Upheld, recommendations

Summary

Miss C decided to proceed with a surgical procedure (to divert the normal flow of urine from the kidneys and ureters into a specially created stoma) to address urine incontinence when other procedures had failed. As a result of the operation, which was performed at the Southern General Hospital, Miss C said she suffered from urinary infections and altered acid-based metabolism (tendency for the blood to become more acidic than normal that required medication) and that she had not been informed of any possible side effects or complications of the procedure beforehand.

We took independent advice from a medical adviser who specialises in urological surgery. We found that while it was documented that medical staff had several discussions with Miss C about the procedure, they failed to document the details of the consent discussions and it was not possible to determine if the risks were discussed with Miss C and understood by her before the operation. Therefore, we were not satisfied that Miss C was fully informed of the risks and in a position to give informed consent.

Recommendations

We recommended that the board:

• review the consent form to ensure that discussions between patients and clinicians about possible risks and complications are clearly recorded;
• bring the failings in record-keeping to the attention of relevant staff;
• consider the adviser's comments in relation to the use of information leaflets; and
• apologise for the failings this investigation identified.

Summary

Mrs C complained that there was a four-month delay in the board carrying out her six-month follow-up scan at Gartnavel General Hospital to monitor her condition. When Mrs C had the scan done, it showed secondary cancer which she felt could have been avoided had her care plan been properly followed. In responding to the complaint, the board accepted that there had been an administrative error and apologised to Mrs C. They said that the scan would likely have gone ahead had a return clinic appointment been made then and took steps to remind administrative staff of their responsibilities. However, Mrs C remained concerned that the board were unable to explain why the error had occurred and if adequate steps had been taken to avoid the matter recurring.

We took independent advice from a consultant urological surgeon and found that the delay was unreasonable and not in line with local guidance. However, we considered that Mrs C's prognosis would not have been significantly affected had the scan and treatment been done sooner. We concluded that there was a lack of evidence to demonstrate whether or not the form requesting the scan was mislaid by either clinical or administrative staff or whether the urology doctor had in fact completed it in the first instance. Whilst an electronic system is now in place which will assist in reducing the likelihood of paper forms going missing, we made a recommendation to address the matter and we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• demonstrate what systems are in place to ensure that scan results are reviewed by the clinician responsible for the patient's care and that further monitoring takes place where appropriate; and
• draw these findings to the attention of the clinical team responsible for Mrs C's care.

Summary

Mrs C's late husband (Mr A) was admitted to Glasgow Royal Infirmary with numerous fractures following a fall. After eight days in hospital, his condition deteriorated and he died of a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Mrs C raised concerns about the orthopaedic, medical and nursing care and treatment provided saying that Mr A had not been given the best opportunity to survive given the failures in care.

We took independent advice from several medical advisers and a nursing adviser. We found that the treatment decisions to reduce the risk of pulmonary embolism were reasonable and that the risks of a pulmonary embolism could not be eliminated completely. Having said that, there was a missed opportunity for a more senior specialised medical review during this period as Mr A's National Early Warning Score (NEWS), a guide used to determine the degree of illness of a patient, was at a level that should have triggered an escalation of clinical care. We also found that there was poor record-keeping, and these failings resulted in unnecessary distress to Mrs C and her husband. In relation to nursing care, we also found record-keeping failings and a failure to alert medical staff of Mr A's deterioration during this period. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• ensure record-keeping by medical staff complies with relevant guidance;
• bring our findings to the attention of relevant medical staff;
• take steps to ensure healthcare professionals comply with the NEWS guidelines or clearly set out the rationale in patients' clinical records for non-compliance;
• ensure record-keeping by nursing staff complies with relevant guidance;
• bring our findings to the attention of relevant nursing staff; and
• apologise for the failings identified.

Summary

Mr C complained about the board after they shared a letter containing sensitive information about him with his school. He said that he had made it very clear that he was not comfortable with information being shared in this way and felt that his confidentiality had been breached.

Mr C then wrote to his doctor, outlining his concerns and explaining that these circumstances had caused him a great deal of distress and anxiety. His doctor responded, apologising if she had misunderstood but had thought that consent had been given by him for this to happen. Mr C remained dissatisfied with this response, as he did not feel that his complaint had been taken seriously.

We found that Mr C's complaint had not been formally investigated through the board's complaints procedure. His doctor had also noted in her records that she intended to seek consent from Mr C at their next appointment. However, the notes for the appointment in question did not contain clarification on whether or not consent had been asked for or given. We took independent advice from an adviser, who stated that they did not consider it to be reasonable to share sensitive information without consent being clearly given and recorded. We accepted this advice and, as such, upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C both for breaching his confidentiality and for the on-going distress and anxiety that this breach has caused him; and
• apologise to Mr C for not properly escalating his concerns and investigating them through their complaints procedure.

