Upheld, recommendations

Summary

Mr C complained that his stoma reversal surgery (a surgery to reconnect the bowel) was delayed because of his mental health.

We took independent advice from a consultant colorectal (bowel) surgeon. We found that the surgeon acted unreasonably in failing to seek specialist advice from the mental health team when initally considering Mr C for surgery. In addition, we found that the surgeon did not respond when advice from the mental health team was offered. Mr C's maximum waiting time for treatment under the requirements of the Patients Rights (Scotland) Act 2011 was exceeded by ten months. There was no evidence that consideration was given by the board to arranging treatment by another provider or if any decision was made that this would not be an efficient and effective use of healthcare resources. We concluded that there was an unreasonable delay in the stoma reversal surgery going ahead, and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings this investigation has identified. 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:

• Staff should work together with other members of the healthcare team in a professional and supportive manner to maintain continuity of patient care.
• The board should take all reasonably practicable steps to ensure that it complies with the Treatment Time Guarantee.
• Where the board is not able to meet the Treatment Time Guarantee, they should consider arranging treatment by an alternative provider (as required by the Patient Rights Act and Regulations).

Summary

Mr C complained about the care and treatment he received at the Royal Infirmary of Edinburgh. He attended A&E after experiencing pain in his back and leg. Mr C was assessed by the on-call orthopaedic (conditions involving the muscoskeletal system) doctor and an x-ray was performed. Following this, Mr C was admitted to an orthopaedic ward. He was then discharged four days following admission. Weeks later, Mr C returned to hospital and a hip x-ray was performed. Investigations over the following days identified that Mr C had a pathological hip fracture and advanced prostate cancer. Mr C underwent a hip replacement procedure and was referred to the uro-oncology (the diagnosis and treatments of tumors of urinary systems) service.

Mr C complained about the delay in accurately diagnosing his condition and that he was unreasonably discharged from hospital during the first admission. We took independent advice from a consultant orthopaedic surgeon. We were critical that the board were unable to provide the in-patient orthopaedic notes for Mr C's first admission, other than the summary of ward rounds.

We found that the investigations performed following Mr C's initial presentation to the board were inadequate. We found that a hip examination and hip x-ray should have been performed given the examination findings. We considered it was likely that the failings in this case led to a delay for hip replacement surgery, during which time Mr C continued to suffer pain from the condition. We upheld this aspect of Mr C's complaint.

In the absence of the orthopaedic records for the first in-patient admission, we noted that the board were unable to demonstrate that Mr C had been safely discharged. We concluded that the decision to discharge Mr C was unreasonable and we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to examine and investigate Mr C's hip during the admission and for the poor record-keeping. 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:

• An individual with thigh pain and an inability to weight bear should have a hip examination performed. An individual who is unable to do an active straight leg raise and is unable to weight bear should have a hip x-ray performed.
• Ensure clinical records are appropriately managed.

Summary

Mrs C attended hospital to undergo colonoscopy (a procedure to look at the lining of the large bowel) and gastroscopy (a procedure to look at the inside of the oesophagus and first part of the small intestine). The information booklet she had been given in advance indicated that she would be sedated. However, Mrs C said she was persuaded to go ahead without sedation which she found extremely painful. She said that she felt traumatised and violated. She complained to the board who said that the matter of sedation had been discussed with her and it was her decision to go ahead without it; staff had no recollection of her complaining of pain.

We took independent advice from a gastroenterologist and from a registered nurse. We found that the procedures concerned were ones where sedation would normally be given as the information booklet indicated. There was no evidence that medical staff had discussed the procedures with Mrs C and the associated consent forms had not been properly completed. Similarly, we found concerns about the nursing records and although at one point Mrs C was recorded as having a pain score of 2-3 (out of 4) she was not monitored or assessed further. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs 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/leaflets-and-guidance.

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

• Medical staff should fully discuss risks and record the risk and benefits of any medical procedures.
• Nursing staff should follow the Nursing and Midwifery Council (NMC) guidelines when completing records.
• Nursing staff should respond appropriately to pain score data.

