Upheld, recommendations

Summary

Ms C complained on behalf of Ms A, who was diabetic, that after she had a stent (a mesh tube) inserted into her kidney in April 2013, staff at the Southern General Hospital failed to monitor or remove it. As a result, Ms C said that Ms A was caused extreme pain, which led to her having an emergency operation early in 2014 to remove her kidney. Ms C believed that early intervention with regard to the stent could have avoided this.

We took independent medical advice from a consultant urologist (a doctor who treats disorders of the urinary tract). We found that after the insertion of the stent, it was planned to remove it in July 2013. However, at her anaesthetic pre-assessment for the removal of the stent, Ms A was found to have poor diabetic control, which meant that her operation could not go ahead. Her GP was asked to inform the hospital when Ms A's condition improved so that her operation could be rescheduled. However, the hospital was never updated. The investigation also showed that Ms A's name continued on the waiting list for stent removal and this should have provided an adequate safety net, but it did not. In the meantime, Ms A's stent was removed in England. In these circumstances, we upheld the complaint about the monitoring of the stent. However, in reaching our decision we did not conclude that the failure to monitor the stent ultimately led to Ms A losing her kidney, as there was no evidence that this had been the case.

Recommendations

We recommended that the board:

• make a formal apology in recognition of the failures identified; and
• advise us of the processes that have since been put in place as a consequence of the complaint made.

Summary

Mr C complained that after breaking a bone in his foot, despite four visits to hospital over a six month period, staff at the Southern General Hospital failed to diagnose and treat him properly. As a consequence, he said that he suffered prolonged and unnecessary pain. Mr C subsequently had an operation abroad to remedy his foot problem. He then complained to the board. The board said that, generally, with the exception of his final attendance at hospital, he had been treated appropriately. However, they apologised that his final visit had been below the standard expected. They said that they had since learned from the situation.

The complaint was investigated and we took independent advice from a consultant in emergency medicine. We found that when Mr C first went to hospital after injuring his foot, he had been diagnosed with a low risk, undisplaced fracture (a break in the bone, where the two parts of the bone are still aligned) and treated accordingly. Although it was more rare, we found that he had actually suffered a high-risk, complex fracture (a Jones fracture) which required significantly different management as the blood supply to his foot could have been affected. His further attendances at hospital also failed to establish the nature of Mr C's fracture, so we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• make a formal apology recognising the failures in care and treatment identified; and
• ensure that appropriate staff in the A&E department are made aware of the circumstances of this case and the failures identified, particularly with reference to a Jones fracture.

Summary

Mr C, an advice worker, complained on behalf of his client (Mr A) who had injured his back at home while breaking wood. Mr A was seen at the practice and complained of pain, pins and needles, and numbness. Mr A asked for an MRI scan (magnetic resonance imaging scan), but was referred for an x-ray which raised no concerns. He continued to experience severe pain and numbness in his legs. Following further consultations at the practice he was advised to attend the local A&E department. He was admitted to hospital and diagnosed with a compressed disc which required surgery.

Mr C complained that the practice had ignored serious red flag symptoms of spinal injury on three occasions and considered that Mr A should have been referred for an MRI scan.

We took independent medical advice from one of our GP advisers, and found that the practice would not have been able to refer directly for an MRI scan. However, the GPs at the practice followed the wrong diagnostic pathway and, as such, failed to identify three red flag symptoms. We concluded that, had the correct pathway been followed, Mr A would have been referred urgently to a specialist.

Recommendations

We recommended that the practice:

• apologise to Mr A for failing to make the appropriate referral during his initial consultations; and
• ensure that all the practitioners involved in reviewing Mr A in this case undertake a review of their practice in relation to management of patients with lower back pain. This should include familiarising themselves with the scope of the relevant Pathway for Management of Lower Back Pain referred to in our decision.

Summary

Mr C complained about the board's role in the decision-making that he should be taken to a respite care facility (run by a private care provider) for 24 hours when he had already told them that he did not want to go, and then kept there against his express wishes. Mr C told staff when they arrived at the facility that he did not want to be there, but was persuaded to stay until the following day when his father picked him up. Mr C also raised concerns about an earlier decision by the board to instruct members of staff from the private care provider to covertly befriend him at a radio station where he was volunteering given the effect this had on him, particularly when he saw the staff members at the facility the following year.

We took independent advice from our medical adviser. We found that the board failed to act in line with the relevant legislation, which meant that Mr C's rights were not respected. We also said that it was not reasonable that Mr C was told he was going to the facility on the journey there and that this posed a risk. In relation to Mr C's stay at the facility, we found that there was a responsibility on board staff to ensure that Mr C would be returned to his home if that was his wish. The board had accepted that Mr C told staff when he arrived that he did not want to go in and refused initially to leave the car. We found that most of the healthcare professionals involved were doing everything they could to provide Mr C with treatment, despite his clearly stated wishes to the contrary, believing it was in his best interests. We were critical of the board's actions in relation to the decision that staff should befriend Mr C covertly. In doing so the board failed to respect his autonomy. It was our view that the board failed to act in a reasonable way in respect of Mr C's stay at the facility.

