Some upheld, recommendations

Summary

Mrs C complained about the care and treatment received by her late husband (Mr C) while he was a patient at Raigmore Hospital. Mr C underwent surgery to treat colon cancer but he continued to experience health problems and had a number of readmissions over the course of the following months. Around five months after surgery, investigations showed a recurrence of Mr C's cancer. He was admitted to a hospice for palliative care and died two months later. Mrs C raised concerns about the steps taken to investigate her husband's ongoing symptoms and pain following the surgery. She also complained about a lack of planned follow-up action, including the omission of a referral to oncology.

We obtained independent advice from a consultant colorectal and general surgeon, who considered that the investigations undertaken during Mr C's admissions were reasonable and consistent with applicable guidance. The adviser noted that it was unfortunate that the investigations did not detect the recurrence of Mr C's cancer earlier but did not consider that this was due to a failing on the part of the board. We accepted this advice and did not uphold this complaint.

In relation to the decision not to refer Mr C to oncology following his surgery, the board indicated that the multi-disciplinary team had not felt that he would be fit enough to undergo chemotherapy. They noted that this was discussed with Mr C at the time but this discussion was not recorded in the clinical records. They acknowledged that it might have been useful for Mr C and his family to have met an oncologist to discuss the risks and benefits of chemotherapy and they apologised that this was not arranged. While accepting that Mr C was unlikely to have been fit enough for chemotherapy within the relevant time period, the adviser agreed that the opportunity to speak to an oncologist should have been considered. The adviser was critical of the board's failure to record their discussion with Mr C and noted that this was not consistent with the General Medical Council (GMC)'s guidelines on record-keeping. In the circumstances, we upheld this complaint.

Recommendations

We recommended that the board:

• reflect on the record-keeping failure highlighted in this case and take steps to ensure staff adhere to the relevant GMC guidelines in this area.

Summary

Mrs C complained about the care and treatment provided to a resident (Mr A) of the care home she managed when he was admitted to Glasgow Western Infirmary to have a catheter fitted. Mr A had dementia. Medical staff had to make a number of attempts to fit the catheter, which distressed Mr A. Mrs C said that staff failed to provide adequate care when they attempted to insert a catheter and properly manage his pain. She also said that staff failed to provide Mr A with adequate sustenance and communicate with his carer as they should have done.

We took independent advice from a nursing adviser. We found that the board failed to provide Mr A with adequate sustenance or communicate with his carer as they should have done, particularly given Mr A's dementia. However, we found no evidence that the placement of a catheter was unreasonable (although we appreciated how distressing an experience this was for Mr A) or that staff had failed to manage his pain.

Recommendations

We recommended that the board:

• consider and report on steps taken to address the failings we identified;
• bring the nursing adviser's comments about communication to the attention of relevant staff; and
• apologise for the failures we identified.

Summary

Mr C complained to us about the care and treatment he received from Stobhill Hospital when he had a circumcision operation. He complained that he had received poor treatment from nursing staff immediately after his operation. When he developed an infection in the wound, he sought specialist input. However, he complained that the surgeon did not examine him properly and dismissed his concerns. He returned to the same surgeon two more times over the following year, and was told that the wound had healed and nothing could be done to improve his discomfort. Mr C was then referred to a different surgeon who identified an issue with the way the scar had healed. He had another procedure which corrected this problem. Mr C said this should have been identified earlier. He also raised concerns about the way his complaint was handled.

We took independent advice from a nursing adviser and an adviser specialising in urology (relating to the urinary system and male reproductive system). They reviewed the care and treatment Mr C had received. The urology adviser noted that there was very little evidence that Mr C had been appropriately informed of the risks involved in the procedure prior to providing consent. However, he was satisfied that the operation was conducted appropriately, and that the follow-up consultations were reasonable. He said that the differences in the conclusions of the two surgeons related to their professional opinions about the scar, and this was reasonable. The nursing adviser was satisfied that nurses had monitored Mr C appropriately after his operation, and noted that the concerns he raised were not evident from his medical records.

