Glasgow

Report no:

202207986
Date:

February 2025
Body:

Greater Glasgow and Clyde NHS Board - Acute Services Division
Sector:

Health

The complainant (C) complained to my office about the treatment provided to their late parent (A) by Greater Glasgow and Clyde NHS Board - Acute Services Division (the Board).

A had a number of pre-existing health conditions and had previously had a laryngectomy (the surgical removal of the larynx (voice box) which disconnects the upper airway (nose and mouth) from the lungs). A had a laryngectomy ‘larytube’ stoma and cannula in situ (where the trachea (windpipe) is cut and then the open end is stitched onto the front of the neck).

On 20 April 2021, A had a fall at home and was taken to the Emergency Department (ED) at Glasgow Royal Infirmary (the hospital) via ambulance. A was admitted to the Acute Medical Receiving Unit (AMRU). A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Order was put in place (meaning a patient does not receive resuscitation where their heart stops beating or their breathing stops).

On 21 April 2021, A indicated that they felt that their larytube was blocked. A student nurse provided laryngectomy care to A and was unable to replace the larytube. A experienced respiratory arrest (where breathing stops) followed by a cardiac arrest (where the heart stops beating) and sadly died.

The Board carried out a Significant Adverse Event Review (SAER). In their SAER, and their written response to C’s complaint, the Board’s overall conclusion was that the care provided to A was both appropriate and competent despite some failings having been identified.

C complained to my office about aspects of A’s laryngectomy care, including the decision to put a DNACPR Order in place and the conclusions reached by the SAER investigation.

During my investigation I sought independent advice from Consultant Physician in Acute Medicine and a Consultant Ear, Nose and Throat (ENT) Surgeon. Having considered and accepted the advice I received, I found that:

Appropriate equipment was not available at A’s bedside for laryngectomy care.
It was unreasonable that A did not receive humidified oxygen in the Emergency Department and did not receive humidification in accordance with National Tracheostomy Safety Programme (NTSP) guidelines. This may have prevented the blockage in A’s larytube from happening.
A student nurse acted without supervision in providing laryngectomy care to A.
In the circumstances, given A’s complex co-morbidities, it was reasonable for the medical team to put a DNACPR in place without discussion with the family. Notwithstanding this, it was unreasonable (both in placing the DNACPR order and in following it through) that no distinction was made between the context of an expected death/sudden cardiorespiratory arrest and an unforeseen event/ readily reversible cause. As a result, it was unreasonable that ventilation/ resuscitation was not attempted.
Airway help was not sought immediately when the larytube could not be reinserted.
There was a failure to activate the duty of candour process in this case.
There was a failure to undertake a reasonable SAER that identified key learning and improvements. This included recording conclusion Code 2 (Issues identified but they did not contribute to the event) when conclusion Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.

Taking all of the above into account, I upheld C’s complaints.

Redress and Recommendations

The Ombudsman’s recommendations are set out below:

What we are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to do for the complainant:

Rec. number	What we found	What the organisation should do	What we need to see
1.	Under complaint point (a) I found: it was unreasonable that appropriate equipment was not at A’s bedside. it was unreasonable that A did not receive adequate humidification. it was unreasonable that the student nurse acted without supervision in providing laryngectomy care to A. unreasonable that airway help was not sought immediately when the laryngectomy cannula could not be reinserted. it was unreasonable that ventilation/ resuscitation was not attempted. Under complaint point (b) I found: there was a failure to activate the duty of candour process in this case. there was a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. This included recording conclusion Code 2 (Issues identified but they did not contribute to the event) when conclusion Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.	Apologise to C and her family for: The failure to ensure appropriate equipment was at A’s beside. The failure to administer adequate humidification to A. The student nurse acting without supervision in providing laryngectomy care to A. The failure to attempt ventilation/ resuscitation of A. The failure to activate the duty of candour process. The failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. This included recording conclusion Code 2 rather than conclusion Code 3. The apology should be specific and meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets	A copy or record of the apology. By: 19 March 2025

Rec. number

What we found

What the organisation should do

What we need to see

Under complaint point (a) I found:

it was unreasonable that appropriate equipment was not at A’s bedside.
it was unreasonable that A did not receive adequate humidification.
it was unreasonable that the student nurse acted without supervision in providing laryngectomy care to A.
unreasonable that airway help was not sought immediately when the laryngectomy cannula could not be reinserted.
it was unreasonable that ventilation/ resuscitation was not attempted.

