Upheld, recommendations

Summary

Mrs C complained to the council about their handling of confidential documents relating to her mother (Mrs A). Her complaints were upheld and a number of recommendations were made, but the council delayed in implementing the recommendations. We investigated Mrs C's complaint about the delay. We found that the delay had been unreasonable and upheld the complaint. Although the council said that they had now implemented all of the recommendations, we requested evidence of this to satisfy ourselves that this had been done.

With regard to the complaints handling, the council should have followed their complaint process from the outset but failed to do so. When the council said that they were treating Mrs C's complaint as a Stage 2 complaint (investigation stage), as requested by Mrs C, their response showed no sign of investigation and contained inconsistent statements. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in implementing the recommendations, with a recognition of the impact. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to Mrs C for their unreasonable complaints handling. 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 involved in complaint investigations should be familiar with the Complaints Handling Procedure and ensure it is followed appropriately.

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 her late child (Child A) received from the board before their death. Child A had been diagnosed with a rare disorder that affected their development. Child A had a CT scan (a scan which creates detailed images of the inside of the body) of their brain, which identified cerebellar tonsillar descent (the lower part of the brain pushes down into the spinal canal). Ms C found out about this after Child A died. She said that Child A's behaviour had changed around that time, and she complained that the board had failed to tell her about this.

We took independent advice from a consultant neuroradiologist (a specialist who uses scans to diagnose and characterise abnormalities of the central and peripheral nervous system, spine, and head and neck). We found that it had been unreasonable not to discuss the findings and the clinical implications with Ms C and, therefore, upheld this aspect of the complaint.

Ms C also complained that the board had failed to provide reasonable care and treatment to Child A in relation to this. We found that it had been unreasonable not to carry out further investigations, and specifically an MRI scan, to evaluate this. We upheld this aspect of the complaint. However, the evidence suggests that it would not have been possible to prevent Child A's death at that time.

Finally, Ms C complained that the board delayed in responding to her complaint. The board had acknowledged that there were delays in responding to Ms C's complaint and that she was not kept updated on the delays. We also upheld this aspect of the complaint, although we noted that the board had apologised to Ms C for this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to discuss the findings and implications of the CT scan and for failing to carry out further investigations to evaluate Child A's condition. 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:

• In cases of this nature, the imaging findings should be shared with patients and their carers.
• Radiology staff reporting head CT scans should be aware of the clinical implications of cerebellar tonsillar descent (congenital or acquired) and appropriate imaging confirmation and evaluation should be undertaken where clinically relevant.

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.

Amendment

When originally published (18/9/2019), this summary included the line: "However, the evidence suggests that it would not have been possible to prevent Child A's death."

For clarification, this has since been changed to: "However, the evidence suggests that it would not have been possible to prevent Child A's death at that time."  We apologise for any confusion caused.

Summary

Mrs C complained on behalf of her late husband (Mr A) that the Royal Infirmary of Edinburgh Hospital failed to call Mr A to a follow-up review appointment with the cardiology department.

Mr A had been diagnosed with heart disease. He attended an out-patient appointment and saw a consultant cardiologist. During that appointment, it was agreed that Mr A should be reviewed two years from then. Some years later, Mr A collapsed. An ambulance took Mr A to hospital, but he died on arrival. On becoming aware that Mr A had not attended his follow-up appointment with cardiology, Mrs C wrote to the board to ask why he had not been called back to the follow-up appointment as agreed. The board said that Mr A had been asked to make a follow-up appointment but nothing was noted in the system, and they were unable to explain this conclusively. Mrs C complained about the board's failure to call Mr A in for his review appointment. She said that the appointment system seemed flawed and there needed to be a backup system in place so no one else missed an important appointment.

We found that at the time when Mr A was advised to make a review appointment, all patients were advised during their consultation if and when a follow-up appointment was required. The patient would be asked to book an appointment accordingly at the reception desk. Once the appointment was booked, a letter was sent out confirming the date and time of the appointment. No further letters or reminders were sent. It was the patient's responsibility to remember to attend the appointment.

The board told us that having reflected on Mr A's case, they acknowledged that there were failings in the appointment process. They told us that going forward, when staff typed the clinic outcome letter, they would now check that any requested follow-up appointments had been made. If an appointment had not been made, staff would contact the out-patient department requesting that the appointment be made and confirmation sent to the patient.

We took independent advice from a consultant cardiologist. We found that the appointment process described by the board was not common practice and it was susceptible to problems. We found that the boards process placed undue responsibility on the patient.