We concluded that, while Mr C's operation had been reasonable, it appeared that he was not given enough information to provide informed consent, so the procedure was not conducted appropriately. We were satisfied that Mr C's subsequent examinations were reasonable. However, we found that the board had not provided a reasonable response when Mr C first raised concerns. When he persisted with his complaint, the board then took too long in providing a final response.

Recommendations

We recommended that the board:

• consider revising their leaflet for patients having circumcision taking into account the guidance from the British Association of Urological Surgeons and the Royal College of Surgeons;
• take steps to ensure adequate information is provided on the risks and potential complications of this procedure at an appropriate time prior to any decision being made to proceed with it, and that this is recorded;
• feed back the findings of this investigation to relevant staff; and
• apologise to Mr C for the failings identified.

Summary

Mrs C complained about the care her daughter (Miss A) received from Parkhead Hospital for anorexia nervosa. Mrs C was dissatisfied that Miss A lost weight in hospital and was not given enough calories. She said that the re-feeding plan was not tailored to meet Miss A's needs and that staff did not respond properly to the concerns she raised at the time of the hospital admission.

We took independent advice on this case from two of our advisers experienced in working with patients who have eating disorders, one of whom is a dietician and the other a mental health nurse. We found that there was an appropriate re-feeding plan and measures in place which were in line with national guidance. However, for approximately two weeks, Miss A's calorie intake was not in accordance with the re-feeding plan which the board acknowledged and apologised for. We also identified that the records made by the nursing staff should have been more detailed, and that there was insufficient historical information documented about Miss A's background and whether any psychological therapies had been offered to her or the family.

We considered that there was evidence to show that staff had listened to concerns raised by the family about Miss A's preference to have liquid nutritional supplements instead of solid food. Furthermore, an agreement had been reached for Miss A to follow the re-feeding plan rather than have a feeding tube put in place.

Recommendations

We recommended that the board:

• ensure their re-feeding policy includes guidance on offering psychological therapies and support to patients and their families; and
• draw to the attention of nursing staff involved in Miss A's care the importance of documenting relevant information related to a patient's behaviours, weight and family background.

Summary

Miss C had an ovarian cyst. A referral was made for it to be drained and possibly removed. The surgeon reviewed Miss C's notes the day before the operation was due to be carried out. They determined the procedure was inappropriate in the circumstances and that removal of both ovaries was recommended in guidelines produced by the Royal College of Obstetricians and Gynaecologists. Miss C was unaware of this change until she arrived at Aberdeen Royal Infirmary the following morning. After discussion, the operation went ahead. Miss C subsequently complained that consent was not properly obtained and that inappropriate treatment had been provided in light of her existing conditions, particularly fibromyalgia (a long-term condition that causes pain all over the body).

After taking independent advice from one of our advisers, who is a consultant gynaecologist, we upheld Miss C's complaint about consent. We found that the guidelines recommended removal of both ovaries in most cases but said that this should be determined by the wishes of the patient. The adviser considered that as it had been clear that Miss C had concerns, removal of just the affected ovary should have been discussed as a compromise, but this did not happen. We considered that Miss C should have been offered this information as part of the consent process. The adviser also highlighted concerns about the consent procedure, although it was noted that some changes had taken place following Miss C's complaint.

In relation to Miss C's other complaint, the adviser explained that there is a large volume of literature on the effects of hormones on fibromyalgia, but that most of the findings are contradictory. It was therefore considered that it would have been impossible to assess if the removal of both ovaries would affect Miss C's existing conditions and we did not uphold this complaint.

Recommendations

We recommended that the board:

• issue Miss C with an apology for the failure to advise her of the option of removing the affected ovary only; and
• review the process for obtaining consent, taking the adviser's comments into account.

