Upheld, recommendations

Summary

Ms C complained on behalf of her in-law (Mr B) about the care and treatment provided to his wife (Mrs A). Mrs A was diagnosed with breast cancer and a full computerised tomography (CT) scan was carried out. The CT scan of Mrs A's chest, abdomen and pelvis showed liver and bony metastases (the development of secondary malignant growths) at a distance from a primary site of cancer. The head scan showed a 6mm lesion of uncertain significance on the left frontal lobe of Mrs A's brain. The consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer) involved in Mrs A's care advised her of the liver and bony metastases. However, they did not share the results of the head scan. Following this, the board's records indicate that the results of this scan were not shared with Mrs A by the consultant oncologist, the clinical nurse specialist (CNS) involved in her care, or any other member of staff.

Ms C complained that the board had unreasonably failed to disclose information about the lesion on Mrs A's brain. We took independent advice from an oncology adviser. We found that it was unreasonable for the board not to disclose this information to Mrs A. The board had advised that the medical professionals involved did not disclose this information to avoid causing further anxiety or upset to Mrs A. Even if the board had good intentions, we considered the evidence to strongly indicate that this was not a reasonable course of action to take and, under the circumstances, was not a medical professional's choice to make. This evidence included the General Medical Council's (GMC) guidance Good Medical Practice and Consent: Patients and Doctors Making Decisions Together. We concluded that it was not reasonable for information about the head scan not to be shared with Mrs A. Therefore, we upheld this aspect of the complaint.

Ms C also complained that, following the head scan, the board unreasonably failed to provide appropriate treatment to Mrs A or manage her condition appropriately. We found that, overall, Mrs A received a good quality of care and treatment. However, we noted that it would have been reasonable for a Magnetic Resonance Imaging (MRI) scan to be carried out, in line with the recommendations of the consultant radiologist (a specialist in the analysis of images of the body). This would have resulted in clearer information about the lesion on Mrs A's brain and identify whether there were other smaller lesions. Further MRI or CT scanning would also have helped identify whether brain radiotherapy would have been an appropriate or effective form of treatment.

We found that the evidence suggested that further scanning would not have extended Mrs A's life but may have made some difference to her treatment. We concluded that, by not carrying out further MRI or CT scans, the board failed to provide appropriate treatment to Mrs A or manage her condition appropriately. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to both Ms C and Mr B for the failings my investigation 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:

• Staff should be aware of the circumstances in which it is acceptable to withhold information from a patient.
• The board should reflect on their position on disclosing information to patients, as detailed in their response to my enquiries.

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

Mrs C complained about the treatment her husband (Mr A) received during his admission to Wishaw General Hospital. Mr A was admitted with abdominal pain and a temperature and was discharged the same day with a principal diagnosis of gastritis (inflammation of the lining of the stomach). Mr A latter suffered a ruptured appendix and damaged bowel which required emergency surgery. Mrs C complained that if Mr A had received the correct diagnosis in his initial admission, with reasonable investigations carried out, the rupture could have been avoided.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that the treatment provided to Mr A was unreasonable. Insufficient notice was taken of Mr A's raised temperature, white cell count and CRP (inflammatory marker) as objective evidence together with lower abdominal pain. We considered that appendicitis should have been considered as a possible diagnosis. We also found that Mr A was discharged too early without a second examination and on discharge the wrong diagnosis was recorded and advice on what to do next was unclear. We upheld this aspect of Mrs C's complaint.

Mrs C also complained about the board's response to her complaint. Mrs C raised a number of questions about the treatment Mr A received. The board explained the actions taken and why they considered this was reasonable.

We sought advice about the accuracy of the board's response in terms of Mr A's presentation and treatment. We found that the board failed to provide a reasonable response to Mrs C's complaint. While the board responded to the questions Mrs C raised, the medical records did not evidence the board's outline of the treatment provided, including that appendicitis was considered in Mr A's initial admission and the advice provided when discharging Mr A. We also upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide a reasonable complaint response.
• Apologise to Mr A for failing to provide reasonable treatment to him. The apologies should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets .

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

• Documentation, including discharge summaries, needs to be clear, including who saw, when and what.
• Formal discharge summaries should be completed in a timely manner.
• Learning should be taken from the complaint and reflected upon in a morbidity review to highlight the importance of high index of suspicion of appendicitis in young adults with abnormal tests and atypical history.
• Relevant staff should be reminded of the importance of difficult cases being re-assessed by more senior clinicians.