We considered that the appointment process was open to weaknesses and because of that, the board had been unable to say whether Mr C's review appointment was in fact scheduled. We noted that the most common appointment process would be for each patient to be given a routing card at the end of their consultation which they would return to the clinic reception desk; this would be a record of the discussion held with the patient and the next steps agreed. Even though the board's proposed change would be an improvement to the current process, it did not go far enough as it relied only on verbal communication between clinical staff, the patient and staff at the reception desk. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to arrange an appropriate review appointment for Mr A. 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 reflect on these findings, particularly the view of the adviser and the feedback provided by Mrs C, and consider what further improvements can be made to the appointment process.

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 that that board failed to provide his late wife (Mrs A) with reasonable care and treatment at Western General Hospital and that they did not respond reasonably to his complaint.

We took independent advice from a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a consultant surgeon and a consultant oncologist (cancer specialist).

In relation to a CT scan, we found that a lymph node which was partially visible at the bottom of the CT scan, despite being enlarged and abnormal looking, was not noted by the reporting radiologist at the time. The failure to identify the abnormal lymph node was an unreasonable error. We also noted that the review of the CT scan showed concerning nodes with an increase in size in comparison with a CT scan of Mrs A's chest carried out previously. Given this and Mrs A's clinical history, this should have been noted in the scan report. We considered that, had these nodes been noted on the CT scan report, it was likely further investigation would have occurred as a result. We acknowledged that the board had accepted there was a missed potential to make a detailed diagnosis of Mrs A's condition and said they have taken action to learn from this. We asked the board to provide us with evidence of this.

We also found that a haematology consultant (a specialist in blood and bone marrow) appropriately referred Mrs A to the surgical department for an excision biopsy of the lymph node. However, due to poor communication between the haematologist and the surgeon about the exact anatomical position of the lymph node, the wrong lymph node was removed for biopsy and the diseased lymph node was left in Mrs A's groin. As a result, the pathology report of the biopsy was falsely reassuring.

We also considered that the errors identified in Mrs A's care and treatment led to a delay in the diagnosis that she had terminal metastatic lung cancer. However, it was most likely that when Mrs A first presented with the swelling in her groin, this was evidence of metastatic cancer and she was already in an incurable state. Although earlier diagnosis of the cancer could have been made, it would have made no difference to Mrs A's outcome.

We found that the palliative treatment Mrs A received was reasonable and appropriate and was consistent with national clinical guidelines. However, the delay in diagnosis of the cancer would have caused Mrs A intrusive and distressing symptoms that could have been mitigated had the excision biopsy been correctly undertaken or palliative treatment instigated at an earlier time.

We also found failings in communication concerning how the news that Mrs A had cancer had been conveyed to her. Apart from the delay in diagnosing Mrs A's cancer, there was also an unreasonable delay in informing her that she had metastatic terminal cancer. We considered that the board failed to provide Mrs A with reasonable care and treatment and upheld this aspect of Mr C's complaint.

In relation to complaint handling, we considered that the board's letter to Mr C about his complaint contained medical jargon which could have been better explained. We also considered that Mr C was not provided with all the relevant information. Given that there were a number of medical specialities involved, we considered it would have been helpful if the board's offer of a meeting to Mr C to discuss his complaint had not been restricted to the radiology service. We also noted that the board's complaint response contained factual errors in relation to dates. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in the care and treatment that Mrs A received from the radiology, haematology and surgical departments in relation to the diagnosis of her cancer; for the unreasonable delay in the diagnosis; for the unreasonable delay in informing Mrs A about her diagnosis; for the poor communication with Mrs A and Mr C about her diagnosis. 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 have all relevant areas of their scan reviewed and reported. When referring a patient for surgical excision biopsy, communication between the referring clinician and the operating surgeon about the exact anatomical position of target lymph nodes should be clear. Communicating significant news, especially bad news, to a patient and/or their family should be carried out in a clear and sensitive manner and without any unreasonable delay.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate, user friendly and easily understood by the complainant and include details of action taken to address failings identified.

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 actions of staff at the GP practice when she had a seizure in the reception area. Ms C has a medical condition in which she experiences seizures. During seizures she is unable to move or speak, however, is aware of what is happening and can feel pain. Ms C complained that when she had a seizure at the GP practice, her dignity and privacy was not maintained.

We took independent advice from a GP. We found that Ms C was not given appropriate privacy when she had the seizure, and this was unreasonable. We also found that Ms C's son was called to take her home in a wheelchair, before she had recovered from the seizure. Staff at the practice should have waited until Ms C had recovered in order to assess her clinically when she was fully conscious and allow her to coordinate her own transfer home as appropriate. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to act reasonably to ensure her privacy, and regarding the arrangements for her to return home. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.
• Review Ms C's care plan in light of the findings of this investigation, and discuss with her whether further details should be added in order to prevent similar failings recurring.

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

• The practice should ensure that patient dignity and privacy is maintained in similar situations where a patient has a medical event such as a seizure or collapse at the practice.

