Upheld, recommendations

Summary

Mr C complained about the care his late wife (Mrs A), who suffered from diabetes, received from the board. In particular he complained that when a home visit was made by a district nurse, his wife's podiatry appointment was not brought forward by the board.

During our investigation we took independent advice from a consultant podiatrist. The adviser considered that when Mrs A's diabetic foot ulcer was noted during the home visit, an urgent referral should have been made to the board's multi-disciplinary diabetic foot care service which would have given her access to vascular assessment and a vascular consultant.

The adviser, when commenting on the care given during the home visit, also referred to the podiatry care Mr C's wife received when she was admitted to Western Isles Hospital. In particular, the adviser commented that there was no record of a vascular assessment having being carried out and that this represented a failure in assessment by podiatry.

Recommendations

We recommended that the board:

• ensure podiatrists and district nursing teams have the competencies required to provide assessment for patients with diabetes and acute foot conditions;
• ensure all health care professionals are aware of the available guidance for diabetic foot conditions;
• ensure the pathways and signposting for urgent referrals are in place and implemented;
• consider the adviser's comments on referral to an acute multi-disciplinary diabetic foot care team and report back on action taken;
• ensure clinical data is available across the organisations; and
• issue Mr C with an apology for the failings identified in this investigation.

Summary

Mr C complained that, following a collapse in the street where he vomited blood, his son (Mr A) was taken to Ninewells Hospital where he was discharged after treatment for a head injury. Later that day Mr A was again found collapsed in the street and he was again taken to Ninewells Hospital where he died that evening. Mr C noted from the post-mortem report that the cause of death was recorded as a massive gastrointestinal haemorrhage (bleed) and said that had this been identified during the first visit to hospital then the outcome may have been different.

We obtained independent advice from a consultant in emergency medicine about the treatment provided during the first attendance at hospital. We found that the assessment of the cause of Mr A's collapse was reasonable. We also found that the assessment of his head injury was reasonable. However, we found that an insufficient risk assessment had been made when considering Mr A's reporting of vomiting blood and as such he should have been admitted to hospital on the first attendance or kept in for a longer period of observation. However, even if this had been case we could not say with certainty that the outcome would have been different, but we acknowledged that Mr A would have had an earlier review by clinical staff. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in this investigation; and
• share our report with the relevant staff so that they can reflect on their actions.

Summary

Mr C underwent an operation at Ninewells Hospital to remove a skin tag on his penis. He was concerned about the outcome of the operation and the appearance of the resulting scar, and he said that he was left with some disfigurement. Mr C complained that the consultant urological surgeon told him before the operation that the appearance of his penis would improve with surgery and that he was not warned that there was any risk of disfigurement. Mr C also had concerns about the standard of the operation itself, and follow-up care.

We took independent advice from an adviser who specialises in urological surgery. We found failings in the consent process. We found that there was no evidence that Mr C had been warned of the risk of scarring and that the outcome of the surgery may not meet his expectations until the day of the operation. This meant that he had not been given enough time and appropriate information to make an informed decision, particularly in light of his additional needs. We found no evidence to suggest that the standard of the operation was not reasonable and while there were failings in relation to a follow-up appointment, this was addressed by the board.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in this investigation;
• bring the failings identified in this investigation to the attention of relevant staff; and
• review the consent process and related documentation to ensure that clinicians properly obtain, and document, consent for procedures.

Summary

Mr C complained that his wife (Mrs A) was inappropriately diagnosed as having suffered a miscarriage and that she was not provided with appropriate and timely treatment.

Mrs A was in the early stages of pregnancy when she experienced bleeding. During the night, Mr C and Mrs A attended the gynaecology out-of-hours service at the Royal Infirmary of Edinburgh. After waiting, they were seen by a doctor, who examined Mrs A. A procedure was offered and it was noted that this would not harm the baby should the pregnancy still be viable. Miscarriage was recorded as being very likely and the couple were sent away to return the following morning for a scan.

The scan confirmed that the pregnancy was ongoing and that the bleeding had been caused by a haematoma (a collection of blood outside the blood vessels).