Summary

Mr C complained about the care and treatment his mother (Mrs A) received at Lorn and Islands Hospital. Mrs A initially presented to the emergency department experiencing vomiting. Following assessment, Mrs A received antibiotics and was discharged home. Mrs A returned to the emergency department two days later again with vomiting symptoms. After further assessment was carried out, Mrs A was discharged home. Mrs A attended the hospital again approximately five days later and was admitted to a ward. During the admission, investigations were carried out which indicated that Mrs A had metastatic cancer (cancer that has spread to other parts of the body). Mrs A's condition deteriorated during the admission and she died from her illness. Mr C complained about the care and treatment his mother received as well as the way hospital staff communicated with the family.

We took independent advice from a consultant in general medicine and a registered nurse. We found that Mrs A was unreasonably discharged from the emergency department on two occasions without her symptoms being effectively managed. We also found that an incorrect diagnosis had been reached during the first presentation to the emergency department, whilst the second presentation was poorly documented. We noted that once Mrs A was admitted to the ward, there was an unreasonable delay in obtaining a CT scan (a scan that uses x-rays to create detailed images of the inside of the body) of Mrs A's chest/ abdomen. We upheld this aspect of Mr C's complaint.

In response to Mr C's complaint, the board apologised that inaccurate information was given to family members regarding the length of time to obtain test results. We also found that there was a lack of discussion between nurses, doctors and the family around the possibility of discharging Mrs A home and a lack of clarity with the family about this. We upheld this aspect of Mr C's complaint.

Finally, Mr C was also unhappy with the time that the board took to investigate and respond to his complaint. We found that the delay was unreasonable and we were critical of the board's communication surrounding the delay. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise to Mr C for the unreasonable decisions to discharge Mrs A on two occasions; the incorrect diagnosis of urinary tract infection; poor documentation of Mrs A's second hospital attendance; the unreasonable delay obtaining a chest/ abdomen CT; the lack of local multidisciplinary discussion around the possibility of discharge; and failing to provide a reason for the complaint handling delay and a revised timescale. 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:

• Clinicians should take time to observe whether a patient requiring anti-sickness medication needs this medication to be given from a route other than oral, or needs alternative anti-sickness medication to manage their symptoms.
• A diagnosis of urinary tract infection should be supported by presence of relevant symptoms and appropriate tests.
• Patient records should include documentation of a full assessment by the medical team; details of any subsequent discussions; and plans for follow-up.
• CT imaging should be performed timeously.
• Patients and families should receive realistic estimates for how long it will take for biopsy results to become available.
• Where possible, patients with a life limiting diagnosis and their families should be involved in discussions around their preferred place of end of life care and what would be required to facilitate this.

In relation to complaints handling, we recommended:

• Where the complaint investigation cannot be completed within 20 working days, the person making the complaint should be provided with an explanation for the delay and a revised timetable for the response.

Summary

Ms C complained that her partner (Mr A) had been misdiagnosed with brain cancer.

We took independent advice form a consultant clinical oncologist. We found that it was unreasonable for the board to have given Mr A the wrong information by misdiagnosing him with brain cancer. We accepted that this was likely a mistake or human error as a result of misreading Mr A's scan report. Following the discovery of the error, most of the action taken by the board was reasonable. We noted that the board apologised to Mr A and the consultant involved had reflected on this matter. However, we also found that the board failed to record on Datix (incident reporting system) or another similar reporting system that Mr A had been misdiagnosed with brain metastases. They also failed to carry out a serious adverse event review to consider whether there were any contributory factors that could be mitigated. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately record and carry out an appropriate review to ensure that there were no other contributory factors that could be mitigated. 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:

• Near misses and errors should be reported via Datix or another similar reporting mechanism and, if indicated, a Serious Adverse Event Analysis should be carried out.

Summary

Mr C complained that the board failed to carry out a Significant Clinical Incident (SCI) investigation reasonably. Mr C's late partner (Ms A) underwent a hernia repair operation (an operation to correct a hernia, which is a bulging of internal organs or tissues through the wall that contains them) at a private hospital and later found this surgery had perforated her bowel. This perforation was successfully repaired with further surgery at Glasgow Royal Infirmary, however, Ms A continued to deteriorate and died shortly afterwards. The board carried out a SCI investigation which highlighted a number of failings in Ms A's care and several recommendations were made to improve practice going forwards. Mr C was unhappy with this report and complained to the board. Mr C remained unhappy with their response and brought his complaint to us.