Summary

Mrs C complained to us about the care and treatment her late father (Mr A) received at Aberdeen Royal Infirmary before his death from a urological cancer (relating to the urinary system and male reproductive system) that had spread through his body. Mrs C said that the urology care and treatment the board had provided to her father over a number of years had been inadequate. We took independent advice on this aspect of Mrs C's complaint from a number of medical advisers who are specialists in various relevant fields. We found that, although communication with Mr A and his family could have been better, there had been no major failings in relation to the urology service's care and treatment of Mr A. We did not uphold this complaint.

Mrs C also complained about the care and treatment the board had provided to her father over a number of years for his abdominal symptoms. We upheld this complaint, as we found that there had been a delay in carrying out a colonoscopy (examination of the bowel with a camera on a flexible tube) or alternative investigations. Although this led to a four-month delay in diagnosing Mr A's rectal tumour, there was no impact on the overall outcome, as the tumour was benign (non-cancerous). Mr A's urological cancer had already spread to other parts of his body by that time.

Mrs C also complained that the board had provided inadequate care and treatment to her father in the last few weeks of his life. Although we found that the care Mr A had received in relation to his visual problems had not been adequate, we found that the end of life care provided to him had been reasonable overall. We did not uphold this aspect of the complaint.

Finally, Mrs C complained about the board's handling of her complaint. We found that the board's former medical director should have ensured that Mrs C's correspondence to him was dealt with as a complaint rather than trying to deal with the matter personally. We also found that comments the former medical director had made to Mrs C in an email had been inappropriate, and that it had also been inappropriate to send Mrs C a gift voucher. In view of this, we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings we identified;
• take steps to make the surgical staff responsible for the delay in the colonoscopy or alternative investigations being carried out aware of our decision on this matter and consider if the matter should be discussed at their annual appraisal;
• make the staff in the gastroenterology team aware of our comments on communication with Mrs C and Mr A;
• provide us with evidence that steps have been taken to improve the care delivered to patients with visual impairments since Mr A was in hospital; and
• provide evidence to us that the recommendations made in relation to their investigation into the former medical director's actions have been implemented.

Summary

Mr C complained to us that staff at Forth Valley Royal Hospital had removed a cannula (a small tube inserted into the body that can be used to drain fluid or to give medication) against his will when he was being discharged from hospital. We took independent advice on the complaint from a medical adviser. We found that it had been reasonable for staff to remove the cannula, as there was a risk of infection. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the board failed to deal with his complaints about this appropriately. He had complained to a prison health centre and they sent the complaint to the board's complaints handling team to respond. However, the complaints handling team did not receive the complaint and, as a result, Mr C did not receive an acknowledgement or a response to his complaint at that time. He had to write to the board again and faced a significant delay before receiving a response to the complaint. Some of the information in the board's response was also factually inaccurate. In view of this, we upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• provide evidence that they have taken steps to ensure that all complaints referred by prison health centres to their Patient Relations and Complaints Service are received and responded to; and
• remind complaints handling staff that responses to complaints must be factually accurate.

Summary

Mr C was concerned about the care and treatment given to his son (Mr A) by the University Hospital Crosshouse immediately before his death. Mr A had recently been diagnosed with terminal and inoperable cancer. He was told that his time was short. He was admitted to the hospital as an emergency with increasing pain and sickness but he died a few days later. Mr C complained to us that he had not been told how advanced his son's illness was; that his son had no treatment plan; that his son was treated without dignity or privacy; staff were inflexible about visiting times; and that communication was poor.

We took independent advice from a consultant clinical oncologist and from a nurse practitioner. We found that while Mr A's medical care and treatment had been reasonable, there had been poor communication by staff. Mr C should have been informed that Mr A was extremely ill and had very little time. We also found that while arrangements were confirmed with Mr C that he and his wife were able to visit on a more flexible basis, this instruction was not passed to all staff involved. In light of this, we upheld two of Mr C's complaints.