Recommendations

We recommended that the board:

• inform us of how they intend to ensure that decision-making capacity is assessed and clearly documented;
• review their actions in light of our findings and bring our decision to the attention of relevant board staff;
• consider using this decision as a case study to inform current practice in similar circumstances; and
• apologise to Mr C for the failings we found.

Summary

Miss C complained that a paediatric consultant carried out a manual labial separation (separation of the small inner lips around the entrance to the vagina which have become sealed together) on her young daughter at an out-patient clinic without the consent of her and the child's father (Mr B), and without anaesthetic. Miss C said the procedure had caused her daughter to suffer pain and bleeding, ongoing distress, and develop a fear of doctors.

Our investigation included taking independent advice from one of our medical advisers who was of the view that the consultant should have explained and discussed the treatment options with Miss C and Mr B, and had them sign a consent form prior to carrying out the procedure. However, there was no evidence the consultant did so. We were satisfied the consultant failed to obtain informed consent before he carried out the procedure. Our medical adviser also was of the view that undertaking the procedure without a topical anaesthetic (a local anaesthetic whereby a substance is applied directly to the skin to temporarily numb the skin) was unreasonable.

Recommendations

We recommended that the board:

• ensure that the consultant reviews his record-keeping and his practice in relation to the obtaining of informed consent;
• review their policy for the treatment of labial adhesions and consider providing parents with an information leaflet about the procedure and treatment options;
• ensure a consent document is signed by the child's parent or guardian prior to any clinical intervention being carried out;
• apologise to Miss C and Mr B for failing to obtain informed consent;
• ensure that the consultant is made aware of our adviser's comments and reflects on them; and
• apologise to Miss C and Mr B for the performing the procedure on the child without anaesthetic.

Summary

Mrs C complained about the delay in diagnosing her late husband (Mr C)'s cancer. Mr C suffered intermittent pain over about two years, following a fall. Mrs C said Mr C attended A&E at Glasgow Royal Infirmary on numerous occasions, as well as being seen by colorectal (bowel) and gastroenterology (digestive system) specialists. Mr C's cancer was first diagnosed over two years after his fall, following a scan which showed possible cancer in his liver. Mrs C raised concerns that Mr C should have been given this scan earlier.

The board considered that Mr C received appropriate treatment and investigations. They said they only had records of Mr C attending A&E on two occasions, although Mrs C said he attended numerous times.

After taking independent medical advice from A&E, colorectal and gastroenterology specialists, we upheld Mrs C's complaint. We did not find any evidence that Mr C attended A&E on more than two occasions, and we found that the care and treatment at A&E was mostly reasonable. However, on one occasion the A&E doctor did not specifically record checking whether Mr C was losing weight (which would have been a 'red flag' symptom), and we were critical of this. We found the investigations carried out by the colorectal service were reasonable and timely, and there would have been no reason for them to arrange a scan, based on Mr C's symptoms and the results of other tests and examinations at that time. We also found the gastroenterology clinic arranged appropriate investigations. However, we found there was a delay of several weeks in performing the initial investigations (including the scan) and reviewing the results, which meant that Mr C's care did not meet the Scottish Government's standards for cancer waiting times (HEAT targets).

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings our investigation found;
• raise our findings about the A&E review with the doctor involved for reflection and learning; and
• review their processes for scheduling investigations arising from suspected cancer referrals, taking into account the 62-day HEAT standard.

Summary

Mr C complained that a nurse at his prison health centre gave his medication to a prison officer to administer.

We looked at Mr C's medical records and the board's file on Mr C's complaint, and we took independent advice from one of our nursing advisers. We found that the board took Mr C's complaint seriously, and the nurse was managed in line with the board's medication safety policy. We concluded this was appropriate action to take. However, this was a serious incident which the board should have acknowledged in their response to Mr C's complaint, and for which they should have offered him an apology. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the error made in the administration of his medication;
• explain to us what steps have been put in place to prevent such an incident from occurring again; and
• provide us with a copy of a drug recording sheet.

Summary

Mr C complained that the board had contributed to the decision that he no longer needed to be managed under the Scottish Prison Service's process for prisoners at risk of suicide or self-harm (the ACT 2 Care process). Mr C had been managed under this process for a number of days, as he had carried out acts of self-harm. During that period, two medical reports had been obtained identifying that he was at risk of further self-harm, and successive case conferences had also reached the decision that he was at risk of this. However, a further case conference decided that Mr C was not at risk. A mental health nurse was a participant at this case conference and agreed with the decision reached. Mr C carried out a further act of self-harm and was put back on the process.

