Upheld, recommendations

Summary

Ms C, an advocate, told us that her client (Mr A) was referred to the neurology department at Ninewells Hospital because of continuing back pain. In November 2012, a neurologist (a specialist in diseases of the nerves and the nervous system) decided that further investigations, including an magnetic resonance imaging scan (MRI scan - used to diagnose health conditions that affect organs, tissue and bone), would not be beneficial as it was extremely unlikely that further back surgery would be considered. The following month, Mr A was admitted to hospital for a different problem but his back and leg pain were noted. An anaesthetist suggested that the neurosurgical team review him but they declined, saying he had been seen three weeks previously. Mr A continued to suffer back pain and in March 2013 his GP wrote to the neurosurgical team requesting an MRI scan, who responded saying that this would not be helpful. In June 2013, because of the level of his pain, Mr A paid for a private MRI scan which was forwarded to the neurosurgical team. Several weeks later, an out-of-hours (OOH) doctor saw Mr A, again because of his pain, and phoned the hospital about admitting him. Mr A was not, however, admitted and said that a member of the neurosurgical team refused to see him again. However, after reviewing the MRI scan the neurosurgical team did then arrange decompression surgery (used to treat some conditions affecting the lower back that have not responded to other treatments), which was carried out at the end of July.

Ms C complained that Mr A had to organise and pay for the MRI scan himself. He was concerned that his assessment in November 2012 was inadequate, and that a scan should have been arranged then. He felt that his pain and distress was not taken seriously and that the neurosurgical team should have acted on the reports from the anaesthetist and the OOH doctor. He was also concerned that his records said that he was to be treated for sciatica, which he believed unreasonably influenced his treatment, and about the length of time it took the board to respond to his complaint.

We took independent advice on this complaint from one of our medical advisers, who is a specialist consultant spinal surgeon. The adviser said that it was unreasonable not to order a scan in November 2012, and that a neurosurgeon should have ordered the test based on the evidence available at that point. The medical adviser also said there may have been undue reliance on the results of a test (the Hoover test) used by the neurosurgeon, which the adviser did not consider was an evidence-based diagnostic tool. The results of the private MRI scan informed subsequent treatment decisions by the board's neurosurgery team, and it was clear to us that they should have arranged this earlier. Their failure to do so meant that Mr A both paid for a test that was required for his NHS treatment, and endured prolonged suffering. We also found that there were several missed opportunities to consider requesting a scan and that it would have been reasonable to have referred Mr A to a spinal specialist in light of the evidence of his condition. However, the reference to sciatica was reasonable.

We found too that, given the complexity of Mr A's complaint, it was clear from the beginning that the investigation and response would take time and that the board should have better managed his expectations around this. The holding letters they sent him did not give him likely timescales for responses, and the delay in responding to his further concerns was unreasonable.

Recommendations

We recommended that the board:

• consider the use of the Hoover test as a diagnostic tool in light of our medical adviser's comments and advise us of the outcome;
• ensure the findings of this investigation are fed back to the relevant clinicians and the learning points discussed at their next appraisal;
• refund Mr A the cost of his private MRI scan; and
• apologise to Mr A for the failings this investigation identified.

Summary

Mr C complained on behalf of his wife (Mrs C) about the care and treatment she received at the Princess Alexandra Eye Pavilion. Mr C said that mistakes were made during an operation, and that his wife was left virtually blind in her left eye. Mr C also complained about the board's response when his wife complained about this.

During our investigation, we took independent medical advice from an experienced cataract surgeon. The advice we received was that the care and treatment Mrs C received was appropriate and that no mistakes were made during the surgery. Mrs C had, however, suffered two rare complications. While the advice we received was that, in general, both complications were handled well, there was a small error in relation to the first one, in that the vitrector (a machine used in eye surgery) used as a result of the complication was not tested before it was used on Mrs C's eye, and was not working. Our adviser said that this was unlikely to have had a material impact on the outcome and was not the cause of the second complication, but we were concerned that the machine was not fully tested before it was used. We were satisfied that there was no evidence that work continued on Mrs C's eye after it was discovered that the machine was not working.