Under complaint point (b) I found:

there was a failure to activate the duty of candour process in this case.
there was a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. This included recording conclusion Code 2 (Issues identified but they did not contribute to the event) when conclusion Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.

Apologise to C and her family for:

The failure to ensure appropriate equipment was at A’s beside.
The failure to administer adequate humidification to A.
The student nurse acting without supervision in providing laryngectomy care to A.
The failure to attempt ventilation/ resuscitation of A.
The failure to activate the duty of candour process.
The failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements. This included recording conclusion Code 2 rather than conclusion Code 3.

The apology should be specific and meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

A copy or record of the apology.

By: 19 March 2025

We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to improve the way they do things:

Rec. number	What we found	Outcome needed	What we need to see
2.	Under complaint point (a) I found it was unreasonable that A did not receive adequate humidification.	Patients with laryngectomies should receive appropriate humidification as set out in The National Tracheostomy Safety Programme (NTSP) guidelines.	Evidence that: these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions). the learning from these events is reflected in policy/ guidance and staff training with details of how this will be disseminated to relevant staff. By: 19 August 2025
3.	Under complaint point (a) I found it was unreasonable that airway help was not sought immediately when the laryngectomy cannula could not be reinserted.	Where there is a difficulty reinserting laryngectomy cannulas, airway help should be sought without delay.
4.	Under complaint point (a) I found it was unreasonable that ventilation/ resuscitation was not attempted in the circumstances of A’s case.	Decisions in relation to ventilation/ resuscitation when a DNACPR is in place should be taken in line with relevant national guidance. Where a decision is taken not to follow relevant national guidance this decision, and the reasons for it, should be clearly recorded.
5.	Under complaint point (b) I found that there was a failure to activate the duty of candour process in this case.	When an incident occurs that falls within the duty of candour legislation, the Board’s Duty of Candour processes should be activated without delay.	Evidence that the Board have reviewed their Duty of Candour processes, including their process for identifying and activating the process. By: 19 May 2025
6.	Under complaint point (b) I found that there was a failure to undertake a reasonable Significant Adverse Event Review that identified key learning and improvements.	Local and Significant adverse event reviews should be reflective and learning processes that ensure failings are identified and any appropriate learning and improvement taken forward. Adverse event reviews should be held in line with relevant guidance.	Evidence that the Board have reviewed their process for carrying out adverse event reviews to ensure these reviews properly investigate, identify learnings, and develop system improvements to prevent similar incidents occurring. By: 19 May 2025
7.	Under complaint point (b) I found that the Board unreasonably recorded a conclusion of Code 2 (Issues identified but they did not contribute to the event) on the SAER when a conclusion of Code 3 (Issues identified which may have caused or contributed to the event) would have been more appropriate.	Conclusion codes on adverse event reviews should reflect the findings.	Evidence that the Board have noted the incorrect conclusion code on the SAER report and have ensured this is a matter of record either by reissuing a revised SAER report, or by issuing an addendum, in line with any relevant Healthcare Improvement Scotland guidance and advice. By: 19 May 2025

We are asking Greater Glasgow and Clyde NHS Board - Acute Services Division to improve their complaints handling:

Rec. number	What we found	Outcome needed	What we need to see
8.	There was a failure to fully investigate and identify the significant failings in this case in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. There was also a failure to apologise to C as part of the complaint response.	Complaints should be investigated and responded to in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified.	Evidence that: the Board have carried out a review of the management of this case from a complaint handling perspective these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions). By: 19 May 2025

Rec. number

What we found

Outcome needed

What we need to see

There was a failure to fully investigate and identify the significant failings in this case in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. There was also a failure to apologise to C as part of the complaint response.

Complaints should be investigated and responded to in accordance with the Board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified.