Mr C felt that the lack of scanning facilities at night time meant they had an unnecessary wait to find this out. Mr C also said that the doctor they had seen told them that Mrs A had miscarried and that he was concerned about the procedure that was offered.

After taking independent advice from a consultant gynaecologist, we upheld Mr C's complaints. The board previously acknowledged that there had been an inappropriate diagnosis of miscarriage and had apologised for this. The advice we received was that the doctor had mistaken blood clots that were present during the examination for tissue and that it was inappropriate to make a firm statement about miscarriage without a scan taking place. We noted, however, that the availability of scanning facilities at the hospital was in line with the relevant guidance. We found that there were issues with record-keeping and that the procedure offered by the doctor was not clinically necessary.

Recommendations

We recommended that the board:

• apologise for the offer of a procedure that was not clinically indicated;
• take steps to ensure that all emergency gynaecology referral notes are appropriately completed with timings and an identifiable name and grade of the doctor;
• ensure that the adviser's comments are fed back to the doctor for learning and discussion at their appraisal;
• consider whether further training for doctors working in this area is necessary to improve communication with patients suffering from problems in early pregnancy; and
• consider how electronic records of consultations can be maintained in circumstances such as these in future.

Summary

Mrs C complained on behalf of her brother (Mr A), that staff at the Royal Infirmary of Edinburgh failed to ensure he was safely transferred to a trolley. In addition, Mrs C raised concern that the incident was not properly investigated, that Mr A was not reviewed following the incident, and that the complaints handling by the board was poor.

We took independent medical advice. We found that Mr A was not transferred to the trolley in accordance with the moving and handling plan that had been put in place following his mobility assessment. Furthermore, when the incident was reported to a nurse later that evening, we were critical that the nurse did not take appropriate steps to formally record the incident on the hospital's system for reporting adverse events. We considered this would likely have resulted in the incident being investigated in a timely manner, and that Mr A would have been reviewed by a doctor sooner. We were also critical of the board's handling of the complaint. Specifically, that they had inaccurately said that a nurse had been present at the time of the trolley transfer for which they apologised. We also found that the board had not acknowledged that the porter's recollection of the transfer was contrary to the manual handling plan documented in Mr A's clinical records. We therefore upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the delay in reviewing him after the incident was reported to the nurse;
• share these additional findings with the nurse involved;
• take steps to ensure that porter staff are made fully aware of patients' mobility limitations and needs prior to carrying out inter-departmental transfers; and ensure that nursing staff are available to provide the necessary support indicated in mobility assessments;
• apologise to Mrs C for the additional failings in the complaints handling identified in this investigation; and
• provide evidence of the steps taken to address the issue related to the complaints handling.

Summary

Mrs C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). She said that an orthopaedic consultant at Hairmyres Hospital should not have referred Mrs A for a Magnetic Resonance Imaging (MRI) scan because she had metal clips in her head from surgery performed in the past.

We took independent medical advice and found that MRI scanning should not be used in patients with metal clips as this can lead to movement of the clips in the strong magnetic field.

We considered that the orthopaedic consultant had not taken an adequate previous medical history when deciding to refer Mrs A for an urgent MRI scan. However, we noted that further safety checks by radiology staff prevented the scan from going ahead. We acknowledged that the board had apologised for the distress caused to Mrs A in relation to the referral but made two further recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failure to obtain her previous medical history at the time of the consultation and for inaccurately completing the MRI request form; and
• draw these findings to the attention of the orthopaedic consultant for future learning.

Summary

Mrs C complained that the dental practice failed to deal with her complaints in a reasonable manner. We found that the practice had failed to establish in the first instance what Mrs C's complaint involved and that this resulted in a missed opportunity to resolve the complaint at an early stage. We also found that Mrs C's complaint was not acknowledged by the practice within the three working day timescale set out in the Scottish Government's 'Can I help you?' guidance for handling healthcare complaints, and that the practice did not communicate with Mrs C by her preferred method. Finally, we found that the practice's response to Mrs C's complaint was not sent to her within the 20 working day timescale that is set out in the Scottish Government's 'Can I help you?' guidance. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings identified by this investigation;
• ensure all staff are familiar with the 'Can I help you?' guidance for handling healthcare complaints;
• ensure their complaints policy is in line with the 'Can I help you?' guidance; and
• ensure that their complaint response letters comply with the 'Can I help you?' guidance, and in particular give details for contacting our office.