We took independent medical advice from our mental health nurse adviser. Our adviser said that Mr C was removed from the process on the basis that he was not suicidal, however, as it is also a strategy for minimising the risk of self-harm this was not a reasonable decision. We found that the risk of life-threatening self-harm had not been sufficiently taken into account when the board contributed to the decision to remove Mr C from the process. The adviser also said that an entry that had been made in Mr C's healthcare record was unreasonable in both tone and clinical approach to self-harming behaviour. We also upheld a second complaint that Mr C made about the board's failure to provide him with a legible copy of his completed complaint form.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for their role in the decision to remove him from the ACT 2 Care process at the meeting in question, and also for the inappropriate entry made in his healthcare record;
• ensure all relevant staff are aware of the ACT 2 Care approach to self-harm;
• make the mental health nurse involved in this case aware of the adviser's comments and ensure that this is included for discussion at their next appraisal; and
• issue Mr C with a legible copy of the complaint form.

Summary

Mr C was taking rivaroxaban (medication that thins the blood in order to minimise the risk of a stroke) when he was scheduled for non-emergency surgery. Due to the possibility of excessive bleeding during a surgical procedure, Mr C was advised to stop taking his medication seven days prior to surgery. Four days after Mr C stopped taking his medication, he suffered a stroke.

When Mr C complained, the board and Mr C's consultant appeared unclear about whether Mr C was on rivaroxaban or warfarin (another drug used to prevent blood clots, which Mr C had previously been taking). The board said they had followed guidelines for warfarin as rivaroxaban was a very new type of medication. They also said Mr C was classed as 'low risk' of stroke and the advice he was given was accurate. They said that, in light of his complaint, they would develop further protocols for staff.

Mr C complained he should not have been classified as low risk, and should not have been advised to stop his medication. We sought independent advice from one of our advisers, who is a consultant geriatrician with specific experience in stroke medicine. The adviser was clear that Mr C was given incorrect advice about stopping his medication. Warfarin guidelines are not applicable to rivaroxaban, and Mr C should only have been advised to stop his medication for 24 to 48 hours prior to the surgery. The adviser accepted rivaroxaban was a relatively new drug, however, he stressed that this meant clinicians should be more cautious and seek guidance from colleagues if they were unclear. The adviser also noted that the board did have specific guidelines for the drug and there were many more available online. The adviser also concluded, in light of Mr C's previous medical history, that he should have been classified as being at 'moderate risk' of stroke.

For these reasons we upheld Mr C's complaints. We were also critical of the complaint investigation, which was unable to clarify whether or not Mr C's consultant was aware of the type of medication Mr C was on.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• provide us and Mr C with the updated protocols regarding rivaroxaban;
• ensure Mr C's consultant discusses this complaint as part of their annual appraisal; and
• feed back to staff the importance of clarifying at the time why a situation occurred, not retrospectively.

Summary

Ms C's daughter (Miss A) was born with hydrocephalus (a build-up of fluid on the brain causing pressure), and from the age of about two years old, she began to suffer multiple infections and seizures. She was admitted to hospital on many occasions and Ms C was informed that her daughter was likely to have epilepsy. Miss A was diagnosed as having gastroenteritis (inflammation of the stomach and intestines) when she was three. Meanwhile, her seizures continued and Ms C was advised that they were probably due to her underlying fever and gastroenteritis. Ms C was unhappy as she considered that no progress was being made to establish the cause of her daughter's symptoms or to treat her properly. In the circumstances, she took Miss A to a children's hospital in another board area where she was diagnosed with a cerebral abscess and where she remained for five months.

Ms C complained of the delay in diagnosing her daughter and of the board's failure to refer her to the children's hospital in another board area for treatment. She was unhappy with the way they responded to her complaint.

We investigated the complaint and took independent advice from one of our medical advisers, who is a consultant paediatrician (doctor dealing with the medical care of infants, children and young people). We found that there had been a delay in diagnosing Miss A and that there may have been a missed opportunity to do this sooner. We also found that, while the board had intended to refer Miss A to the children's hospital in another board area, for reasons unknown, no appointment was made. We also found that there had been undue delay in providing a response to Ms C's concerns and that although a detailed letter was drafted, it was not sent. A meeting arranged to replace the letter took place months later. The complaint was upheld.

Recommendations

We recommended that the board:

• make a formal apology to recognise the delay in diagnosis;
• advise us what actions have been taken since the meeting to improve the two-way flow of communication between the hospitals identified;
• make a formal apology for their failure to respond adequately to the complaint; and
• emphasise to the staff concerned the importance of adhering to their complaints process and of the necessity for good, clear and timely communication.