Evidence that:

the Board have carried out a review of the management of this case from a complaint handling perspective
these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (for example, a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 19 May 2025

Feedback

Response to SPSO investigation

The Board’s response to our enquiries initially provided us with the accounts of different specialists employed by the Board which differed in opinion on some significant points, without providing the Board’s overall view. This resulted in delays to our investigation while we established what the Board’s overall view was. When responding to SPSO enquiries, the Board should ensure that their response reflects the Board’s overall position. I am including this as feedback for the Board to reflect on.

Report no:

202100560
Date:

May 2023
Body:

A Medical Practice in the Lanarkshire NHS Board area
Sector:

Health

The complainant (C), a representative of the Patient Advice and Support Service, complained to my office on behalf of A about the treatment A’s spouse (B) received from their GP practice (the Practice) between July and October 2020. B developed cellulitis (a bacterial infection of the skin) on one of their legs. Although B was treated with multiple courses of antibiotics, the infection did not improve. Following an allergic reaction to the antibiotics, B chose not to receive further treatment. Sadly, B’s condition deteriorated and B died.

C complained that the Practice prescribed five courses of antibiotics without seeing B and considered that a GP should have reviewed B face-to-face when the infection did not resolve. A complained that B was not told of the risks of refusing antibiotic treatment. A also considered that the Practice should have carried out blood and skin tests to ensure that an effective antibiotic was prescribed and that the Practice should have referred B to hospital for intravenous antibiotics when B’s condition did not improve.

The Practice detailed the contact they had with B and said that skin conditions such as cellulitis are treated by their Advanced Nurse Practitioners (ANPs) and that they considered the treatment offered to B had been appropriate. The Practice said that they would not recommend the referral of B to hospital due to the COVID-19 restrictions in place at the time.

I sought independent advice from a GP (the Adviser). The Adviser told me B should have been closely monitored and specialist advice should have been sought early on in B’s care pathway. The Adviser told me B should have been seen face-to-face at the first appointment and a doctor should have been involved after the first course of antibiotics failed to work and in line with NICE accredited guidelines, specialist input should have been sought after a second course of antibiotics failed to improve B’s condition and admission for intravenous antibiotics considered.

The Adviser also told me there were no restrictions in place preventing patients from being admitted to hospital should their condition require this between July and October 2020. The Adviser gave their view that the failings they had identified had contributed to B’s death.

In light of the evidence I have seen and the advice I received, I found that: the Practice did not provide reasonable care and treatment to B between July and October 2020. As such, I upheld C’s complaint.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Practice to do for A:

Rec. number	What we found	Outcome needed	What we need to see
1.	Under (a) we found that the care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable. In particular that: B should have been seen face-to-face at their first appointment and by a GP after the first course of antibiotics failed to work. Swabs should have been taken when there was no improvement. Specialist input should have been sought after B’s condition failed to improve. A Significant Event Analysis or similar reflective review should have been carried out. The Practice’s complaint response was unreasonable.	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.	A copy or record of the apology. By: 21 June 2023

Rec. number

What we found

Outcome needed

What we need to see

Under (a) we found that the care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable. In particular that:

B should have been seen face-to-face at their first appointment and by a GP after the first course of antibiotics failed to work.
Swabs should have been taken when there was no improvement.
Specialist input should have been sought after B’s condition failed to improve.
A Significant Event Analysis or similar reflective review should have been carried out.
The Practice’s complaint response was unreasonable.

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.

A copy or record of the apology.

By: 21 June 2023

We are asking the Practice to improve the way they do things:

Rec. number	What we found	Outcome needed	What we need to see
2.	The care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable.	Patients presenting with symptoms suggesting cellulitis should be appropriately assessed including a face-to-face assessment and being appropriately monitored. If their condition does not improve treatment should be escalated in line with relevant guidance.	Evidence that the Practice have: Critically reviewed their guidance and training needs on the management of cellulitis for all relevant staff to ensure achievement of the outcomes needed. Ensured relevant guidelines are appropriately referred to and reflected. Confirmation should be provided of the review and the changes implemented as a result of this review; how the guidance has been updated and disseminated, and how the training needs of staff have been addressed. By: 16 August 2023, with a progress update by 5 July 2023.
3.	A Significant Event Analysis or similar reflective review should have been held.	Where there has been a significant adverse event a reflective review should be considered, and either a clear reason recorded as to why it was not carried out, or held, ensuring that events are considered against relevant standards and guidelines and that failings, and good practice, are identified and any appropriate learning and practice improvements made.	Evidence that the Practice have systems and processes in place for reflective review of significant adverse events that support staff involved to identify learning and improvement By: 16 August 2023