Summary

Mr C was referred to a urologist at Raigmore Hospital to have his history of erectile dysfunction and low testosterone investigated. Mr C raised a complaint nine months later as he had not received an appointment and was distressed by his ongoing symptoms.

The board informed Mr C that there was a long waiting list. Mr C raised further concerns that he had not received an appointment, 13 months after his original referral. It took until 19 months after his referral for Mr C to be seen by a urologist.

We took independent medical advice. We found that Mr C's wait to see a urologist was entirely unreasonable and significantly exceeded the Scottish Government's waiting time of 12 weeks for a new out-patient appointment. We were also concerned that the board had not provided evidence to show whether steps had been taken to reduce the waiting time of the urology clinic.

Recommendations

We recommended that the board:

• apologise to Mr C for the unreasonable delay in his receiving a urology appointment; and
• provide clear evidence showing the steps they are taking to meet the 12-week waiting time target for appointments in the urology department at Raigmore Hospital and what they will do in cases where they are unable to meet the target.

Summary

Mr C was admitted to Queen Elizabeth University Hospital and diagnosed with atrial fibrillation (irregular and often rapid heartbeat). He was advised at this time that he would possibly need cardioversion (treatment to restore the normal heart rhythm) and that referrals would be made for him to have a scan of his heart and an out-patient appointment with a cardiologist. Mr C complained that it took eight months to receive treatment.

We took independent advice from a consultant cardiologist. We found that there were delays in Mr C receiving the scan, an out-patient appointment and treatment. We considered that the delays were unreasonable and failed to meet the Scottish Government's 18-week treatment time target.

Although we upheld Mr C's complaint, we did not consider that the delays would have affected Mr C's overall outcome. However, there would have been additional stress for Mr C in not knowing what was happening with his care.

Recommendations

We recommended that the board:

• apologise to Mr C for the delays that occurred in relation to his treatment plan after the diagnosis of atrial fibrillation; and
• take steps to ensure the problems which caused the delays do not recur and evidence the action they have taken to prevent them from recurring.

Summary

Mr C's father (Mr A) was admitted to the Queen Elizabeth University Hospital. Mr A died there several days later. Mr C complained to us about Mr A's nursing and medical care and treatment during his admission.

We obtained independent advice from a nurse and a consultant in the care of the elderly. The nursing adviser identified failings in relation to the planning, monitoring and recording of Mr A's nutritional care and hydration and his personal care. They also identified that documentation had not been adequately completed. Mr A appeared to have suffered four falls during his admission. We found it was of concern that Mr A's falls risk appeared to have been ineffectively assessed and there was an unreasonable delay in making a referral to a falls prevention specialist. We also considered that communication with Mr A's family was unreasonable.

While we were unable to conclude that any of these failings were significant contributing factors in Mr A's death, we were satisfied that Mr A's nursing care and treatment fell below a reasonable standard and upheld this aspect of Mr C's complaint.

The medical adviser said Mr A was frail, had a history of heart disease and that there was evidence he had chronic kidney disease. While the advice we received was that a number of aspects of Mr A's medical care and treatment were reasonable, the medical adviser identified issues concerning Mr A's medications. The medical adviser also commented that there was a failure to contact Mr A's family when there was a serious deterioration in his condition. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• issue a full written apology to Mr C and Mr A's family for the failings in Mr A's nursing care and treatment and communication this investigation has identified;
• feed back the comments of the nursing adviser and the findings of this complaint to the nursing staff involved for reflection and learning;
• issue a full written apology to Mr C and Mr A's family for the failings in Mr A's medical care and treatment and communication this investigation has identified; and
• feed back the comments of the medical adviser and the findings of our investigation to the medical staff involved for reflection and learning.