Summary

Mrs C complained on behalf of her son (Mr A) about the severe toe pain he suffered since undergoing a total nail avulsion (complete removal of the toenail) in 2013. Mr A had been seen by podiatry staff on a number of occasions following the surgery. As a result of the severe pain, Mrs C said that Mr A had lost his confidence and been unable to undertake his usual activities. Mrs C was concerned that a number of investigations, tests and referrals appeared to be undertaken only when she complained to the board two years after the initial surgery.

We took independent advice from a medical adviser. They said that the treatment decisions were reasonable in light of the main post-operative complications associated with a nail avulsion. However, while the initial referrals, tests and investigations appeared to be carried out within a reasonable time, repeating the surgical and other investigations when previous investigations had not provided a diagnosis to the problem delayed referral onto a specialist pain team. We found this to be unreasonable, so we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• review their processes to ensure referrals to specialised pain teams are made within a reasonable time;
• bring our decision including the adviser's comments to the attention of relevant staff; and
• apologise for the failures our investigation identified.

Summary

Ms C and her cousin (Mr A), complained about the care and treatment Mr A's late mother (Mrs A) received at Kincardine Community Hospital. Mrs A had dementia and had been admitted to Kincardine Community Hospital from Aberdeen Royal Infirmary for a period of rehabilitation following a fall at home. Ms C and Mr A also complained about the board's handling of their complaint.

Mr A said that he raised concerns with nursing staff about his mother's care while she was a patient in Kincardine Community Hospital, in particular, in relation to her developing pressure ulcers. Staff at the hospital and Mr A were also not told for several weeks that Mrs A had been diagnosed with a pelvic fracture while she was in Aberdeen Royal Infirmary. When Mrs A was discharged to a nursing home she was found to have a pressure ulcer on her sacral area (at the base of the spine) but Mr A had not been informed about this.

We took independent advice from a nursing adviser who said there were serious failings in record-keeping and in compliance with guidance and best practice on the prevention and management of pressure ulcers. As a result, Mrs A's care was random and left to chance. Furthermore, although Mrs A was at high risk of developing pressure ulcers, there was a delay in managing her as high risk. We also found that the pelvic fracture incident had not been recorded as it should have been and there were failures in communicating with Mr A concerning aspects of Mrs A's care. Overall, the advice we received was that the standard of nursing care provided to Mrs A was very poor and we were critical of those failings.

In relation to the board's handling of Ms C and Mr A's complaint, although the board had apologised to them and had carried out a significant event analysis (SEA) we found that the board had not identified and acknowledged serious failings with Mrs A's nursing care and that, overall, the board's complaints handling was poor.

Recommendations

We recommended that the board:

• feed back the findings of the investigation to relevant staff, for reflection and learning;
• provide us with an action plan to address the failings identified in relation to record-keeping; skin and tissue viability care (to include a review of the education and training of nursing staff in skin and tissue viability care); and communication;
• apologise to Mr A and Ms C for the failure to provide reasonable care to Mrs A;
• feed back the findings of this investigation to the relevant staff who were involved in the SEA and complaints handling and reflect again on Mrs A's complaint by reviewing what went wrong with her care;
• consider a review of their SEA process and the training of staff who carry out such reviews, and give consideration to whether there should be an external independent review of how this is undertaken;
• provide evidence that the pelvic fracture incident has been reported and the date when it was recorded on the system;
• provide evidence of the review process concerning discharge documentation; and
• apologise to Mr A and Ms C for the failings to respond reasonably to their complaints.

Summary

Mrs C complained about a number of issues regarding her care and treatment at the Golden Jubilee National Hospital. She was also unhappy about the way in which her complaint was handled.

Mrs C was concerned about the lack of action by a doctor between November 2012 and September 2013 which she felt impacted on a decision taken in August 2014 that she required further heart surgery. Mrs C also complained about the actions of a second doctor in dealing with her care given that he was aware of her dissatisfaction with the first doctor.

We took independent advice from a cardiologist. We found that the first doctor unreasonably delayed in discussing Mrs C's case at multi-disciplinary team meeting and in reviewing Mrs C, which meant that her symptoms would have persisted unnecessarily causing her distress. We made a recommendation about this.

However, we did not consider that these delays would have impacted on Mrs C's need to undergo further surgery. We considered that the second doctor's actions were reasonable and noted that Mrs C had been given an apology about the delays in the management of her earlier care.

