Upheld, recommendations

Summary

C, a support and advocacy worker, complained on behalf of their client (A) who was a student at Edinburgh College. A has Autism Spectrum Disorder (ASD, a developmental disability that affects how a person communicates with, and relates to, other people) and dyslexia (a common learning difficulty that can cause problems with reading, writing and spelling) and required additional support to fully access their course. C said that the college failed to provide the support that had been identified as being required for A. As a result of the lack of support, A felt that they had no option but to drop out of the course.

We found that, whilst A's support needs had been appropriately assessed and shared with their lecturers, the college failed to adequately document and record the support process in a structured way. Important information about A's support package was not available due to staff absences or departures. We acknowledged that the college has since taken steps to improve their processes in this respect. A had also applied to the Student Awards Agency Scotland (SAAS) for funding for an upgraded laptop due to the software requirements of their course. We were critical that the college were unable to demonstrate that they presented the information that A asked to be considered by the SAAS in its entirety and without comment. As a result, we upheld this 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.

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). A is profoundly deaf and British Sign Language (BSL) is their first language, and so A relies upon BSL interpreters when attending medical appointments. A requested a gender specific interpreter for a GP appointment but when they arrived they found that the interpreter was not the gender they had requested. The interpreter had to leave the room when A required an intimate examination and they were unable to communicate with their GP during this time. C said A felt that they had not been treated with respect and dignity.

We found that A did not receive the level of service they could reasonably expect from the board which led to difficulties in accessing general practice services and significant distress. The failings in the service provided included an unreasonable delay in the provision of an interpreter, misleading information about the status of interpreters, lack of a gender specific interpreter, and an inadequate risk assessment. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Ensure that the level of service provided meets the requirements of patients with additional needs to enable them to fully access all services within a healthcare setting.

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). A, whose first language is British Sign Language (BSL), was admitted to Perth Royal Infirmary with concerns about their heart and lungs. During their admission, A's spouse (B) had to translate for them, which they found extremely difficult as B is severely deaf and BSL is their preferred method of communication. C said that this was contrary to the board's policy on their interpretation and translation service and showed a lack of deaf awareness.

We took independent advice from a specialist in equality. We found a number of failings that had an impact on the board's ability to meet A's communication requirements effectively which caused distress to A and B. These failings included misleading information about the level of the interpretation translation service provided to patients and staff; and that the level of the aforementioned service was inadequate and not in line with the board's policy. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified in this investigation and inform C of what and how actions will be taken to prevent a future reoccurrence. The apology should meet the standards set out in the SPSO guidelines on apologyavailable atwww.spso.org.uk/information-leaflets.

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

• Ensure the board's Interpretation and Translation Policy is implemented effectively by clinical staff.

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 was referred to the board's urology service (specialists in the male and female urinary tract, and the male reproductive organs) via an urgent referral due to suspected cancer. C was diagnosed with transitional cell carcinoma (a type of cancer that typically occurs in the urinary system). C underwent laparoscopic (keyhole surgery) nephroureterectomy (a surgical procedure to remove the renal pelvis, kidney and entire ureter, along with the bladder cuff). C then had follow-up appointments and treatment. C complained about delays in diagnosis, in surgery, in follow-up appointments and treatment, along with poor communication from the board.

We took independent advice from a consultant clinical oncologist with specialised urology oncology practice. We found that the board failed to meet the Cancer Waiting Time (CWT) standards with regards to the 62-day timescale from referral to treatment, and the 31-day timescale from decision to treat to treatment. Since C's complaint, the board have taken a number of actions to improve waiting times within the urology service and their communication about waiting times. We considered that the actions the board had already taken were comprehensive and we did not make further recommendations to the board to improve the way they do things. However, we recommended that the board apologise for the failure to meet the CWT standards. As a result, we upheld this aspect of C's complaint.

C also complained that the board's handling of their complaint was unreasonable. We found that the board did not acknowledge C's complaint within the timescales set out in the Model Complaints Handling Procedure, and did not always update C with revised timescales as to when C could expect a response to their complaint. In addition, the board did not reply to two letters from C, sent in reply to the board's response to C's complaint. As a result, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to meet the Scottish Cancer Waiting Time (CWT) standards regarding the timescale for C to begin treatment, failing to acknowledge C's complaint within three working days, failing to provide C with a revised timescale for when they could expect to receive a response to their complaint and for failing to acknowledge or respond to two of C's letters. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 are asthmatic and suffer from chronic obstructive pulmonary disease (COPD). C was referred to the board by their GP due to a flare up of COPD. C was reviewed by a locum consultant respiratory (relating to or affecting the action of breathing or the organs associated) physician at Monklands Hospital. C was concerned that the decision was made to change their inhalers from Relvar and Incruse to a Trelegy inhaler. C said that this caused their condition to flare up and resulted in their breathing becoming laboured.