Rec. number

What we found

Outcome needed

What we need to see

The care and treatment provided by the Practice to B between July 2020 and October 2020 was unreasonable.

Patients presenting with symptoms suggesting cellulitis should be appropriately assessed including a face-to-face assessment and being appropriately monitored.

If their condition does not improve treatment should be escalated in line with relevant guidance.

Evidence that the Practice have:

Critically reviewed their guidance and training needs on the management of cellulitis for all relevant staff to ensure achievement of the outcomes needed.
Ensured relevant guidelines are appropriately referred to and reflected.

Confirmation should be provided of the review and the changes implemented as a result of this review; how the guidance has been updated and disseminated, and how the training needs of staff have been addressed.

By: 16 August 2023, with a progress update by 5 July 2023.

A Significant Event Analysis or similar reflective review should have been held.

Where there has been a significant adverse event a reflective review should be considered, and either a clear reason recorded as to why it was not carried out, or held, ensuring that events are considered against relevant standards and guidelines and that failings, and good practice, are identified and any appropriate learning and practice improvements made.

Evidence that the Practice have systems and processes in place for reflective review of significant adverse events that support staff involved to identify learning and improvement

By: 16 August 2023

We are asking the Practice to improve their complaints handling:

Rec. number	What we found	Outcome needed	What we need to see
4.	The Practice’s complaint response was unreasonable. There is no evidence to support the Practice’s recording that the complaint was acknowledged or that the complaint was responded to within 20 working days in line with the Model Complaints Handling Procedure. There was a failure to investigate and respond to all the concerns raised by C and provide an appropriate response that recognised the significance of the events for A and the impact of B’s death. The response was undated.	The Practice’s complaint handling monitoring and governance system should ensure that: Complaints are properly investigated and responded to in line with the NHS Scotland Model Complaints Handling Procedure. Failings and good practice are identified, and learning from complaints is used to drive service development and improvement. Complaint responses recognise and acknowledge the significance and human impact of the events complained about, particularly when a death has occurred. Complaint responses are clearly dated and records reflect when and how they are shared.	Evidence that the findings on the Practice’s complaint handling have been fed back in a supportive manner to relevant staff and that they have reflected on the findings of this investigation. (For instance, a copy of a meeting note or summary of a discussion.) By: 19 July 2023

Rec. number

What we found

Outcome needed

What we need to see

The Practice’s complaint response was unreasonable.

There is no evidence to support the Practice’s recording that the complaint was acknowledged or that the complaint was responded to within 20 working days in line with the Model Complaints Handling Procedure.

There was a failure to investigate and respond to all the concerns raised by C and provide an appropriate response that recognised the significance of the events for A and the impact of B’s death.

The response was undated.

The Practice’s complaint handling monitoring and governance system should ensure that:

Complaints are properly investigated and responded to in line with the NHS Scotland Model Complaints Handling Procedure.
Failings and good practice are identified, and learning from complaints is used to drive service development and improvement.
Complaint responses recognise and acknowledge the significance and human impact of the events complained about, particularly when a death has occurred.

Complaint responses are clearly dated and records reflect when and how they are shared.

Evidence that the findings on the Practice’s complaint handling have been fed back in a supportive manner to relevant staff and that they have reflected on the findings of this investigation. (For instance, a copy of a meeting note or summary of a discussion.)

By: 19 July 2023

Report no:

202002915
Date:

January 2022
Body:

Greater Glasgow and Clyde NHS Board - Acute Services Division
Sector:

Health

C complained about the standard of care and treatment provided to them in relation to a hysterectomy they underwent in January 2020, which resulted in damage to their bowel requiring additional, emergency surgery. In addition to concerns regarding the procedure itself, C also complained that the Board had failed to provide reasonable ongoing care, before, between, and after the surgeries in question.