Recommendations

We recommended that the board:

• make a formal apology for their communication shortcomings;
• remind the medical team involved in Mr A's care and treatment of their obligations to keep families and carers informed particularly at the end of life; and
• confirm to us that they are satisfied that such an occurrence would not occur again.

Summary

Ms C complained about the information provided by the university in respect of the work she was required to submit for assessment at the end of the academic year. She said she asked her course tutor for information about the submission requirements but that the course tutor could not help her. She failed this aspect of the course. She said she contacted a senior secretary who advised her not to appeal but to resit the assessment in August. She felt this advice was wrong. She submitted her work in August after the deadline and, as a result, it was given a zero mark. She also said she was advised after her late submission that even though her submission was late it would still be assessed. She was also unhappy with the level of information provided by the university about the academic appeals process and about the late submission of work. Ms C was advised that she would need to resit the following year. As a result, she appealed the university's decision to give her a zero mark but her appeal was rejected. She was also unhappy with the time taken by the university to tell her their decision on her appeal.

We reviewed the information available to students and noted that there was a description of the assessment submissions required for this course. Contact details were also provided for members of the academic staff who could assist where there was any doubt or confusion. We also found that there was clear information on the late submission of work and the academic appeals process online and in the student handbook. Whilst we could not say with sufficient certainty what information she was given by staff, we noted that the appeals process was clear and that she could have sought advice about this from a number of sources. We also noted that, even if she was told that her work which she submitted late would be assessed, the policy was clear in that this was not the case. However, we noted that consideration of her appeal had taken much longer than the published timescales and, as a result, we upheld this aspect of the complaint.

Recommendations

We recommended that the university:

• write to Ms C to apologise for the time taken to consider her appeal; and
• remind staff that all appeals should be dealt with within the published timescales.

Summary

Miss C said there was a lack of support during her course, and lecturers acted unreasonably in relation to a holiday she planned during term-time (first agreeing to reschedule assessments, then raising concerns about her attendance and expecting her to do the outstanding exams immediately on her return). Miss C also raised concerns about lecturers' communication on several occasions, and said the reference the college gave her was incomplete and inaccurate. When Miss C complained to the lecturer's manager, the manager arranged an impromptu meeting with Miss C and her lecturers to discuss this, without talking to Miss C first. Miss C made a further complaint, which the college investigated under their complaints handling procedure, but Miss C was concerned that they did not speak to the witnesses she had named or take into account all the evidence she gave them.

The college upheld several parts of Miss C's complaint. They agreed that lecturers' communication was inappropriate on some occasions, and that Miss C's first complaint was not handled in line with college procedures. They also agreed that there was a lack of support during the first semester (as there was no learning development tutor), but they said this was beyond the college's control (as it was due to the unexpected absence of learning support staff).

We investigated the issues and upheld four of Miss C's complaints. We found that lecturers failed to follow their policies for raising concerns about attendance, and we were critical that the college's response to Miss C's complaints did not refer to the relevant policies, and did not take account of Miss C's witnesses. We also found that lecturers failed to follow Miss C's learning support plan (without agreeing alternative arrangements), some of their communication was unreasonable, and some aspects of the college's reference were inaccurate or misleading. However, we found the lack of a learning development tutor during the first half of semester was beyond the college's control and they took appropriate action to address this. We also found Miss C had reasonable notice of the exams on her return to class.

Recommendations

We recommended that the college:

• take steps to ensure teaching staff are familiar with the requirements of the attendance procedures and the student disciplinary policy;
• take steps to ensure that staff comply with the specific requirements of personal learning support plans (PLSPs), or arrange for changes to the PLSP if this is not possible or practicable;
• review the process for student references, to ensure that any factual statements are based on clearly identified and accurate information;
• apologise to Miss C for the failings our investigation found;
• feed back our findings to the teaching and complaints handling staff involved; and
• take steps to ensure that complaint investigations take account of all evidence and appropriate witnesses, and relevant college procedures.