We took independent advice from a consultant in respiratory and general internal medicine. We found that a clinic letter from a few years earlier did not make it clear that a diagnosis of asthma (in addition to the confirmed diagnosis of COPD) was suspected nor list the medication with doses that C was receiving. We noted that the lack of clarity regarding C's suspected diagnosis and treatment resulted in C's GP and subsequent hospital consultants not being aware that C had a possible diagnosis of asthma and was on the higher steroid dose of Relvar. Based on the information known to the consultant at the time, it was reasonable to consider combining the Relvar and Incruse inhalers in to a Trelegy inhaler. However, there was no evidence in the records that the change in medication was explained to C in a reasonable way. In particular, we noted that the possible risks and benefits of this change were not explained to C so that they could make an informed choice about whether to make the change.

In these circumstances, we considered it was unreasonable for the board to substitute the medication C was taking for their respiratory condition (Relvar and Incruse) with a Trelegy inhaler. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to make it clear that a diagnosis of asthma was suspected or list the medication with doses that C was receiving on the clinic letter and for failing to make C aware of the possible risks and benefits of changing their inhalers so that C could make an informed choice about whether to make the change. 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:

• Changes to inhalers should not be recommended without discussing the risks and benefits with the patient first.
• Clinic letters should clearly list confirmed and suspected diagnoses and treatment (including type of dose).

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 relative (A). A had surgery for a fractured hip and wrist at Hairmyres Hospital. At a clinic appointment a few weeks later, A was advised that there was an issue with a screw being close to the joint in their hip. A was not keen on further surgery and there was an agreement to review them again in six weeks. Subsequently, A's pain increased and their mobility decreased. An x-ray showed that the screw had failed; therefore, surgical correction was considered and further surgery was subsequently performed. A's clinical condition deteriorated and they died a number of weeks later. C complained to the board about A's care and treatment. The board responded to the complaint and carried out a review of A's care. The board identified some evidence of poor care.

C remained unhappy and complained to us about A's care and treatment and the board's handling of their complaint. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and from a trauma and orthopaedic (a specialist in the treatment of diseases and injuries of the musculoskeletal system) consultant. We found that A was appropriately reviewed by medical staff and that there was no evidence of a delay in A's pain being identified following their first operation.

However, we identified that medication errors in relation to the prescription of vitamin D had occurred which were significant. Whilst we did not find evidence that the errors caused harm to A, the errors had not been appropriately documented in the medical records when they were identified; nor were they reported on the second occasion as they should have been. A and their family were also not informed about the medication errors at the time, contrary to General Medical Council (GMC) guidance. We were critical that the board's review of A's care did not take sufficient action to adequately address these errors.

We also found that, when A consented to further surgery (which was major and complex), there was no evidence to show that the option of a girdlestone procedure (removal of the metal work only which would have left A with a significant functional disability) had been discussed with A or their family. We considered that this was unreasonable and contrary to national guidance on consent.

We upheld the complaint on the basis that there was a missed opportunity for the board's review to adequately address failings in care and to fully learn from these events.

We also found that there were failings in the board's handling of C's complaint in that there was an unreasonable delay in investigating and C receiving their final response. We also considered that the board's response was inadequate in that it failed to identify and address the potentially serious medication errors that occurred. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to appropriately prescribe vitamin D; document and report the medication errors when they were identified; inform A and the family at the time; take sufficient action to address the errors when they were identified in the board's review; discuss the option of a girdlestone procedure; and handle C's complaint adequately. 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 fully advised of all relevant surgical options and the discussion should be clearly recorded, in accordance with relevant standards and guidance.
• Any reviews undertaken should sufficiently address any errors/failings identified.
• Medication should be prescribed safely. Medication errors should be appropriately documented in the medical records when they are identified and reported by the board's reporting system. Patients and their relatives should also be appropriately informed in line with GMC guidance.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the board's and 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 was diagnosed with a malignant melanoma (a type of skin cancer) and referred to a consultant oral and maxillofacial (the specialty concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) surgeon for surgery. A wide local excision (WLE, a surgical procedure to remove a small area of diseased or problematic tissue with a margin of normal tissue) was carried out. C complained that they should have been offered a sentinel lymph node biopsy (SLNB, a procedure in which the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present) at the same time as the WLE, in accordance with clinical guidelines. C complained that without having had SLNB, their disease could not be accurately staged.