We did, however, find that the complications that arose in Mrs C's case were not discussed with her before the surgery and were not included in the information leaflets that she was given. In addition, we were concerned that Mrs C was not given enough time to make a considered decision about the surgery. We were also concerned about the handling of Mrs C's complaint - in particular that the response she received to her representations contained unnecessary, confusing details and did not meet her needs.

Recommendations

We recommended that the board:

• ensure that the relevant staff members are made aware of our adviser's view that it is wise, where a vitrector has been set up, that the flow of fluid through the vitrector is checked and that a check is carried out to ensure the guillotine cutter is working before it is used;
• consider the process for informed consent for cataract surgery to ensure that it complies with guidance about informed consent, in particular, in relation to the information provided about serious or frequently occurring risks;
• draw to the attention of relevant staff our adviser's comments that where potentially serious complications have occurred it would be wise to make a note in the medical records of the discussions held with patient/relatives;
• apologise to Mrs C for the handling of her representations; and
• ensure that their written responses to complaints meet the needs of the patient in relation to tone and language etc.

Summary

Miss C told us she was not treated with reasonable courtesy during a breast screening appointment. She said she did not receive adequate information before, during, or after the appointment and was unprepared for her experience which she found both distressing and painful. Miss C said she told staff that she was afraid of hospitals, needles and the sight of blood. She complained in particular about her x-ray guided biopsy (where a special machine uses x-rays to help guide the radiologist to the site of an abnormal growth to take a tissue sample). She said she did not know what was involved with this procedure, or about the side effects or aftercare. She said she did not get the chance to ask questions or speak to anybody about it. Miss C told us the treatment room was full of people and that no introductions were made. Her treatment lasted more than four hours, although her appointment letter said that the appointment might take up to three hours.

We took independent advice on this complaint from one of our medical advisers, who is an experienced GP. We found evidence that staff checked she was available to stay for the biopsy, but not that they explained in any detail what it would entail or how long it would take. We found confused and conflicting evidence about who was present during the procedure, and it was clear that people in the room were not introduced to Miss C as they should have been. The board had already apologised for the distress Miss C experienced on the day of her appointment. They acknowledged the importance of giving information, obtaining consent and introducing members of staff. We found that Miss C was given only limited information in advance, which did not meet her needs. Although she could have taken a more cautious approach to giving consent for the procedure, it was the board's responsibility to tell her what the biopsy involved and what degree of discomfort she might experience afterwards. They should also have offered her the opportunity to ask any questions before asking for consent.

Although we upheld Miss C's complaint and made recommendations, we commended the board for meeting with her to hear from her first-hand, and noted that the tone and content of their correspondence showed that they wanted to learn from her poor experience and were willing to improve.

Recommendations

We recommended that the board:

• offer an additional apology in light of the failings identified;
• carry out a review of the information and communication needs of patients attending Assessment Clinics, particularly those attending on recall, to ensure that at each stage patients can make informed and supported choices prior to giving their consent; and
• remind staff with responsibility for handling complaints of the correct procedures to follow.

Summary

Mrs C complained about the care and treatment she received in the Royal Alexandra Hospital. She had been transferred there from a community hospital in another board's area after injuring her upper back and neck.

We obtained independent advice on the complaint from one of our medical advisers, after which we upheld both of Mrs C's complaints. We found that although Mrs C was triaged (triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are) within ten minutes of arriving in the hospital, there was some confusion about whether the orthopaedics team (who deal with conditions involving the musculoskeletal system) were told that she had been transferred there. She was not seen by a doctor from that team until nearly four hours after her arrival. During this time, staff in A&E failed to escalate the matter to ensure that she was seen by a clinician, and failed to record her neurological status. After Mrs C was eventually seen by the orthopaedics team, there was then a further 45-minute delay before she was reviewed by a more senior doctor and an additional delay in obtaining a CT scan (a scan that uses a computer to produce an image of the body).

We also found that, although it had been reasonable for staff to carry out a rectal examination (a physical examination during which a doctor or nurse inserts a finger into the rectum/back passage) to assess the extent of Mrs C's spinal injury, this was not adequately explained to her. The overall quality of the medical notes was good, but there was a failure in relation to the prescription of morphine in the drug chart. There was also a delay in arranging an ambulance for Mrs C when it was decided that she should be transferred to the national spinal injuries unit.