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 underwent gallbladder removal surgery at University Hospital Monklands. She became unstable in recovery and needed to return to theatre for open surgery to repair tears in her bowel and an artery. She required a large blood transfusion.

Ms C complained that the procedure was described to her as a simple keyhole operation, and she did not recall being told of any potential risks as serious as her bowel or anterior aortic wall being damaged. We took independent medical advice from a general and colorectal (bowel) surgeon. It was noted that steps were taken to obtain Ms C's consent the day before her surgery, and many of the risks were explained to her. However, she received no explanation of the small risk of major vascular (circulatory system) injury, or what actions may be necessary in the event of a serious complication. We, therefore, upheld this complaint.

Ms C also complained that a mistake had been made during her surgery. We considered that the major vascular injury could have been avoided if the operating surgeon had exercised reasonable skill and care. In technical delivery, decision-making and note-keeping, the surgical care provided during the operation fell seriously below the standard we would expect of a reasonably competent consultant general surgeon. Additionally, in their failure to undertake a formal investigation into the incident, the board's response also fell seriously below the standard we would expect. We upheld this complaint.

Finally, Ms C complained to us about the board's response to her complaint. She was concerned that the board had failed to provide her with a copy of any internal investigation report, and also that they had not spoken to the operating surgeon as they were on a period of extended leave and subsequently did not return to their post. In the surgeon's absence, the board received comments from another surgeon but these were submitted late, after the board had issued their complaint response. The board acknowledged that they should have sent these comments to Ms C. It was also unclear from the response whether the complaint had been upheld. We considered that the board failed to address Ms C's desired outcome. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately inform her of all the risks and the likelihood of those risks prior to gallbladder removal surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/information-leaflets. The apology currently offered by the board in their response to SPSO enquiries does not meet these standards.
• Apologise to Ms C for failing to properly investigate what happened during her operation. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/information-leaflets.
• Apologise to Ms C for failing to provide a full response to her complaint. 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 ensure that all surgical departments are reminded of the requirement to obtain informed consent, with discussion of all material risks, to the current Royal College of Surgeons standard.
• The board should develop a standardised consent process for patients undergoing gallbladder removal and ensure staff are fully trained in it. This should include an operation-specific patient information leaflet that outlines all material risks of the gallbladder removal procedure.
• The board should initiate a root cause analysis and disseminate any learning from it to all surgeons undertaking gallbladder removal surgery. That analysis should include the decision-making and subsequent responses to the event.
• The board should contact the General Medical Council to make them aware of concerns about the main operating surgeon in this case. If the surgeon is practising in a country outside the UK, if known, the board should contact the relevant healthcare regulator in that country and advise them about the concerns raised.
• The board should remind surgical staff that operation notes should be as accurate and complete as possible.
• The board should remind clinical staff of the need to respond to requests for information relating to a complaint within the appropriate timescale.

In relation to complaints handling, we recommended:

• The board should ensure that their complaint responses: address complainants' desired outcomes, and make clear whether or not they have upheld a complaint and what action they will take as a result of it. This may involve a reminder to staff, further staff training, and/or a change to their template letter to ensure these issues are not omitted.

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 was suffering from, amongst other symptoms, back pain and was referred to a physiotherapist. Shortly after, a magnetic resonance imaging (MRI) scan of her back was taken. Months later Ms C was referred to a gynaecologist (medical specialism of the female genital tract and its disorders) who ordered a further MRI scan as her symptoms continued. When the radiologist reviewed this request, Ms C's previous MRI scan was also reviewed. This second review noted the abnormalities in Ms C's pelvis and documentation was added to their records at that point. A subsequent CT scan confirmed that Ms C had ovarian cancer, and she had an operation to remove two large tumours. However, it was only during an appointment with her consultant oncologist (cancer specialist) a year later that she learned that these tumours had been detected in the MRI scan taken years earlier.

We took independent advice from a medical adviser who specialises in radiology (the analysis of images of the body). We found that the report of the first MRI was unreasonable, because it failed to mention abnormalities in the pelvis and advise further investigations. This meant that there was, at the least, a missed opportunity to diagnose Ms C with ovarian cancer earlier. We also found that it would have been reasonable for the gynaecologist to have informed Ms C earlier about what happened. Instead, Ms C only found out after asking specifically how long the tumours had been present. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in the initial review of the scan and communication identified in 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:

• Review what happened in light of the medical adviser's comments and address any systemic or training issues.
• Share the results of this investigation with the radiologist.
• Discuss the imaging at a learning discrepancy meeting.
• Share the results of this investigation with all relevant clinicians including the gynaecologist.

