Summary

Ms C complained about the care and treatment she received from University Hospital Crosshouse for what she believed was suspected appendicitis. She said she made frequent visits to the A&E department at the hospital and was also admitted to the hospital, but her condition was not reasonably assessed and treated. She said her condition then deteriorated and spread to her bowel and she had to have part of her large and small bowel removed. Ms C also complained that her complaint about her treatment was not reasonably responded to by the board.

We took independent advice from two advisers, one a consultant in emergency medicine and the other a consultant colorectal surgeon (who specialises in conditions relating to or affecting the colon and rectum). The emergency medicine adviser said that the treatment Ms C received in the A&E department at the hospital was reasonable.

The colorectal surgical adviser said they did not think that there was an unreasonable failure by the board to diagnose Ms C's appendicitis sooner, as the initial clinical signs would not have been very obvious for acute appendicitis. They also said there was a delayed diagnosis of acute appendicitis, but explained that the diagnosis of this is sometimes challenging even to an experienced surgeon and it would have been difficult to know and impossible to determine at what precise moment Ms C actually had acute appendicitis. We therefore did not uphold Ms C's complaint that her condition was not reasonably assessed and treated, but we did make a recommendation based on the advice we received about how the board should have shared the learning points from Ms C's complaints.

In terms of the complaints handling, Ms C indicated in her complaint to the board that she was concerned about the care and treatment she received from the board and her GP. The board did not appear to take any action to assist in progressing Ms C's complaint about her GP, either by contacting Ms C's GP practice or by advising Ms C to do so herself. We, therefore, considered that her complaint was not reasonably responded to by the board and we upheld this part of Ms C's complaint. We also found that at the time of Ms C's complaint, the board did not have a full written complaints procedure in place. They said that they were in the process of compiling a toolkit that would address this, so we made a recommendation about this too.

Recommendations

We recommended that the board:

• take steps to ensure that in future they keep documentary evidence of the remedial action taken as a result of patients' complaints;
• feed back our decision on their handling of Ms C's complaint to the staff involved;
• provide us with a copy of their comprehensive complaints tool kit and evidence that this has now been launched; and
• provide Ms C with a written apology for failing to respond reasonably to her complaint about her GP.

Summary

Mrs C complained about the gastroenterology care she received from the board. Mrs C was attending an out-patient clinic at University Hospital Ayr and had previously undergone surgery to remove her gallbladder. She continued to experience various problems with her digestion along with skin problems, particularly on her hands. Mrs C complained that there had been too many consultants involved in her care and that there had been a lack of continuity in her care. Mrs C also complained that the board had not coordinated her care appropriately and that they unreasonably failed to reach a diagnosis of her condition.

During our investigation, we took independent advice from a consultant gastroenterologist. We found that the board had acknowledged there were a number of gastroenterologists involved in Mrs C's care due to retirement and sick leave and they had apologised for this. However, the advice we received was that for patients with chronic conditions like Mrs C, the use of short term locum consultants should be avoided. We found that this had affected the continuity of Mrs C's care and resulted in a potentially avoidable referral to another NHS board. We upheld Mrs C's complaints regarding the number of consultants involved and the lack of continuity in her gastroenterology care.

The adviser considered that there was evidence of good coordination of Mrs C's care with referrals to other specialties being followed up promptly by a single consultant and consequently we did not uphold that element of her complaint. We also did not uphold Mrs C's complaint about a lack of definitive diagnosis. The advice we received was that the board had carried out numerous investigations to try to determine the cause of Mrs C's continuing symptoms and that reasonable steps were taken in attempts to reach a definitive diagnosis. The adviser highlighted two blood tests that could be carried out for completeness but overall, the board's action on diagnosis was considered to be reasonable.

Recommendations

We recommended that the board:

• ensure that all relevant staff are made aware of the adviser's comments on locum consultations for patients with chronic conditions; and
• ensure that Mrs C's consultant is made aware of the adviser's comments on additional blood tests that could be carried out for completeness.

Summary

Mr C complained that he had been unfairly prevented from completing a university masters degree. Mr C said he had never been informed of the course-marking criteria. He had been invoiced for the third year of his studies, and paid the fees in full. The university had accepted the fees and had not offered a refund until he had complained. Mr C felt his academic appeal had been poorly handled and had taken an excessive amount of time.

The university said Mr C had been informed at the end of his first year that his marks were not high enough to proceed to year three of his studies: he had met the criteria to proceed to year two (successful completion of year which would result in a postgraduate diploma level qualification) but not to proceed to the third year (masters level). They acknowledged he had been invoiced in error, and apologised for this. They noted his refund had been processed as quickly as possible and that at busy times, such as the start of the academic year, refunds could be subject to delay. The university said that Mr C's academic appeal had been delayed due to the level of workload the academic appeals section had at that time.

We found that Mr C had been told at the end of the first year his marks were insufficient to proceed to year three of his studies. There was no evidence that Mr C had questioned this decision at the time. We did not uphold the complaint that the university unreasonably failed to make clear the criteria for progression.

The university had accepted the invoice was issued in error, but had not provided evidence the error had been addressed. We therefore upheld the complaint that the university unreasonably invoiced Mr C and accepted payment for tuition fees for the third year of the course. However, we did not consider the time taken for the university to refund the payment to be unreasonable in the circumstances, so we did not uphold this aspect of the complaint.

We also found that the academic appeal process had taken too long and the university had not been pro-active in informing Mr C of the delays, and so we upheld the complaint that the university unreasonably failed to meet their stated timescales in relation to the academic appeal.

Recommendations

We recommended that the university:

• provide evidence of the action they have taken to prevent a recurrence of the administrative error which led to a course invoice being issued before the final examination board meeting;
• review the handling of the academic appeal in order to prevent a recurrence of the delays that affected it; and
• apologise for the delays in determining the academic appeal and for failing to provide updates on its progress.