Mrs C also complained about the board's handling of her complaint. We found that their investigation into the problems in her care was inadequate. There was no in-depth review of the communication failures that caused the delay in her being reviewed by the orthopaedics team, and formal statements had not been taken from the key members of staff involved in her care and treatment to establish their views directly. As a result of all of this, opportunities both to identify a possible cause of the poor experience she had and to learn and rectify behaviours and improve care for the next patient were lost. In addition, the board delayed in responding to the complaint.

Recommendations

We recommended that the board:

• carry out an significant clinical incident review regarding the care and treatment provided to Mrs C;
• remind staff in the orthopaedics team to clearly explain the need for a rectal examination to patients before it is carried out;
• provide evidence that they have taken steps to try to prevent the recurrence of the problems that occurred in relation to the handling of Mrs C's complaint; and
• issue a written apology to Mrs C for the failings identified during our investigation.

Summary

Mr C complained about the board's handling of his complaint. He had tried to speak to staff about a friend in hospital, and complained that the staff gave him inaccurate information about the board's policy on restrictions on providing information about patients. When the board investigated the complaint they also provided inaccurate information in their response, although they still maintained that staff were acting in the patient's best interests.

We found that the board had apologised for the inaccurate information and that all staff had been made aware of the correct procedure to follow in future. However, we were concerned that the investigation into Mr C's complaint took six months and should have been resolved much earlier.

Recommendations

We recommended that the board:

• apologise to Mr C for the time taken to resolve his complaint.

Summary

Mrs C, who is an advice worker, complained on behalf of her clients (Mr and Mrs A) that there was a delay in diagnosing Mr A's cancer.

During our investigation, we took independent advice from one of our medical advisers, following which we upheld Mrs C's complaint. The adviser said that there was an unreasonable delay in the diagnosis of Mr A's cancer. Two abnormal chest x-rays should have been reported to the clinicians caring for Mr A, which would have prompted them to consider further investigations. This did not happen and was a failure in care. We noted that the board had accepted that the diagnosis of cancer should have been reached sooner, which might have enabled treatment to have started earlier and afforded Mr A an improved outcome. We noted that the matter was to be discussed by the appropriate clinical staff to increase staff awareness of this type of situation and to take more appropriate action in the future.

Recommendations

We recommended that the board:

• report back to us on the outcome of the discrepancy meeting attended by the Head of Radiology to discuss this case.

Summary

Mr C was diagnosed with alopecia (hair loss) as a child. It became progressively worse and he now suffers from alopecia universalis (a condition where a patient has no body hair). Mr C's GP referred him to Aberdeen Royal Infirmary where he saw a consultant dermatologist. Mr C complained about the care and treatment he was given which he believed was neither reasonable nor appropriate. He said that he had been forced to take medication that was ineffective and possibly had long-term side effects. He questioned his treatment plan and said that he had not been properly reviewed. Mr C was unhappy that he had not been prescribed an experimental treatment and said that the board did not provide him with appropriate support.

We took independent medical advice on the complaint from a dermatology specialist. Our adviser said that alopecia universalis has a very poor prognosis and that there is little or nothing that is effective in its treatment. The treatment given to Mr C was reasonable and appropriate and in accordance with his symptoms but, given the devastating consequences of this condition, we upheld his complaints as our adviser said that the board did not go as far as could have been reasonably expected to treat him. They did not seek support from neighbouring health board services or try to establish whether there were medical trials that might assist him. Their follow-up was poor, as a consequence of which he was effectively discharged and lost his wig entitlement, and had to visit his GP again for a further referral. Our adviser said that the board were, however, correct to refuse him the unlicensed treatment that he sought.

Recommendations

We recommended that the board:

• make a formal apology for their oversights in this matter;
• bring our findings to the consultant dermatologist's attention for him to reflect upon;
• make a formal apology in recognition of these failures; and
• emphasise to staff the importance of responding to complaints in a full and timely manner.