On investigation, we sought independent clinical advice from an experienced consultant gynaecologist. The advice we received, and which we accepted, was that there were a number of unreasonable failures in the care and treatment provided. Particular key points from our findings were that:

the damage caused to C's bowel during surgery should have been identified at the time;
the Board failed to inform C of the complication in a timely manner; and
the Board failed to subsequently investigate how the injury occurred and the overall conduct of the procedure in a reasonable manner, or apply their duty of candour appropriately.

As a result of these failures, we upheld both of C's complaints.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C:

Complaint number	What we found	What the organisation should do	What we need to see
(a)	The Board failed to carry out the operation in a reasonable manner, with damage occurring which was not identified during the operation, that the operation was carried out by a trainee doctor and this was not openly referred to in the complaint response.	Apologise to C for the care provided by the Board, acknowledging the impact the bowel injury had on C.	A copy of the letter of apology which should meet the standards of the SPSO guidance accessible here: https://www.spso.org.uk/meaningful-apologies. By: 1 month of publication of report

Complaint number

What we found

What the organisation should do

What we need to see

(a)

The Board failed to carry out the operation in a reasonable manner, with damage occurring which was not identified during the operation, that the operation was carried out by a trainee doctor and this was not openly referred to in the complaint response.

Apologise to C for the care provided by the Board, acknowledging the impact the bowel injury had on C.

A copy of the letter of apology which should meet the standards of the SPSO guidance accessible here: https://www.spso.org.uk/meaningful-apologies.

By: 1 month of publication of report

We are asking the Board to improve the way they do things:

Complaint number	What we found	Outcome needed	What we need to see
(a)	The Board failed to carry out the operation in a reasonable manner.	A Significant Adverse Event Review (SAER) is carried out which includes review of the pre-operative investigations, the decision to undertake the procedure, the missed complication during the operation, a trainee conducting the operation, senior input during and after the operation, the aftercare, investigations postoperation and support given to the clinicians concerned in relation to the event, in particular to trainee and junior doctors.	Evidence a SAER has been completed. By: 6 months of publication of report
(a)	The Board failed to inform C of the complication in a timely manner.	Complainants should be informed candidly, openly and honestly when a complication occurs during a procedure, including explaining what happened and what action the Board have taken (or intend to take).	A review of how surgical complications are communicated with patients and consideration for a standard operation procedure for such instances. By: 3 months of publication of report

Complaint number

What we found

Outcome needed

What we need to see

(a)

The Board failed to carry out the operation in a reasonable manner.

A Significant Adverse Event Review (SAER) is carried out which includes review of the pre-operative investigations, the decision to undertake the procedure, the missed complication during the operation, a trainee conducting the operation, senior input during and after the operation, the aftercare, investigations postoperation and support given to the clinicians concerned in relation to the event, in particular to trainee and junior doctors.

Evidence a SAER has been completed.

By: 6 months of publication of report

(a)

The Board failed to inform C of the complication in a timely manner.

Complainants should be informed candidly, openly and honestly when a complication occurs during a procedure, including explaining what happened and what action the Board have taken (or intend to take).

A review of how surgical complications are communicated with patients and consideration for a standard operation procedure for such instances.

By: 3 months of publication of report

We are asking the Board to improve their complaints handling:

Complaint number	What we found	Outcome needed	What we need to see
(a)	The response to C’s complaint failed to adequately investigate how the injury occurred, the overall conduct of the procedure and learning from the event.	Complaint responses are open and candid as to what happened and identify learning and what action will be taken in response.	Evidence that the findings of my investigation have been fed back to the staff involved, in a supportive manner, for reflection and learning. By: 2 months of publication of report
(a) and (b)	The Board failed to identify through their own investigation the need for a SAER. This includes why this incident was not reported/consideration given to a SAER at the time, and why duty of candour wasn’t applied. The complaint investigation did not consider these omissions and prompt a robust investigation into the incident and candid explanation as to what happened.	Where an incident occurs measures are in place to consider whether further investigation is required and providing open and honest communication with a patient.	Evidence a review of the reporting processes has been undertaken and whether further action is required to reduce the likelihood of a recurrence. By: 3 months of publication of report

Complaint number

What we found

Outcome needed

What we need to see

(a)

The response to C’s complaint failed to adequately investigate how the injury occurred, the overall conduct of the procedure and learning from the event.