The board said their priority had been the excision and that on review by the surgical team SLNB was not recommended. C received a computer tomography (CT) scan and the report from this was discussed at the appointment attended with the consultant oral and maxillofacial surgeon. The consultant confirmed at the appointment that the pathology report staged C's melanoma at stage 2 (the melanoma is only in the skin and there is no sign that it has spread to lymph nodes or other parts of the body). C also received an ultrasound fine needle aspiration (FNA) of their right neck and biopsy. The board said accuracy of SLNB at this stage was limited and likely to carry more morbidity; therefore they suggested to follow up with six monthly CT scans and consideration of repeat ultrasound at alternate six monthly intervals. In their response to our enquiries, the board acknowledged that C ought to have had a SLNB at the time of their wide excision, providing their general medical fitness was appropriate for general anaesthesia.

We took independent clinical advice from an appropriately qualified adviser. The adviser confirmed that C met the criteria for SNLB to be offered in accordance with Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Health and Care Excellence (NICE) guidance. While the adviser noted C had an effective operation with no delays, there had been a missed opportunity for SNLB. The adviser considered the impact was hard to see, and that given C's good pathology report, which found no pathological lymph nodes by ultrasound and their internal organs free of melanoma, their prognosis was excellent. The adviser nevertheless considered that C ought to have been given the choice to undergo SNLB at the time of the WLE, and noted the effect on C was that they could not take part in melanoma trials nor could they have confidence in the possibility of being successfully treated. The adviser was critical of the board for not having ratified the guidelines. Taking all of the above into account, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to offer a sentinel lymph node biopsy at the time of excising their melanoma, with a recognition of the distress this matter has caused them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information leaflets.
• In their apology letter, the board should explain to C why the guidelines have not been ratified and advise C of their future intentions in this regard.

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

• An action plan should be devised for ratification of the SIGN/NICE guidelines.
• The outcome of this complaint should be fed back to relevant staff in a supportive manner.

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.

Following publication on 24 March 2021, this complaint was subject to a review.  The overall outcome of the complaint remained unchanged however, amendments were made to both the summary and recommendations.  The summary as originally published can be found at the bottom of the page. 02/03/2022

Summary

C complained about the care and treatment they received from Inverclyde Royal Hospital. C underwent colorectal surgery during which it was identified that they had rectal cancer which had spread into the vascular system. Prior to the surgery, a lesion on C’s lung was noted but was not thought to be typical of cancer and a plan was made to keep it under review. C raised a number of concerns regarding the reasonableness of the management plan for their cancer and delays to their treatment. They considered that treatment decisions were made without their involvement and they were given misleading information about their treatment options.

We took advice from a general and colorectal surgeon who noted that the monitoring of C’s lung lesion was unstructured. We were advised that a CT PET scan was not carried out in a timely manner; there was no referral to a lung multi-disciplinary team (MDT) when scans subsequently showed an increase in lesions; and there was a delay in referring to oncology for discussion of treatment options. As such, C was not provided with a clear picture of their condition and management plan, and treatment was not instigated as soon as it might have been. While it was accepted that treatment options were limited and earlier treatment may not have altered C’s prognosis, earlier discussion with oncology could have cleared up some of the uncertainty and alleviated C’s associated distress. We accepted the advice and upheld this complaint. Whilst not raised in the complaint, the adviser also observed a failure during the colorectal surgery to check for a tattoo marker that had previously been placed to mark the tumour. While this did not result in a failure to fully remove the tumour, the adviser described it as a ‘near miss’.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C's next-of-kin for the lack of clarity in follow-up monitoring; the failure to refer C to the lung MDT and carry out a CT PET scan in a timely manner; the delay in referring to oncology; and the failure to check for the tattoo marker during 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:

• The colorectal MDT should reflect on C's care and treatment and review its processes for referrals to oncology or other MDTs, to ensure appropriate input is received and acted upon.
• The colorectal MDT should review its processes in respect of ensuring there is a clear pathway for monitoring specific issues separate to standard post-surgical follow-up.
• The board should tell the Ombudsman what their process is for reporting and reviewing 'near miss' events, and why there was an apparent failure to identify this one.
• The colorectal team should discuss the failure to check for the tattoo marker during surgery, and how a similar future error can be avoided.

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.

Original summary published on 24/03/2021

Summary

C complained about the care and treatment they received from Inverclyde Royal Hospital. C underwent colorectal surgery during which it was identified that they had rectal cancer which had spread into the vascular system. Prior to the surgery, a lesion on C's lung was noted but was not thought to be typical of cancer and a plan was made to keep it under review. C raised a number of concerns regarding the reasonableness of the management plan for their cancer and delays to their treatment. They considered that treatment decisions were made without their involvement and they were given misleading information about their treatment options.