We concluded that the handling of Mrs C's complaint fell below a reasonable standard because the hospital initially dealt with it outwith their complaints procedure and because of the time they took to complete their investigation. We made a recommendation to address this.

Recommendations

We recommended that the board:

• share these findings with relevant staff involved in Mrs C's care to ensure timely case discussions and follow-up reviews are carried out;
• share these findings with relevant staff in order to ensure that staff dealing with complaints inform people of their right of appeal to us on complaints which have been time barred; and
• ensure that relevant staff provide timely responses in terms of their complaints procedure and apologise to Mrs C for failing to handle her complaint within a reasonable timescale.

Summary

Mr C complained to the board about the treatment they offered him for an injury he suffered to his knee. He had originally attended a GP at the prison health centre and received an x-ray which showed no problems. It was therefore decided that he should attempt physiotherapy and return if the pain persisted. However, when he requested a further appointment to see the GP because he felt he should have a scan, his request was triaged by a nurse who advised that as his x-ray had been normal, he did not need an appointment or a scan.

We took independent advice from two advisers, one a GP and one a nurse. We found that Mr C's records showed that after the x-ray, his GP mentioned that a scan may be required if problems persisted. The advisers confirmed that the nurse in question should have consulted a GP and that, in line with national guidelines for the management of knee pain, further investigation would have been appropriate in the circumstances. As such, we upheld the complaint.

Recommendations

We recommended that the board:

• bring the failings to the attention of relevant staff;
• review their clinical decision-making in light of the relevant guideline;
• review the triage system to ensure that decision-making is made appropriately within the clinician's scope of expertise;
• apologise to Mr C for the failings identified; and
• arrange for a further GP assessment of Mr C's knee, if this has not happened already.

Summary

Mr C complained that a surgeon failed to properly carry out a laser prostatectomy (surgical removal or resection of the prostate gland) at the Queen Margaret Hospital causing him severe pain, blood loss and the need for further surgery two weeks later.

The board advised Mr C that the surgeon was assisted by a mentor experienced in this type of surgery, and no complications occurred during the procedure. However, they apologised that Mr C had experienced the recognised risk of post-operative bleeding. Mr C remained unhappy that there was a need for more surgery to address his pain and bleeding.

The laser surgery carried out is a relatively new technique which has not be universally adopted by urologists. We took independent advice from a consultant urological surgeon who has undertaken laser prostatectomy. We found evidence of poor record-keeping which fell below a reasonable standard in relation to Mr C being properly informed about all the risks associated with the laser surgery. We were also critical that there was no record of the surgeon's mentor having been present during the operation. Whilst we considered that there was no evidence of damage having been caused, the treatment was inadequate in removing tissue that was causing obstruction. We therefore upheld Mr C's complaint and made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified;
• draw to the surgeon's attention the findings in relation to obtaining informed consent; and
• inform us of the outcome of their review and any action taken in relation to the surgical recording process.

Summary

Mr C attended the practice on three occasions between 2010 and 2013 for blood glucose tests (a standard test for blood sugar levels, used in diagnosing diabetes). Mr C was not diagnosed with diabetes until a fourth blood test later in 2013. He has complained that, based on these test results, the practice could have diagnosed his diabetes earlier than they did.

We took independent advice from a GP adviser. They noted national guidance and the protocols in place in the practice for diagnosing diabetes. They also reviewed the test results from Mr C's blood glucose tests. They identified that it was not clear whether the first test, in 2010, had been a 'fasted' blood sample (ie whether Mr C had been told to fast prior to the blood test). They noted that this would have had an impact on what further action was appropriate. Given that the GP involved at that point had since retired, and that the actions could have been reasonable, they were not critical. However, the second blood test results showed concerns and should have been immediately responded to. Instead, Mr C was advised to return for another test in six months. When he had another blood test 18 months later, the test results were conclusive of diabetes, and the adviser noted that the error in identifying this had already been picked up by the practice in their response to the complaint.

We concluded that the GP had not taken reasonable steps in their response to Mr C's second blood test, as further tests should have been taken at that time. We agreed with the practice's assessment of their response to Mr C's third blood test. We were also concerned that the local protocols in place for the assessment of blood glucose results did not fully reflect the national guidance.

Recommendations

We recommended that the practice:

• ask the GP involved to consider reviewing this case in conjunction with the World Health Organisation (WHO) Guidance on the diagnosis of diabetes and identifying any learning point at their next appraisal; and
• review their protocols for the management of abnormal diabetic blood results, to ensure they are in line with the WHO Guidance.