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 provided to her by the board for a number of symptoms over a period of several months. We took independent advice from a GP, from a consultant in acute medicine, from a gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and from a neurologist (a doctor who specialises in the brain and nervous system). We found that whilst much of the care and treatment provided to Ms C was reasonable, the possibility of Ms C's symptoms being caused by other disorders should have been discussed with her. Therefore, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to recognise and discuss the possibility of her symptoms being caused by a functional disorder or chronic fatigue syndrome. The apology should meet the standard set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance .
• Consider carrying out a further review of Ms C's symptoms (should she still wish to have this done) if she is referred to the board via her GP in light of the findings of this investigation.

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

• Staff should be aware of how to recognise and manage functional disorders, including chronic fatigue syndrome.

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

Miss C complained that the board had unreasonably delayed in diagnosing and treating her brother (Mr A)'s prostate cancer. We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs).

We found that communication about Mr A's diagnosis and prognosis had been reasonable. However, we found that there had been an avoidable delay in diagnosing his prostate cancer, and as a result there had been a possible delay of six to eight weeks in staring his treatment. We upheld the complaint. However, we noted that the delay had no significant clinical impact on the disease progression or prognosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C and the family for the delays identified in this case. 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 presenting with signs or symptoms of prostate cancer should be referred to the local multidisciplinary team meeting as soon the diagnosis is suspected.

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

Mrs C complained that medical staff failed to diagnose her husband (Mr A) with urethral obstruction (a blockage that inhibits the flow of urine through it's normal path). Mr A presented to Royal Alexandria Hospital on a number of occasions with urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system) problems, including difficulty urinating and passing blood. An X-ray was carried out which showed no kidney stones and tests confirmed no infection. He was discharged but attended several days later to the emergency department, unable to pass urine. He was examined, catheterised and discharged home with medication to relax the bladder neck. No follow-up appointment was arranged. Nine days later Mr A was admitted to hospital as he was unable to pass urine. Following further tests, and subsequent attendances at hospital with issues regarding his catheter, including treatment with antibiotics for infection, Mr A underwent a cystoscopy (bladder examination using a narrow tube-like telescopic camera) where a intra-urethral stone was extracted from the penis. Mrs C said that doctors did not take account of the symptoms Mr A had presented with and they failed to carry out basic checks. It was not until they sought private opinion that appropriate tests were carried our and the stone causing the obstruction was discovered.

We took independent medical advice from a consultant urologist. We found that on the initial presentations to hospital, physical examinations of the abdomen and genitals were not carried out, despite repeat presentation and reported symptoms indicating this should have occurred. Appropriate examinations, particularly of the penis when indicated, would likely have identified the presence of the stone. Medical and nursing staff did not adequately document and act on difficulties which were encountered in passing the catheter. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to carry out appropriate physical examination, escalate difficulties in catheterising, and to arrange for further assessment with flexible cystoscopy. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance .

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

• Emergency staff, when presented with blood in urine in the absence of infection, should recognise this requires urgent investigation.
• Relevant medical and nursing staff should be aware of the need to take a good history and perform appropriate genital examinations. Nursing staff should be aware of potential causes for difficulties in catheterisation and empowered to ask for support or abandon catheterisation if difficulties are encountered.

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

Mr C complained about the care and treatment that his late father (Mr A) received at Aberdeen Royal Infirmary and at a palliative care facility.

We took independent advice from a consultant head and neck surgeon, from a consultant clinical oncologist (cancer specialist) and from a nursing adviser. We found that the surgical and medical care and treatment Mr A received was reasonable.

However, we found failings regarding Mr A's nursing care. In particular, we found that Mr A was not prescribed two hourly position changes at Aberdeen Royal Infirmary and the palliative care facitility when he was at risk of developing pressure damage and that Mr A did not receive care in accordance with the board's policy on adults with tracheostomies (an incision in the windpipe made to relieve an obstruction to breathing). We upheld this aspect of Mr C's complaint.

Mr C also complained about how the board handled his complaint. We found that Mr C was not kept updated regarding a timescale for when he could expect to receive the board's complaint response and the minutes of a meeting. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not prescribing Mr A with care and comfort rounds every two hours; not delivering appropriate tracheostomy care to Mr A in accordance with the board's policy; the delay in responding to his complaint and that he was not kept updated. 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 at risk of developing pressure damage should be repositioned every two hours.
• Patients with a tracheostomy should receive care in accordance with NHS Grampian's Care of the Adult with a Tracheostomy Policy.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found at https://www.spso.org.uk/the-model-complaints-handling-procedures .

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, a patient advice and support advocate, complained on behalf of her client (Miss A). She complained about the care and treatment Miss A received by the diabetology (diagnosis and treatment of diabetes) and neurology (diagnosis and treatment of disorders of the nervous system) services in relation to a range of symptoms including stomach pain, nausea, headaches, and dizziness and her diagnosis of Postural Tachycardia Syndrome (PoTS, an abnormal increase in heart rate that occurs after sitting up or standing).