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 was diagnosed with prostate cancer and he understood from his surgeon that for the best outcome, he should travel to Germany for a specific procedure (nerve sparing radical prostatectomy - a surgical procedure that removes the prostate gland and pelvic lymph nodes while attempting to save the nerves that help cause penile erections). He subsequently travelled to Germany and underwent the mentioned procedure privately. He complained that the failure by the board to offer him the operation was unreasonable and he incurred significant financial cost as a result.

We took independent advice from a medical adviser. We found that Mr C had been advised by the surgeon that he would be a suitable candidate for the aforementioned procedure, but only if a specific type of biopsy procedure was available, which was not reasonable, and that the procedure was not available by the board, which is incorrect. We found no evidence that the three options that were available to Mr C on the NHS were explored with him by clinicians in a reasonable way. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C 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.
• Reimburse Mr C for the direct costs of the operation he underwent privately on receipt of evidence of the costs. The payment should be made by the date indicated: if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

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

• Ensure all suitable patients are offered nerve-sparing surgery and that they are fully informed about all options, including the possibility for surgery with intra-operative frozen section within the UK.
• Ensure that the multidisciplinary team process is clear and well documented and that changes in staging are explained.

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 the board did not provide reasonable care and treatment to her late brother (Mr A) at Inverclyde Royal Hospital and that the board's staff had failed to communicate adequately with her about Mr A. Mr A, who was terminally ill, died in the hospital days after his admission.

We took independent advice from a consultant in acute medicine and from a senior nurse. We found that there were failings in the care provided to Mr A when he was in A&E. There were failures to recognise and respond to Mr A's high blood glucose levels, to perform an electrocardiogram (ECG) as part of initial investigations on admission and to address his pain. We noted the board has acknowledged the failing to address Mr A's pain needs and has taken appropriate steps to improve this area of care.

We found that when Mr A was transferred to another ward, there was a failure to recognise and treat sepsis (blood infection) early enough or adequately for Mr A as a patient with an impaired immune system. We noted, in particular, that Mr A's profound and rapid deterioration may have been avoided with earlier, more aggressive input. Finally, there were a number of record-keeping failures, which meant it was unclear to know exactly what had happened with respect to Mr A's deterioration and the ward move. Therefore, we considered that the board did not provide reasonable clinical treatment to Mr A and upheld this aspect of the complaint.

In relation to Mr A's nursing care during his assessment in A&E, we identified failures to check Mr A's blood glucose levels and to address his pain relief while he was there. The nursing care received after Mr A's ward move was found to be of a reasonable standard. In view of the failings in relation to the nursing assessment in A&E, on balance, we considered that the board did not provide reasonable nursing care to Mr A and upheld this aspect of the complaint.

We noted that the board acknowledged that there were shortcomings in communication, and have offered an apology to Mrs C.

The principal issue our investigation identified was that there was a failure by haematologists (medical specialists of blood and its disorders) to discuss the rapid progression of Mr A's leukaemia with him and his family and that he would be for palliation (care to make you more comfortable, not cure) only. This contributed to the shock Mr A's deterioration had on his family. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and her family for a failure to check blood glucose and carry out an electrocardiogram test; a failure to recognise and treat sepsis; failures in record-keeping; and a failure to discuss the rapid progression of the leukaemia. 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 with diabetes should have their blood glucose checked on admission and regularly during their in-patient stay. Patients presenting with an abnormal heart rate should have an ECG on admission (as part of initial investigations). Patients who are in pain should have their pain needs addressed prior to transfer out of A&E. Patients who are immunosuppressed should be reviewed for sepsis early and frequently and have appropriate therapy commenced. Deteriorating patients should not be transferred between wards unless the move is intended to improve the management of that patient's deterioration/underlying condition. Staff should maintain reasonable medical records, consistent with General Medical Council guidance. Time and the band of nurse should be documented in the patient's records. Staff should communicate with a patient and relatives where it is clear that the patient is deteriorating and only palliative care is to be provided.

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 treatment his mother (Mrs A) received at the practice. Mrs A suffered from chest pain and breathlessness and had concerns she had angina (a heart condition). Mr C complained that appropriate treatment and investigations were not carried out in a reasonable time-frame.

We took independent medical advice from a GP. We found that the practice unreasonably failed to carry out appropriate physical assessments during appointments. While the practice did not consider angina was a likely cause for Mrs A's health concerns, at the point where it was agreed to refer her, the practice used the incorrect referral pathway. They arranged for an electrocardiograph (ECG - test that records the electrical activity of the heart) followed by a routine referral to cardiology (the branch of medicine that deals with diseases and abnormalities of the heart), instead of the appropriate action of an urgent exercise tolerance test (or if the patient was not physically capable of doing this test then an urgent cardiology referral). We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to follow the correct referral pathway for investigation of angina. 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:

• The GP should be familiar with the appropriate referral pathway when investigating angina.

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.