Upheld, recommendations

Summary

C’s spouse (A) was provisionally diagnosed with torticollis (a condition in which the head becomes persistently turned to one side) by their GP resulting in a routine referral to orthopaedics (specialism in the treatment of diseases and injuries of the musculoskeletal system). A’s symptoms continued to worsen and their referral was upgraded to urgent. A had a telephone call with an orthopaedic consultant and an MRI scan was organised. The pain continued to intensify despite strong medication. A presented to the out-of-hours service and also to A&E with worsening pain in their neck. A was referred to the hospital by their GP and advised that they were terminally ill with bladder cancer which had spread to the spine. A later died.

C complained to the board with concerns about A’s initial referral to orthopaedics not being treated as urgent, for the delay for an MRI scan, for orthopaedics not being consulted by A&E and further testing not being arranged. C additionally complained about the lack of process for a patient to be moved up the list of clinical priority when presenting to A&E. The board’s response indicated that no red flags were raised in the initial referral, that the orthopaedic consultant organised an MRI scan after speaking with A and that the out-of-hours assessments did not identify immediate orthopaedic review was required. The response also noted that A&E noted a plan was in place for further investigation, that there was no emergency issue which required immediate referral and that the GP was best placed to expedite further care with the orthopaedic team.

We took independent advice from a trauma and orthopaedic consultant, a GP and a consultant in emergency medicine. We found that it was reasonable for orthopaedics to treat the original referral as routine, but it was unreasonable that there is no evidence of a clinical summary of the orthopaedic consultation, and thereby no evidence that red flags were explored. We upheld this aspect of the complaint. We found that it was unreasonable that a more detailed history and clinical examination was not undertaken at the out-of-hours consultations, especially of red flags. We upheld this aspect of the complaint. We found that it was reasonable that A&E did not refer A urgently to another speciality or arrange further investigation or immediate assessment. We did not uphold this element of the complaint.

We also found that the board failed to identify that a Significant Adverse Event Review should have been carried out and that their complaint response did not clarify that it was a joint response with a second board, resulting in a lack of clarity and transparency.

Recommendations

What we asked the organisation to do in this case:

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

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

• Orthopaedic telephone consultations should be recorded, including evidence that any possible red flag symptoms have been explored and considered.
• Patients should be examined thoroughly and a clear history should be taken which considers the presence or absence of red flag symptoms.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to dealing with complaints which span more than one NHS board.

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 partnership did not provide reasonable care and treatment to their parent (A). A was admitted to hospital on three occasions during one month following falls. After their third admission, A was discharged to C’s home due to the COVID-19 pandemic. A week later, A was admitted to another hospital and was diagnosed with a lumbar (spinal) fracture and incomplete spinal cord damage. C raised a number of complaints with the partnership about the care and treatment A received and about their discharge.

The partnership did not indicate any concerns about A’s care and treatment or discharge but noted that discharge planning had been disrupted due to the COVID-19 pandemic. The partnership also undertook a Significant Adverse Event Review (SAER).

We took independent advice from an appropriately qualified adviser. We found that the partnership did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of changes in A’s condition. Therefore, we upheld this part of C’s complaint.

In relation to A’s discharge, we found no clear evidence that the concerns expressed by the physiotherapist about deterioration were assessed before the decision to discharge A was made. Therefore, we considered A was unreasonably discharged and upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family that partnership staff did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of increased leg weakness in A, that concerns expressed by physiotherapy staff about deterioration in A were not assessed before the decision to discharge A was taken and that the findings of the SAER were not shared with A and their family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. Enquire whether A’s family wish to meet with the hospital manager and lead nurse and, if so, arrange and hold that meeting.

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

• Communications related to changes in patient care or decisions are reasonably documented.
• Decisions to discharge always take into account the circumstances of the patient at the time, and that if any change in a patient’s condition could affect the decision to discharge them, this must be considered at the time.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their parent (A) during an admission to hospital. At the time of admission, A was taking medication for atrial fibrillation (a heart condition affecting the rhythm and rate of the heart). The medication included a blood-thinner to reduce the risk of blood clots. While A’s condition was being assessed, a decision was made to withhold this medication. A developed pain and discolouration in their leg and was unable to weight bear. C complained that there was a delay of 12 hours before medical staff acted upon this. A required a transfer to another hospital by ambulance, where they underwent emergency surgery for clots in the leg. A has been left with deep incisions in the lower leg and their mobility has been significantly reduced.

The board discussed the case at a Morbidity and Mortality meeting, and following review of the circumstances did not think that there was anything from a system perspective that should be changed.

We took independent advice from a consultant physician and geriatrician (specialist in medicine of the elderly). We found failings in record keeping and examination. We found that the board ought to have been alert to the risk of A developing blood clots after the blood-thinning medication was withheld, and should have acted more promptly when A started to deteriorate. We considered that A suffered pain for a longer period because their deterioration was not recognised in a timely manner. Their situation might not have been so serious had their condition been recognised sooner. We also found that the board did not carry out a suitably rigorous analysis of what happened, including review by staff who were not involved in A’s care. The board’s review failed to identify appropriate learning. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings our investigation has 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:

• Before reaching a decision to stop anticoagulant medication in patients with atrial fibrillation, full consideration should be given to the risks and benefits of doing so. Clear records of patient care should be maintained, with all patient examinations documented. Deterioration in patients should be escalated appropriately including clinical examination where merited. Staff are confident in identifying adverse events and conducting appropriate reviews.

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

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

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

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

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

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

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

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

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

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

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

In relation to complaints handling, we recommended:

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

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

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

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

In relation to complaints handling, we recommended:

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

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

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

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

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

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

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

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

In relation to complaints handling, we recommended:

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

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

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

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

Recommendations

What we asked the organisation to do in this case:

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

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

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

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.