Upheld, recommendations

Summary

C complained about the ear, nose and throat surgery (ENT) that they received from the board. C was referred for surgery for biopsy of a nasal ulcer that would not heal, and for treatment of a nasal drip. C complained that the biopsy had not been taken as expected, which they were not aware of until making a complaint. C also complained that they had been left worse off due to a perforation being caused during the procedure. This has caused them to have an audible whistling sound when they breathe. C said that, while the risk of perforation had been mentioned at the outpatient appointment, they were led to believe it was not something they had to worry about. Furthermore, they were not told that if it happened, it wouldn’t heal naturally, and surgery to fix it often fails.

The board explained that the biopsy had not been taken as the ulcer had healed by the time C attended for surgery. The board apologised for the perforation. They noted that the surgeon was not aware of one occurring before in their career but had since changed their practice to ensure it was discussed when obtaining consent.

We took independent advice from an ENT adviser. We found that C had not been reasonably consented for surgery at the outpatient clinic or on the day of surgery. We noted that the documentation did not support the reported discussions which took place about the surgery or the associated risks, or the implications should C have decided not to proceed with the procedure. We also found that the written information provided to C was unreasonable. The patient information leaflet did not provide information about the short and/or long-term implications of a perforation or that it may occur after the surgery has taken place. It did not note that it was unlikely to heal on its own, that surgery to correct it may not be an option or, if attempted, successful.

We considered that C had received reasonable post-operative care and follow-up from the board. It was reasonable to plan to see them back at 3 – 6 months, and for this to be expedited at the point of C reporting their concerns about the whistling noise that had developed. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in relation to the consent process for surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be reasonably consented for surgery and this should be documented in the patient’s medical record and on the consent form for the planned procedure.
• Patients undergoing septoplasty surgery should be given appropriate verbal and written information about the procedure. Risks and complications should be fully explained to allow patients to make an informed decision.

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 late parent (A) received whilst in hospital following a stroke. C said that the board failed to provide appropriate nutrition for A when they lost the ability to swallow. A required a percutaneous endoscopic gastrostomy (PEG) feeding tube to be fitted (a tube passed into the stomach through the abdomen to provide a means of feeding). However, there were delays with this and A died shortly after the procedure was carried out. C was concerned that other types of feeding were not considered by the board and that staff were not appropriately qualified to deliver alternative feeding.

The board said as soon as it became apparent that a PEG feeding tube would be appropriate, a referral was made to have this done. A dietician identified another method of feeding called TPN (a type of nutritional fluid administered to a patient intravenously) however, ward staff were concerned that they were not trained on how to deliver this method of feeding. As such, a decision was taken to expedite the referral to have the PEG tube fitted instead.

Before surgery could take place, A had to be tested for COVID-19. The results of the test were not back in time for surgery to be carried out on the day it was initially scheduled. The board apologised for the delay that this caused.

We took independent clinical advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the clinical decisions made in the management of A’s nutrition were reasonable. TPN feeding is not typically used in cases like this one. The standard of care was in keeping with guidance and was of reasonable quality. However, the delay in receiving the results of the COVID-19 test, and the failure to expedite this, was unreasonable. This led to the delay in treatment. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in receiving the results of the COVID-19 test that led to a delay in A having a PEG tube fitted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Obtaining the results of tests required before surgery should not be delayed. In cases where surgery is urgent, tests should be expedited where required to ensure that they are received timeously in order to avoid delays in the patient receiving surgery. When delays are experienced, the reasons for this should be noted in the medical records.

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, a support and advocacy worker, complained on behalf of their client (A) about the care and treatment that A received from the board in relation to a planned gynaecology (relating to the female reproductive system) surgical procedure. Following a discussion with the operating consultant on the day of the surgery, A said that the planned procedure was changed from a keyhole subtotal hysterectomy (removing the main body of the womb and leaving the cervix in place) to a keyhole total hysterectomy (removing the womb and the cervix). A said that they felt they had been put under pressure to accept the operation, and did not understand the consequences of losing their ovaries.

A’s surgery was carried out at a private sector hospital by the board’s surgical team due to the board experiencing issues with theatre capacity at that time. During the operation, a complication occurred which caused A to bleed and the procedure was converted to an open procedure to manage the bleeding. Having complained about the matter, the board explained to A that an issue with equipment during the surgery meant that the correct equipment had not been available during the procedure. A complained to the board on two further occasions in order to gain more understanding about the complication and the issue with the equipment which had occurred during the operation. A felt that the board’s responses were contradictory and asked C to complain to this office on their behalf.

