Upheld, recommendations

Summary

C complained on behalf of their adult child (A), who underwent septorhinoplasty surgery (to improve the function and appearance of the nose) after a rugby accident. C complained about the care and treatment provided to A following the procedure. C had all skin sutures and brace, seven days after surgery, as per the clinic letters. A developed a post-operative infection and was reviewed again 12 days after surgery, when a further suture was removed. More than a year later, A noted black suture material extruding from the scar line on their nose. They were commenced on antibiotics and further review arranged. C complained that the medical records did not support the board’s position that a suture was intentionally left in place and that the board had failed in their duty of candour.

We took independent advice from a consultant otorhinolaryngologist (specialist in ear, nose, and throat medicine). We found the standard of care and treatment when A attended 12 days after surgery unreasonable. We also found that A was wrongly told that all remaining suture material had been removed at that time.

With regard to the suture material which extruded from the scar line more than a year later, we found that the board’s explanation that this suture was intended to remain in place permanently was not supported by the records. Had it been intended to remain in place permanently, it should have been clearly recorded. We found the board had failed in their duty of candour and that it was unreasonable for the board not to have offered A a second opinion, even if that required referral outwith the board area. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Practitioners document the number and type of skin sutures placed in a wound.
• Where a second opinion is requested this should be appropriately considered in line with relevant guidance.

In relation to complaints handling, we recommended:

• Complaint decisions should be evidence-based. Complaint responses should be quality assured to ensure decision-making is based on the available evidence. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at HYPERLINK "https://www.spso.org.uk/training-courses" https://www.spso.org.uk/training-courses .

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment given to their late spouse (A) by the practice before A died from metastatic renal cancer. C raised concerns that A was misdiagnosed by the practice and that they did not make appropriate referral for further investigation when they should have done.

In response, the medical practice provided a detailed timeline of appointments, symptoms, treatments, and actions taken. They concluded that A had a complicated medical history and that the fact that A found it difficult to attend face-to-face appointments, made it difficult for doctors to gauge how much pain they were in. The medical practice acknowledged that there was some miscommunication between the practice and secondary care colleagues in physiotherapy.

We took independent clinical advice from a GP adviser. We found that much of the care and treatment provided to A had been reasonable. However, we also found that some consultations were unreasonable, and that red-flags were not always appropriately identified and/or recorded and were not followed up. We also found that the SAER was not completed in line with the guidelines. As such, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Instigated a monthly meeting with professionals to discuss patients with complex medical presentations. Hold gold standard meetings monthly including the clinical team, district nurses, and MacMillan nurses. Identified a number of learning points from the SAER that was carried out.
• Documentation of consultations, examinations carried out, and the points raised and discussed should be accurate and complete. Treatment should be in line with the relevant NICE guidelines specifically in reference to red-flag symptoms and signs. Clinicians should take action to identify if any red-flag symptoms are present and take appropriate action when they are.
• Patients should be escalated/ referred to hospital pathways when their presentation indicates it is appropriate. Communication and interactions with other health care teams should be carried out reasonably and effectively.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board did not take reasonable action regarding their referrals. C was privately assessed by specialists in England, who recommended hospital admission for tests. C informed Highland NHS Board and it took over 18 months to approve and arrange referrals.

We found that there was an unreasonable delay in progressing C’s respiratory referral and that the board’s communication was inadequate. The board failed to provide reasonable updates, which might have revealed sooner that the hospital C had been referred to had not received their original submission of the referral. Given this, we upheld the complaint.

We found that the board unreasonably delayed C’s neurology referral. The board’s said that the delay was due to uncertainty over a consultant’s approval for MRI imaging and whether C wished to remain a private patient. We found that C had advised that they would request private care be paused pending the board’s multi-disciplinary team discussions. While the decision to refer C to another NHS Board was reasonable, taking six months to action this was not. We upheld the complaint.

Finally, we found that communication with C was inadequate. Given this, we upheld this complaint and note the steps that the board have taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that their communications were inaccurate. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Apologise to C that they did not take reasonable action regarding the neurology referral. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Apologise to C that they did not take reasonable action regarding the respiratory referral and that they did not keep C reasonably updated regarding the progress of the referral. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Communication with patients whilst referrals are being discussed, or pending a response, is proactive, open, honest, and regular.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that their spouse (A) received from the board during admissions to Dr Gray’s Hospital (Hospital A) and Aberdeen Royal Infirmary (Hospital B).

A was admitted following episodes of vomiting blood and received treatment for gastric varices (enlarged blood vessels in the stomach lining). C complained that the board did not investigate or treat A’s condition timeously, and that treatment was only given when their condition deteriorated. C complained that an oesophageal perforation occurred as a complication of a procedure to stop bleeding. C also complained about aspects of nursing care at Hospital B.

We took independent advice from two advisers, a consultant hepatologist, who provided advice on the medical care and treatment, and a senior nurse, who provided advice on the nursing care and treatment.