Complaint responses are open and candid as to what happened and identify learning and what action will be taken in response.

Evidence that the findings of my investigation have been fed back to the staff involved, in a supportive manner, for reflection and learning.

By: 2 months of publication of report

(a) and (b)

The Board failed to identify through their own investigation the need for a SAER. This includes why this incident was not reported/consideration given to a SAER at the time, and why duty of candour wasn’t applied. The complaint investigation did not consider these omissions and prompt a robust investigation into the incident and candid explanation as to what happened.

Where an incident occurs measures are in place to consider whether further investigation is required and providing open and honest communication with a patient.

Evidence a review of the reporting processes has been undertaken and whether further action is required to reduce the likelihood of a recurrence.

By: 3 months of publication of report

Report no:

201905973
Date:

December 2021
Body:

Greater Glasgow and Clyde NHS Board - Acute Services Division
Sector:

Health

C complained about the care and treatment provided to their adult son (A) when they were admitted to Queen Elizabeth University Hospital for a total thyroidectomy (complete removal of the thyroid gland) and right neck dissection (surgical removal of lymph nodes) due to cancer. On the day of the surgery, the consent form was completed and it mentioned a number of risks, including risk of bleeding.

The surgery went well and two surgical drains were inserted into the right side of A's neck. Three days after surgery, the first drain was removed by a nurse, following instruction by an Ear, Nose and Throat (ENT) Registrar. The second drain was removed the following day. Shortly after, A's neck was numb and swelling and they became distressed with a shortness of breath. A had developed a haematoma (localised bleeding outside of blood vessels) and a subsequent cardiorespiratory arrest. An emergency procedure was performed to relieve the pressure in A's airway. A recovered but was left with mobility and speech difficulties and seizures.

C complained about the nursing care provided to A. They said that A was not appropriately monitored and the removal of the tube was not performed correctly given the haematoma developed. They also complained about the medical care provided, that they were not told of the risk of hypoxic brain injury or of the Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) order that was put in place.

We sought independent clinical advice from a registered nurse (Adviser 1) and a Consultant ENT Surgeon (Adviser 2). Adviser 1 noted that A's drains were removed in accordance with the postoperative and ENT Registrar's instructions and that they were monitored frequently. We concluded that A was appropriately monitored and we did not find any evidence that the removal of the tubes was performed incorrectly. As such, we concluded that the nursing care provided was reasonable and we did not uphold the complaint.

In respect of the medical care provided, Adviser 2 explained that a secondary haemorrhage is a known complication of this kind of surgery and the SCOOP protocol should be followed to help relieve the pressure on the airway. SCOOP protocol advises to open the wound and remove the haematoma.

Our investigation found that while Greater Glasgow and Clyde NHS Board (the Board) said they followed the SCOOP protocol, it was not followed correctly. There was a limited opening of the wound and the haematoma remained present for over 90 minutes, whereas it should have been removed as quickly as possible. If this had been done, it would have most likely prevented A's cardiorespiratory arrest that led to a hypoxic (reduced supply of oxygen) brain injury. Following this event, the Board discussed the case at a morbidity and mortality meeting, however they failed to identify the SCOOP protocol was not followed correctly. Our investigation found that the risk of a blood clot in the neck causing breathing difficulty was not mentioned and this should have been listed on the consent form and discussed. We also concluded that while there was evidence of regular discussion with the family about A's condition and prognosis, it was not recorded that DNACPR was specifically mentioned or that the family fully understood this.

Overall, we concluded that the Board failed to ensure A was provided with a reasonable standard of medical care and treatment during their admission, specifically in the way the emergency situation was handled and we upheld the complaint on that basis.