We took independent advice from a consultant gynaecologist. We found that there were failings in relation to the process of consent at both the pre-operative clinic and on the day of surgery. We also found failings in relation to the documentation of the operation, including the complication and the way this had been managed during the procedure, and in the equipment log of the surgical instruments used during the procedure. To manage the bleeding, we found that the choice of equipment used had been unreasonable, noting it was likely this would have caused further tearing and bleeding, as appeared to have happened in this case. We found that the post-operative communication with A had been unreasonable in relation to the explanation given regarding the complication, and in relation to the change of procedure and the implications of this on A’s future health. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Operations should be carried out to a reasonable standard. Operation notes should provide a clear record of the procedure carried out and include relevant information about technique, and of significant findings and incidents and on the management of same.
• Patients should be given complete and accurate information during the consent process for surgery to enable them to make informed decisions about the planned procedure. Discussions with patients should be fully documented in the medical record and include key areas of discussion in relation to the pros/cons of the procedure; the risks associated with the procedure generally; and with reference to any specific risks for the individual patient.
• Post-operative communication with patients should be informative and transparent. The discussion should be documented in the medical record.
• When significant failings become apparent via the complaint process, the board should commence an internal risk management review process, appropriate to the circumstances of the case.

In relation to complaints handling, we recommended:

• Complaint responses should be clear and fully respond to the issues raised. This should include a full explanation of what occurred and a description of what happened and/or what should have happened at the time.

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 failed to provide their spouse (A) with reasonable care and treatment during an in-patient admission to hospital for a fractured hip. C who is A’s Power of Attorney also complained that the board failed to communicate adequately with them and A’s family.

We took independent advice from an orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found that the board had failed to provide A with adequate care and treatment, particularly in relation to pressure care management. We found that the board had failed to maintain a reasonable standard of care records. We also found that the board failed to communicate adequately with C and A’s family. Therefore, we upheld C’s complaints. Additionally we found that the board failed to adequately investigate C’s complaint and made a recommendation to address this.

In response to our enquiries during our investigation, the board sent us a detailed list of actions that they have taken to address and learn from the failings we identified. We considered that these were reasonable, but that further learning could be identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failings in communication identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the failings in the board’s complaint handling identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide C with a copy of the action plan (redacted to remove any personally identifying or otherwise sensitive details) and an update on the progress of implementation.

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

• All relevant documentation including the nursing notes should be completed in accordance with the relevant policies and guidance.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure.

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 medical practice failed to provide their late parent (A) with reasonable care and treatment after A fell and hit their head. A had sustained a subdural haematoma (where blood collects between the skull and the brain). A was cared for in their home and later admitted to hospital. A died a few months after their fall.

We took independent advice on this complaint from a GP. We found that the head injury assessment was unreasonable and not in line with NICE guidance. We were critical that the practice did not acknowledge this failing in their complaint response, the significant adverse event review (SAER) or in response to our enquiries. We found that it was unreasonable that concerns raised by C, after A’s fall, did not prompt further action by the practice. We also noted that the clinical notes did not adequately describe the head injury and there was no evidence that the practice understood the significance of the head injury and communicated that to the medical service they referred A onto. Therefore, we upheld this part of C’s complaint.

C also complained that the practice unreasonably failed to carry out a SAER in line with the relevant Healthcare Improvement Scotland Guidance. We found that the initial SAER was of poor quality. The enhanced SAER was in line with the guidance, but we were again critical of the quality. Therefore, we upheld this part of C’s complaint.

We also found that the practice’s complaint handling did not mirror the current Model Complaints Handling Procedure. Therefore, we made a recommendation to address this.

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/information-leaflets.

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

• Significant adverse event reviews should be reflective and learning processes that involve the appropriate staff and ensure failings are identified and any appropriate learning and improvement is taken forward in line with relevant guidance.
• When a red flag situation is reported such as a head injury this should be appropriately assessed, including the presence/exclusion of red flags and documented in line with relevant guidance. If further symptoms are reported, all the available information should be considered and action taken as appropriate. Red flag situations such as a head injury should be appropriately reported to other agencies involved in the patient’s care Head Injury: assessment and early management May 2023.