In relation to Hospital A, we found that there were aspects of A’s care which had been reasonably managed. Specifically, a recognised tool was used to assess the severity of the upper gastrointestinal bleeding which had occurred. However, there were aspects of A’s care which we considered unreasonably managed. In particular, having identified A as being at high risk of bleeding, there were delays in acting on this result, arranging diagnostic endoscopy, and making a timely referral and transfer to Hospital B for ongoing treatment. On balance, we upheld C’s complaint about Hospital A.

In relation to Hospital B, we found that it was reasonable to seek specialist advice about the treatment of A’s condition from another health board. While a complication had occurred when inserting a tube to control bleeding, we found that the management of this was reasonable. We also found that Hospital B had reasonably acknowledged the nursing care incidents which had occurred and taken appropriate steps to learn and improve from them. However, there were aspects of A’s care and treatment which were unreasonably managed by Hospital B. In particular, having identified A as being at high risk of further bleeding, there was an unreasonable delay in providing definitive endoscopic treatment. On balance, we upheld C’s complaint about Hospital B.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients presenting with confirmed variceal bleeds should be offered treatment appropriate to their presentation, assessed risk, and ongoing symptoms. When a complication occurs following placement of a Sengstaken-Blakemore tube, the action taken should be appropriate and without risk of harm to the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the practice failed to act reasonably on the symptoms and information provided by C to the practice. The practice acknowledged difficulties in handling the complaint and failed to manage its interactions with a specialist laboratory. C has since transferred to a different practice, and has a diagnosis of Sjogren’s syndrome (a disorder of the immune system where the glands that produce fluid, such as tears and saliva stop working properly). C stated that they had specifically raised these concerns with the original practice and believed that their symptoms and related concerns were unreasonably dismissed.

We took independent medical advice from a GP adviser. We found that C should have been offered a face-to-face appointment. This would have allowed appropriate assessment of C’s symptoms and the possibility of an earlier diagnosis, although this could not be determined with certainty. Therefore, we found that the actions of the practice were unreasonable. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to offer a face-to-face apology. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Review their process for following up blood tests when a laboratory fails to analyse them.
• Wherever possible and where it is clinically appropriate, patients should receive face-to-face appointments, where a detailed clinical examination can be carried out, a detailed history taken, along with a full assessment of any symptoms.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the Scottish Prison Service (SPS) failed to follow the appropriate procedure after they removed C from association (temporarily separated from the normal prison population. A Governor can order a prisoner be segregated from others for up to 72 hours if they believe it is in the interests of good order in the prison or for the prisoner’s or others’ safety.

In response to C’s complaints, the SPS said that C's removal from association had been authorised in line with relevant procedure.

We found that the decision to remove C from association was carried out in line with the relevant procedure authorised by Prison Rules. However, the SPS did not properly record the actions taken. These omissions could make it appear that C was held out of association without proper authorisation.

Accurate record-keeping is important, especially for decisions to remove a prisoner from association, because it ensures that any time spent under specific rules is clearly recorded and monitored. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• The SPS should remind staff of the importance of accurately recording information regarding a prisoner’s removal from association to ensure any periods held under specific rules are clearly documented and monitored. The SPS should also consider whether issuing of guidance or instruction for the circumstances described in this case is required.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their child (A) who is in their late teens. C complained that Child and Adolescent Mental Health Services (CAMHS) failed to carry out appropriate Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) assessments and failed to provide A with appropriate support for a number of years.

The board said that A had undergone a number of assessments and reviews within CAMHS prior to turning 18 and no conclusive diagnosis had been reached. During our investigation they acknowledged that the family may have been unintentionally given the impression that an ASD diagnosis was likely or expected.

We took independent advice from a clinical psychologist with experience in CAMHS. We found that while there were multiple professionals involved, given the complexity of this case there should have been further demonstration of shared, integrated clinical reasoning by the multidisciplinary team (MDT) in formulating a diagnostic conclusion.

We further found that there was a lack of documentation regarding clinical reasoning for the type of psychological therapy offered; and that there was a lack of clarity about the expected/communicated timescales for ASD assessment. Therefore, we upheld C’s complaint.

We noted the board’s explanation that service changes have been implemented and are ongoing since the events considered in this investigation, and that this work is being informed by the Scottish Government and the National Autism Implementation Team. It may be that some of the issues identified in this investigation have been addressed by improvements already made. If that is the case, evidence of those improvements can be provided in support of the recommendations being fulfilled.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A that care and treatment provided to A by CAMHS was unreasonable. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Offer A a second opinion, including consideration of whether re-assessment for ASD, and/or an assessment for ADHD, are required.