We took advice from a consultant diabetologist and a consultant neurologist. We found that much of the care and treatment provided to Miss A was reasonable. However, there was a significant delay in follow-up from the neurologist, which the board had already agreed was unreasonable and apologised for. On this basis, on balance, we upheld this aspect of the complaint. However as the board had already apologised and taken action we did not make any recommendations on this point.

In relation to complaint handling, we found that there was a significant delay in the complaint being responded to by the board. Though we noted that the board had apologised for this, they had not given any explanation as to what caused the delay. They also did not evidence that Miss A was kept updated during the delays. We therefore made a recommendation to the board in relation to their complaint handling.

Recommendations

In relation to complaints handling, we recommended:

• Complaint responses should be provided in a timely manner, and where they will take longer than 20 working days complainants should be kept informed of the reasons for delays, in line with the 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

Ms C complained to us about the care and treatment she received at University Hospital Ayr. Ms C underwent total hip replacement surgery (a surgical procedure where a damaged hip joint is replaced with an artificial one) on both hips. Ms C raised concerns that the risks of each surgery were not communicated appropriately to her; there were failings in carrying them out, which caused her to experience pain and mobility issues; and her post-surgical care was unreasonable.

We took independent advice from a medical adviser who is a consultant orthopaedic and trauma surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). For both surgeries, we found no evidence of failings in carrying them out. We found that Ms C experienced recognised complications of total hip replacement surgery. We also found that Ms C's post-surgical care was reasonable. However, we found that there was no evidence Ms C was appropriately informed of the risks involved in each surgery during the consent process. Therefore, we upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in the surgical consent process for both hip surgeries. 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 consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery. As part of the consent process, there should be a clear discussion of the risks and benefits (of having the surgery and not having the surgery) and of any alternative treatment options; and those discussions should be clearly documented

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

Mr C complained about the care and treatment he received from Ayr Hospital in relation to surgery he underwent for penile deviation (curvature of the penis). Mr C was dissatisfied with aspects of the medical and nursing care. Following surgery, he developed a haematoma and infection. In addition, the end result of the surgery was unsatisfactory for him.

We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) and a registered nurse.

We found no evidence that the surgery was of an unreasonable standard. However, we found that informed consent for the surgery undertaken was not properly obtained from Mr C, in line with the General Medical Council's (GMC) guidance on consent. We considered that the medical care Mr C received was unreasonable and upheld this aspect of his complaint.

In terms of the nursing care, we identified failings in that there was a lack of record-keeping to show that Mr C's wound was regularly checked and assessed with the appropriate dressings applied. In addition, in terms of his discharge from hospital, there was no evidence to show that Mr C was given information about caring for his wound at home or that he was supplied with sufficient dressings. We considered that these aspects were unreasonable and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain informed consent from him and for the nursing care failings in relation to wound care, record-keeping, and discharge information. 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 consent process should follow GMC guidelines.
• Patients should be provided with appropriate information as part of discharge planning and document that this should be documented.
• Patients should receive appropriate wound dressings in line with the wound dressing formulary.
• Post-operative patients should have their wound checked and this should be recorded on each occasion.

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

Mr C complained about the university’s handling of an academic appeal. Mr C had appealed a decision reached by the Board of Examiners following a previous academic appeal which was upheld. Mr C submitted that the calculation method used by the board of examiners was procedurally incorrect. The appeal sub-committee who considered Mr C’s appeal did not consider that he had established grounds for appeal. Mr C complained to us that the report of the appeal sub-committee contained factual inaccuracies and that it did not consider the points of appeal he had raised.

We considered the appeal documentation and the relevant university policies and regulations. We found that the documentation of the board of examiner’s decision was not clear and we also noted that a member of staff had not communicated with Mr C precisely about the decision. We considered that the evidence showed that the appeal sub-committee did not give adequate consideration to the points Mr C made in his appeal. We upheld Mr C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not handling his appeal appropriately and for the imprecise communication in response to an enquiry. The apology should meet thestandards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• An appeals sub-committee should reconsider Mr C's specific allegations of procedural irregularity and provide Mr C with an explanation regarding whether the decision of the Board of Examiners was in accordance with the quoted regulations or not. The appeals sub-committee should decide whether any points should be referred back to the Board of Examiners for reconsideration. The university should ask the appeals sub-committee to take into account Mr C's specific point about script viewing and calculation error and consider whether to recommend that the Board of Examiners consider this point.

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

• Appeal sub-committees should demonstrate that they have considered the grounds of appeal and provide explanation for their decision.
• Where a Board of Examiners does not accept a recommendation by an appeals sub-committee this should be clearly documented including the reasons.
• Responses to requests for clarification should be clear and accurate.

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.