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 provided to their late spouse (A) who had chronic obstructive pulmonary disease (COPD, a group of lung conditions that cause breathing difficulties). A was admitted to hospital as an emergency with kidney failure, and high blood acid and potassium levels. A died the following day. The cause of death appeared to be a cardiac arrest resulting from high potassium, in the context of coronary artery disease.

C complained that A should not have been stepped down from the critical care unit to a medical ward resulting in a lack of monitoring and timely treatment for A and that A had inappropriately been deemed DNACPR (do not attempt cardiopulmonary resuscitation). C also said that the board’s review into A’s death failed to identify or acknowledge clinically significant evidence and that communication and provision for bereaved families was poor.

We took independent advice from a consultant in acute and general medicine. We found that while it was reasonable for the board to have considered moving A to a general medical ward, an arterial blood gas test conducted prior to the transfer had indicated that A’s condition was deteriorating. This test was not acted upon. We were also critical that the board had missed the significance of these test results during their complaints investigation. Furthermore, while the process for declaring a DNACPR was reasonable, we found that the way in which this had been explained to C had been lacking. We also noted that while the board had confirmed that facilities for bereaved families were available, they were not utilised for A’s relatives on this occasion. Therefore, we upheld all of C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that the board’s critical care governance review into A’s death unreasonably failed to identify or acknowledge clinically significant evidence. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for failing to provide reasonable facilities for bereaved families and for failing to provide a reasonable level of communication to the family during A’s admission. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Adequate procedures should be in place to ensure that all arterial blood gas results are reviewed and acted upon by clinical staff. Appropriate clinical assessment and patient observation should be carried out when a patient is admitted to a ward and the patient should be monitored thereafter. Patient admission documentation should be completed in a timely manner.
• Communication and terminology used when talking to a patient’s family should be clear and easily understood. In relation to a DNACPR decision, the resuscitation process should be clearly explained to patients and, where appropriate, their families with the use of easily understood lay terms and in accordance with NHS Scotland’s Cardiopulmonary resuscitation decisions guidance. Notification of a patient’s death should be delivered in person where possible in an appropriate environment e.g. a relative’s room.
• Critical Care Clinical Governance reviews should be comprehensive, accurate and productive. Where adverse event(s) occur, an adverse event review should be held in line with relevant national guidance to ensure there is appropriate learning and service improvements that enhance patient safety.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures. They should fully investigate and address the issues raised and appropriately identify and action learning.

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 they received from the board. C attended hospital to have their gall bladder removed by laparoscopic cholecystectomy (keyhole surgery). The surgery was abandoned and C did not understand why. C also complained that communication was unreasonable.

The board advised that C had a high body mass index which made the operation challenging. This was explained at C’s first consultation. Prior to the operation C was referred to the high risk clinic and the risks of the operation were fully discussed with an anaesthetist. The surgeon was also appropriately consulted by email. During the operation, C became wheezy and medication was administered to manage this. When C had stabilised, the operation had to be abandoned because the surgeon was unable to visualise the gall bladder and therefore could not safely complete the surgery laparoscopically.

We took independent advice from a consultant general and colorectal surgeon (specialist in conditions of the colon, rectum or anus). We found that the decision making in surgery was appropriate and that the team had made a reasonable effort to explain why the surgery had been abandoned. However, we found that C could have been referred to weight management services when they were first put on the waiting list for surgery and that the high risk clinic was only six days before the operation, which was not enough time for C to fully consider the risks. We also considered that the surgeon should have been at the high risk clinic to discuss and assess the situation with C and that advice should have been sought from a regional specialist bariatric centre prior to proceeding with surgery. Therefore, we upheld both parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not cancelling the operation and not recommending non-surgical options. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for not writing to them directly, for not ensuring that they fully understood the risks of surgery and the importance of the liver reducing diet and for not fully discussing non-surgical options. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Ensure that all clinicians write directly to patients and use ‘plain English’ in these letters.
• That specialist input is sought from a regional bariatric centre/specialist before deciding whether or not to proceed with surgery for a severely obese patient. (especially if the surgery is for a condition which is not life limiting).
• When a concern is raised by the pre-operative assessment clinic regarding a severely obese patient, there should be multi-disciplinary involvement, including the surgeon in the high risk clinic so that the BRAN methodology can be genuinely utilised, including for the “alternatives” and “doing nothing” options.