Summary

Mrs C told us that she suffers from fibromyalgia (a long-term condition that causes pain all over the body) and attends a pain clinic. In 2012, she began to experience further pain, which she did not believe was as a result of fibromyalgia. She said that she was virtually suicidal but that clinicians failed to investigate alternative sources for her pain and continued to treat her for fibromyalgia. She said that she should have been x-rayed or scanned and that the board's failure to do so meant that the true nature of the problems with her spine were not identified.

We took independent medical advice from consultants in rheumatology and orthopaedics. We found that while it was more than likely that Mrs C had fibromyalgia, her diagnosis had not been confirmed by a specialist. When Mrs C began to suffer further pain, advice was taken from another practitioner who admitted that this was not his area of expertise. Our advisers said that while the subsequent advice given to Mrs C was mostly correct, it may have been misleading and advice should have been sought from a specialist. Doctors did not carry out further investigations into her pain to exclude either another diagnosis or a further illness.

Although our advisers did not agree that Mrs C needed an x-ray or scan, we upheld her complaint, as we found that the board had failed to carry out an appropriate investigation into her pain.

Recommendations

We recommended that the board:

• make a formal apology for their shortcomings;
• review their system for diagnosing fibromyalgia and confirm to us that they are satisfied that it is fit for purpose and sufficiently robust;
• ensure that details of the complaint are brought to the attention of the speciality doctor and the associate specialist concerned; and
• consider our adviser's comments about including reference to cervical spondylosis (neck pain caused by age related wear and tear) in the diagnosis.

Summary

Mr C is elderly and has dementia. His wife (Mrs C) complained to us about failings in her husband's nursing care during a stay at Cameron House Hospital. These included delays in taking Mr C to the toilet, delay in receiving medication for constipation; lack of stimulation; failure to supervise Mr C, which led to him falling several times; and poor nutrition, which caused him to lose weight. Mrs C said that her husband had suffered a urine infection and that nursing staff did not ask a doctor to test him for this and that he contracted MRSA (a bacterial infection resistant to a number of widely used antibiotics). She was unhappy with the attitude of nursing staff, both towards her and Mr C, and said that they failed to communicate with her about Mr C's care.

We took independent advice from a nursing adviser who said, after considering Mr C's medical records, that his care was reasonable. However, the adviser said that it was clear that staff failed to appropriately communicate with Mrs C about her husband's care and treatment. In addition, there was a failure to ensure Mrs C's views were listened to and acted on. The board had accepted there were some failings in how members of staff communicated with Mrs C, and in record-keeping. They had apologised to Mrs C and put an action plan into place to deal with this.

We took the view that this failure in communication understandably led to a breakdown in the relationship between Mrs C and nursing staff, causing Mrs C to lose confidence in the staff caring for her husband. We accepted that Mrs C had a genuine belief that there was a failure to meet Mr C's care needs. In addition, we also found that there was a lack of support and reassurance from nursing staff to help Mrs C cope with the distressing and worsening nature of Mr C's dementia. We were critical of the apparent lack of empathy by staff, given that caring for relatives is a key part of the healthcare professionals' role. We upheld Mrs C's complaint and made two recommendations for further action.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings identified; and
• provide a copy of the action plan and an updated report on the implementation of the plan.

Summary

Mr C had concerns that, when his late mother-in-law (Mrs A) was discharged from hospital to a nursing home, staff failed to inform the family about the existence of the NHS continuing healthcare procedure and that as a result there were financial implications for Mrs A. The board maintained that Mrs A's medical records contained details about communication with Mrs A's family about her discharge from hospital and that the family were satisfied that placement in a nursing home was appropriate. We upheld the complaint as we found that, although the records showed that there were frequent discussions with Mrs A's family about the plans for her discharge, there was no specific mention of the NHS continuing healthcare procedure.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to advise the family that there was an appeals procedure where there is a disagreement about the decision to provide NHS continuing healthcare;
• issue a written apology to Mr C for the failure to specifically record at discharge that consideration had been given to NHS continuing healthcare; and
• remind staff of the requirement to communicate with patients and carers about the procedure for NHS continuing healthcare and ensure that decisions are recorded in the medical records.