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

• Clear communication with families about expected timeframes should be standard practice and documented in the medical notes.
• Communication around diagnostic uncertainty where neurodevelopmental conditions are being considered should aim to minimise the likelihood of families forming premature expectations about specific diagnoses.
• For complex or borderline cases, the service should ensure that diagnostic conclusions are reached through an integrated multidisciplinary team discussion.
• When psychological therapy options are reviewed, clinical reasoning for the chosen intervention should be explicitly documented.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board's communication around their spouse (A)'s care and treatment was unreasonable. C complained about a lack of face-to-face appointments, delays and the board not following their diagnostic pathway. C said that they were informed of A's prostate cancer over the phone, with no support provided to help them come to terms with the diagnosis or deciding on treatment which, due to A’s co-morbidities, was more complex.

The board apologised that not all of the appointments were face-to-face but explained that this was due to demands on the service. They acknowledged that this was not ideal but it was necessary to reduce delays. The board said that the MRI result clinic was omitted from the diagnostic pathway in order to expedite A's biopsy. The MRI results were shared at the biopsy appointment. An MDT discussion took place a week after the biopsy results were reported and the diagnosis was shared with A by telephone rather than waiting a further four weeks for a face-to-face appointment.

We took independent advice from a consultant urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the board’s communication was unreasonable. There was a lack of explanation about why the MRI results clinic was omitted from the pathway, as well as an inadequate explanation of the MRI result itself. It is clear that A did not understand the likelihood of cancer that prompted the biopsy and their understanding was not checked until the point of diagnosis. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and their family for the poor communication around the MRI results and the diagnostic process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Communication should be in line with General Medical Council guidance on Good Medical Practice.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their friend (A), a care home resident. A became unwell and was in a lot of pain. An Out of Hours GP suspected an internal bleed and arranged for an ambulance to be requested. A call was made to Scottish Ambulance Service (SAS) at 20:20, requesting a ‘one-hour response’ to hospital. The SAS call handler advised that the majority of responses were taking over four hours. An ambulance did not arrive until 02:21, by which time A’s condition had deteriorated and they were too ill to be moved. A was given medication and died in the care home. C complained about the delay in SAS providing an ambulance for A.

In their response to the complaint, SAS explained that they operate a priority-based system of dispatch to ensure that emergency ambulances are available to respond to the most serious and life-threatening cases in the first instance. They operate a welfare call back process when timed admission calls are unable to be met within the requested timeframe. Regular welfare calls were made to A’s care home, during which SAS apologised for the delay, checked on A’s condition, and gave worsening advice to call 999 if A’s condition deteriorated. SAS considered that the final welfare call, which was reviewed by a SAS clinician, was appropriately upgraded to an emergency response.

We took independent advice from a paramedic adviser. We acknowledged that some of the contributory factors which led to the delay in providing an ambulance for A were beyond SAS’s control. There were significant demands on their service and there were also delays in handovers at the receiving hospital. However, our investigation identified a missed opportunity to escalate the request for an ambulance following an earlier welfare call in which symptoms of faster breathing and agitation were reported, indicating a deterioration in A’s condition. Although it was not possible to say whether the outcome for A may have been different had an ambulance been provided sooner, this may have shortened the period of time during which A was in pain and distress. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the unreasonable delay in providing an ambulance for A, and for the failings identified in our investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Clinician escalation/re-triage is mandatory when welfare calls report new or concerning symptoms, especially where serious underlying pathology is suspected.
• Welfare scripts include condition-specific red-flag prompts to improve the detection of deterioration.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care that their adult child (A) received from the prison healthcare team and particularly a failure to formulate a treatment plan for ongoing symptoms of stomach pain, nausea, diarrhoea and weight loss.

The board noted that numerous tests had been carried out to investigate the cause of A’s symptoms, which had come back negative. They initially mistakenly stated that tests were negative for Irritable Bowel Syndrome (IBS), then later clarified that there is no definitive test for IBS and it is diagnosed by a process of elimination. They said that A had no formal diagnosis of IBS, but received treatment and dietary advice for this possibility. They noted that tests for Inflammatory Bowel Disease (IBD) were negative. As A did not have a diagnosed long-term or chronic condition, the board said a treatment plan was not required and they concluded that A received appropriate care.

We took independent advice from a general practitioner. We found that reasonable and thorough tests were done regarding A’s symptoms but a reasonable care plan was not put in place to address possible IBS. Staff appeared to lack a clear understanding of the difference between IBS and IBD. A had an inflammatory eye condition which is associated with IBD, and there was a failure to note this potential link and consider a referral for a colonoscopy (examination of part of the intestines with a camera on a flexible tube). If a colonoscopy was negative for IBD, this would point towards a diagnosis of IBS and a dietician referral and care plan would be appropriate to support dietary changes. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Awareness should be raised amongst clinical staff regarding the differences between IBS and IBD and the potential links between inflammatory eye disease and IBD. Appropriate care plans should be in place to manage IBS and support dietary changes, especially in a prison setting where prisoners have limited control over their food choices. Complaint responses should be factually accurate. Draft findings should be shared with relevant clinicians to ensure the factual accuracy of any clinical references.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.