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 they received from the community mental health team, after C was referred due to suicidal ideation. C said that they did not have a reasonable level of contact with the team and had difficulty changing the frequency of a prescription. C also said that the board unreasonably made reference to a historical referral to a befriending service in their complaint response.

We took independent advice from a specialist in adult mental health nursing. We found that the board’s position that prescribing is a matter for C’s GP to be reasonable. However, we found that C did not receive reasonable or adequate contact from the community mental health team and the board failed to follow through on a plan for C to have a face-to-face appointment with a consultant psychiatrist.

We also found that the board failed to follow through with a plan to discuss a referral to a befriending service with the clinical team. The board’s complaint response made reference to a referral submitted several years previously, which we found unreasonable with respect to complaints handling. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• The community mental health team should have robust administrative systems in place to ensure that planned appointments are arranged as intended and that patients are effectively notified of their personal appointment arrangements in a timely manner.

In relation to complaints handling, we recommended:

• Complaint responses should include information relevant to the events complained about.

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 late sibling (A) received from the practice. A attended the practice with back pain and was given painkillers. Clinical staff noted comments on A’s appearance and demeanour during the appointment. They also noted that they considered A to be drug seeking. A died a few days later.

C complained that the examination was not thorough enough and that clinicians missed the fact that a lung infection was the cause of A’s symptoms. The practice said that they considered the examination to be reasonable, that they felt that A did not present with typical signs of respiratory concern and so auscultation (listening to the lungs) was not indicated. They did not identify anything that could have been done differently.

We took independent clinical advice from an advanced nurse practitioner. We considered that there were enough complicating factors in A’s history and presentation to warrant a more thorough examination of A. Therefore, the examination carried out was unreasonable. We found that the opinion that A was drug-seeking was premature as no differential diagnoses were considered or ruled out. We also noted that an adverse event review was not carried out which we considered to be unreasonable. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a reasonable and thorough examination of A when they presented at the practice for a consultation, for failing to consider/rule out differential diagnoses to explain A’s symptoms and for failing to carry out an adverse event review to investigate what happened and promote learning for the staff involved. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be examined thoroughly. When examination is difficult, and/or it is difficult to obtain a clear history, care should be taken not to reach conclusions prematurely without ruling out differential diagnoses as appropriate.
• When a patient dies shortly after they have been seen at the practice, an adverse event review should be carried out in line with the National Framework for Scotland to ensure that any learning (and good practice) can be identified and acted on.

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 provided to their parent (A). A had been admitted to hospital before being transferred to a mental health facility. A then developed abdominal symptoms, which required them to be transferred to an acute hospital for treatment. A had been considered for surgery, but this was changed to treatment with medication. A was transferred back to the mental health facility but became unwell again and was taken to A&E. A died from a pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung).

C said that A’s medical and nursing care fell below an acceptable standard which resulted in A’s dignity being compromised, their personal care neglected and A not receiving the medication that they required. C believed that A’s death was caused by a failure to examine A properly or ensure that A received anti-clotting medication. C felt that this resulted in A developing deep vein thrombosis (DVT, a blood clot in a vein) which led directly to their death. C was also unhappy with the board’s response to their complaint. C felt that the board had not represented meetings with the family accurately, and failed to follow up on the actions that they had told the family were being taken, despite acknowledging that there was significant learning to be gained from the family’s experience.

We took independent advice from a registered nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that A’s nursing and medical care had fallen below a reasonable standard. We also found that the board failed to communicate reasonably with C and their family and that they could not provide evidence that they had taken the actions promised to the family following the board’s complaint investigation. In addition, the board’s Significant Adverse Event Review had been delayed, reducing the utility of it to the board. We upheld all of C’s complaints.

Recommendations

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

• All nursing staff on the relevant ward should be compliant with the board’s medicine administration policy.
• An assessment by the medical team of the current rota and continuity of care based on the assurances given to A’s family that staff numbers would improve this.
• Patient documentation completed to an appropriate standard, without sections left blank, this should include admission documents, care rounding charts, person centred care plans and delirium screening.
• The board should develop clear guidance to ensure patients with mental health issues can have timely access to nursing staff trained in mental health care, to reduce the reliance on family members providing care.
• The case should be discussed at the next available morbidity and mortality meeting.
• The medical staff involved should include this case for discussion at their next appraisal.

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.