We took advice from a general and colorectal surgeon who noted that the monitoring of C's lung lesion was unstructured. A respiratory physician's recommendation was not followed up and C was not referred to a lung multidisciplinary team (MDT) when scans showed that the lung lesions had increased in size and number. The adviser also identified a delay in referring C to an oncologist for discussion of treatment options. As such, C was not provided with a clear picture of their condition and management plan, and treatment was not instigated as soon as it might have been. While it was accepted that treatment options were limited and earlier treatment may not have altered C's prognosis, earlier discussion with oncology could have cleared up some of the uncertainty and alleviated C's associated distress. We upheld this complaint. The adviser also observed a failure during the colorectal surgery to check for a tattoo marker that had previously been placed to mark the tumour. While this did not result in a failure to fully remove the tumour, the adviser described it as a 'near miss'.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C's next-of-kin for the lack of clarity in follow-up monitoring; the failure to refer C to the lung MDT and follow up the respiratory physician's recommendation; the delay in referring to oncology; and the failure to check for the tattoo marker during 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:

• The board should review and identify why the respiratory physician's recommendation was not followed up.
• The board should tell the Ombudsman what their process is for reporting and reviewing 'near miss' events, and why there was an apparent failure to identify this one.
• The colorectal MDT should reflect on C's care and treatment and review its processes for referrals to oncology or other MDTs, to ensure appropriate input is received and acted upon.
• The colorectal MDT should review its processes in respect of ensuring there is a clear pathway for monitoring specific issues separate to standard post-surgical follow-up.
• The colorectal team should discuss the failure to check for the tattoo marker during surgery, and how a similar future error can be avoided.

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

Ms C complained about the care and treatment she received at Queen Elizabeth University Hospital. Ms C underwent splenic artery embolization (a procedure that involves inserting a fine tube into the blood vessel that supplies blood to the spleen and deploying a device to treat an aneurysm). A complication occurred and following the procedure it was identified that a fine piece of filament was retained in Ms C's leg. A further procedure was performed the following day and the filament was removed. Ms C experienced significant discomfort during and after the procedure. Ms C remained dissatisfied following receipt of the board's response to her complaint and brought her complaint to us.

We received independent advice from a radiology adviser (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the first procedure was not performed reasonably as there was a failure to identify the retained filament before the procedure ended. We found that the second procedure was performed reasonably and we considered that the board had taken reasonable action to learn from the complication that occurred. Finally, we considered that the consent process was inadequate as it was not clear that Ms C was informed about the possibility of pain as a result of the procedure. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in care and treatment 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:

• Patients should be informed about discomfort and common relatively minor side effects following a procedure as well as more serious complications using simple terms.

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 practice failed to provide them with effective treatment for a skin complaint and that they waited an unreasonable length of time before they saw a doctor.

We took independent advice from a nurse adviser and a GP adviser. C had first attended two nurse consultations, a week apart, as they had developed an itchy rash on their back. We noted that the initial working diagnoses (insect bites/fungal infection) and the care and treatment provided at this point was reasonable. Ten days after C's first consultation, they contacted the practice again. As the triage telephone call mentioned 'shingles' as another possible diagnosis, a referral to see a GP should have been made at this time. However, C was given an appointment with an advanced nurse practitioner. Although C was being treated with an allergy tablet, there was no documented working diagnosis of what was causing the itch. We found that the management of C at this time was not reasonable.

C contacted the practice again the following day and requested to be seen by a GP. This was the fourth time C had contact with the practice in eleven days since the onset of the rash, which was getting worse and becoming painful. Although the advanced paramedic practitioner who saw C on this occasion sought advice of a GP regarding treatment, we considered that it was unreasonable that C was not referred to be seen by a GP at this time.

C made a further request for a GP appointment two weeks later and again was given an appointment with an advanced paramedic practitioner. We found that this was unreasonable given that this was C's second request for a GP appointment, they had seen nurse and paramedic practitioners four times over a period of several weeks and had attended the out-of-hours service, during which time their rash was getting worse/not responding to prescribed treatment and was painful.

Due to their ongoing symptoms, C attended again at the out-of-hours service when they were prescribed an oral steroid and advised to contact their GP to expedite a dermatology (diseases of the skin, hair and nails) appointment as soon as possible. At this time, C had still not seen a GP in the practice and we considered this to be unreasonable. When C eventually saw a GP, an urgent referral to dermatology was made. The care and treatment provided by the GP at this time was reasonable.

Taking into account all of the evidence and the advice we received, we found that the practice failed to provide C with reasonable care and treatment. As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to have an appropriate management plan in place and for failing to refer C to be seen by a GP earlier. 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:

• Where a patient presents on several occasions with an acute condition that is not responding to treatment, an appropriate management plan should be in place. Where a patient has seen advanced practitioners on two occasions and requires to be seen a third time with the same acute condition, consideration should be given to having a GP review the patient.

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.