We took independent advice from a consultant surgeon. We found that the scope of the SCI investigation was reasonable and that it had identified many of the issues with Ms A's care. However, there were some areas where the recommendations either did not address, or did not fully address, the failings. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the SCI process did not fully address all the failings in care and treatment provided to Ms A. 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 transfers from a hospital with no facility to manage full emergency assessment/emergency surgery to a hospital where optimal care can be provided, should be regarded as 'blue light', especially in the presence of sepsis.
• Surgical admissions of this type should be discussed with a more senior clinician (senior trainee or higher) to ensure management and treatments are optimised.
• All emergency cases should be assessed for sepsis on the Sepsis Six pathway and prompt management plans be put in place as necessary, including prompt administration of antibiotics.
• There should be standardisation of communication using an appropriate tool such as SBAR (Situation, Background, Assessment, Recommendation).

Summary

Mr C complained about the treatment provided to his late son (Mr A) who died during a hospital admission. Mr A was suffering from heart failure secondary to Friedreich's ataxia (an autosomal recessive genetic disease that causes difficulty walking, a loss of sensation in the arms and legs and impaired speech that worsens over time). After being administered calcium gluconate treatment for high potassium levels, Mr A vomited and collapsed with a cardiac arrythmia (irregular heartbeat) from which he could not be resuscitated. Mr C complained that the most junior doctor on the ward was given the responsibility of carrying out Mr A's treatment. He also complained that it had taken hours to carry out relevant tests on Mr A. The board acknowledged that a number of attempts were made to obtain blood for testing, spanning a period of several hours.

We took independent advice from a consultant cardiologist (doctor who deals with diseases and abnormalities of the heart). We found that there was no clinical need for Mr A's treatment to have involved more senior staff, noting that the challenging issue in this case was the emergency management of an elevated potassium level in a patient who was taking digoxin (a steroid used in small doses as a cardiac stimulant) medication with a higher than desirable blood level. While Mr A's blood potassium was at such a high level there was a risk of cardiac arrest at any time. We found that because of the metabolic complexity of the case and the excessive level of digoxin, full supportive measures should have been in place. In particular, we considered that there should have been continuous ECG (a test that records the electrical activity of the heart) monitoring. We were critical of the fact that there was no record of the junior doctor having discussed the complication of the excessive digoxin level with the cardiology registrar. We noted that the board had subsequently made changes to their protocol for treating hyperkalemia (high potassium level), to take into account concurrent treatment with digoxin.

We found that the apparent failure to recognise the complication of excessive digoxin, and the lack of continuous ECG monitoring, was unreasonable. We therefore upheld this complaint, while recognising that staff involved in Mr A's care were dealing with challenging circumstances.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failings identified in Mr A's treatment. In particular, the potential effects of intravenous calcium gluconate were not given due recognition. Bedside ECG monitoring should have been in place. 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:

• Staff involved in delivering care and treatment, including clinicians, must document discussions which inform their decision-making.

Summary

Mrs C complained about the treatment she had received from the practice. She had reported in consultations that her right big toe was cold, blue and painful. The pain continued and she received additional painkillers. Blood tests revealed a low iron count and iron tablets were prescribed. The pain continued and Mrs C also reported pain in her leg at the groin which was diagnosed as a groin strain. Mrs C continued to report problems and a referral was made to the vascular (circulatory) service where it was found she had blood clots in her leg and groin which resulted in her requiring an amputation of a foot.

We took independent medical advice from a GP. We found that initially it was felt Mrs C had chilblains (a painful, itch/swelling on a hand or foot, caused by poor circulation in the skin when exposed to cold) which was not unreasonable given the presenting symptoms. However, when the symptoms persisted the practice should have considered an alternative diagnosis of critical ischaemia (limb threat due to peripheral artery disease) rather than continue with chilblains. We also found that the diagnosis of tendonitis (groin strain) was unreasonable as Mrs C had not sustained an injury and that safety netting advice should have been given to Mrs C when she was prescribed painkillers. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in staff considering an alternative diagnosis that Mrs C's foot problems were attributable to chilblains.
• Apologise to Mrs C for the failure to carry out an appropriate examination and assessment of Mrs C's reported groin problems. 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:

• Staff should be aware to consider alternative diagnoses where the symptoms, which were felt initially to be attributable to a named diagnosis, were persisting.
• Staff should carry out appropriate assessments in view of a patient's presenting symptoms.

Summary

Miss C suffered from chronic osteoarthritis (a common form of arthritis that leads to pain, stiffness and swelling of the joints) in both of her hips and asked her GP to refer her to a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system) to be considered for hip replacement surgery. The consultant advised that they would not consider Miss C for surgery until her Body Mass Index (BMI, a measure for estimating human body fat) was reduced to an appropriate level. Miss C complained to the board that the consultant wrongly focused solely on her BMI and did not properly examine her or discuss her pain and mobility issues. Miss C requested a private referral for surgery from her GP and underwent hip replacement surgery on both of her hips.

The board explained that the consultant did not physically examine Miss C as there was no clinical reason to do so and that there are considerable risks and increased complication in patients who undergo surgery with a BMI greater than 40. Therefore, surgery is not recommended.

We took independent advice from an orthopaedic surgeon. We found that the board's approach to dealing with referrals of patients with a high BMI for hip replacement surgery was not sufficiently supported by the available guidance and it did not allow for individualised treatment. We also found that the board failed to carry out a thorough clinical assessment and that their reason for not offering Miss C a second opinion was not in line with the relevant guidance. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to carry out her hip replacement surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Reimburse Miss C for the cost of her first private hip replacement surgery on receipt of proof of the cost. The payment should be made by the date indicated. If payment is not made by that date, interest should be paid at the standard rate of interest applied by the courts from that date to the date of payment.

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

• The board should ensure that their approach in dealing with referrals of patients with a high BMI is flexible, in line with available guidance and adopts a holistic approach when deciding whether to carry out surgery.
• The board should ensure that patients with a high BMI who are seeking surgery are fully assessed.
• The board should remind staff of the General Medical Council guidance on consent and emphasise that the offer of a second opinion should not be limited to those occasions when the doctor is considering to offer treatment that they would not ordinarily do so.
• The board should ensure GP practices within their area are aware that patients can be re-referred if there is deterioration in their condition.

Summary

Mrs C complained on behalf of her daughter (Miss A) about the care and treatment she received for ongoing ear problems. Miss A had received care and treatment at Crosshouse Hospital over a number of years. Mrs C complained about information that was shared with her about Miss A at an Ear Nose and Throat (ENT) clinic consultation, specifically that Miss A might be putting fake blood in her ear; the decision to cancel another opinion; and the decision to discharge Miss A from the ENT service and refer her to mental health services. Mrs C also complained about the length of time it took the board to respond to her complaint.

We took independent advice from a consultant ENT surgeon. We considered that it was reasonable to consider the possibility of a psychological factor, cancel the third opinion, and refer Miss A to mental health services, on the basis that extensive investigations and treatments had not identified a physiological disorder. We also noted that Miss A had not been discharged from the ENT service but had been referred to mental health services. However, we found that there was no definitive evidence to clearly show that a fluid sample taken was in fact fake blood. In addition, we considered that the way in which the matter was approached with the family could have been more appropriately dealt with by mental health staff or at the very least their opinion should have been sought in the first instance. We considered that elements of Miss A's care and treatment were not handled reasonably and we upheld this aspect of Mrs C's complaint.

In relation to complaint handling, we found that the board had not responded to Mrs C's complaints correspondence within the 20 working day timescale. Mrs C was advised on two occasions that this may not be possible. We considered that this was reasonable given the board would have needed to review a number of years of care and treatment. However, we were critical that there were many occasions where Mrs C had to contact the board for updates after the 20 working day timescale had passed. On a number of occasions, the board did not proactively update Mrs C, as they should have done, with an expected timescale for the completion of their investigation. In addition, when they had suggested a revised timescale, this was not met. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A and the family for matters related to the fluid sample. 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:

• Staff should obtain speciality advice where appropriate and ensure that accurate information is shared with patients and their families.

In relation to complaints handling, we recommended:

• The board should have in place the necessary systems to ensure that complaints are handled in line with the NHS Scotland Model Complaints Handling Procedure, and that all staff responsible for dealing with complaints are aware of their responsibilities in this respect.