We made a number of recommendations to address the issues identified and we will follow up on these recommendations. The Board are asked to ensure guidance on the SCOOP protocol is fully implemented and that staff are aware of the relevant guidelines for DNACPR orders by the date specified. We will expect evidence that appropriate action has been taken before we can confirm that the recommendations have been implemented.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C:

Complaint number	What we found	What the organisation should do	What we need to see
(b)	We found that the Board failed to follow the SCOOP protocol correctly, by ensuring that the family understood fully the DNACPR process, and by explaining that a bleed in the neck causing breathing difficulty was a risk.	Apologise to C and 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.	A copy or record of the apology. By: 24 January 2022

Complaint number

What we found

What the organisation should do

What we need to see

(b)

We found that the Board failed to follow the SCOOP protocol correctly, by ensuring that the family understood fully the DNACPR process, and by explaining that a bleed in the neck causing breathing difficulty was a risk.

Apologise to C and 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.

A copy or record of the apology.

By: 24 January 2022

We are asking the Board to improve the way they do things:

Complaint number	What we found	What the organisation should do	What we need to see
(b)	We found that the Board did not follow the SCOOP protocol correctly.	BAETS guidelines should be fully implemented in the relevant department(s).	Evidence that appropriate learning has been implemented in the relevant department(s). By: 22 March 2022
(b)	We found that the Board did not ensure that family members fully understood the DNACPR process.	All staff should be aware of the Resuscitation Council UK guidelines for DNACPR orders.	Evidence that all staff have appropriate understanding of DNACPR procedures. By: 22 March 2022

Complaint number

What we found

What the organisation should do

What we need to see

(b)

We found that the Board did not follow the SCOOP protocol correctly.

BAETS guidelines should be fully implemented in the relevant department(s).

Evidence that appropriate learning has been implemented in the relevant department(s).

By: 22 March 2022

(b)

We found that the Board did not ensure that family members fully understood the DNACPR process.

All staff should be aware of the Resuscitation Council UK guidelines for DNACPR orders.

Evidence that all staff have appropriate understanding of DNACPR procedures.

By: 22 March 2022

Feedback

Points to note

Adviser 1 reported that the patient's case record lacked chronology and that some of the notes were difficult to read and it was not always evident who wrote the note or their designation/profession. Whilst appreciating it is not always possible to complete notes at the time of a significant event, someone allocated to noting the timing of events and personnel in attendance should take care to note these details and ensure that records are correct and as full as they can be.

Report no:

201809851
Date:

May 2021
Body:

Greater Glasgow and Clyde NHS Board - Acute Services Division
Sector:

Health

C complained about the care and treatment provided to their spouse (A). A developed Cauda Equina Syndrome (CES, narrowing of the spinal column where all of the nerves in the lower back suddenly become severely compressed) in September 2018. C believed there were avoidable delays in diagnosing and treating A, which meant the damage A suffered was more severe and the outcome worse than it might have been.

A was originally referred to Royal Alexandra Hospital (Hospital 1) by their General Practitioner (GP). C believed that A was displaying red flag symptoms of CES at this point. A attended Hospital 1 on 20 September 2018, but was discharged without consultant review or imaging of their spine.

A continued to deteriorate and attended Hospital 1 again on 28 September 2018 at 09:00 hrs. A Magnetic Resonance Imaging (MRI) scan (a scan using power magnetic fields to generate images of the inside of the body) was carried out at 15:00 hrs. The neurosurgical team at Queen Elizabeth University Hospital (Hospital 2) were contacted, but they declined to accept A for transfer. A was discharged at around 21:00 hrs. They did not have a treatment plan and had not been reviewed by a consultant.

C took A to Hospital 2's A&E the following day. A was admitted to a neurosurgery ward and reviewed by a junior doctor. On 30 September 2018, A was referred for a further MRI by the Consultant Neurosurgeon. A underwent surgery on 1 October 2018.

A was discharged without any follow-up care being arranged. This was later arranged by their GP. They were admitted a month later as a spinal emergency, and again A was discharged without any follow-up care being arranged.

Relevant to this report was case 2016084301; a public report we issued about the Board previously. This investigation looked into a complaint of unreasonable delays in the treatment of CES by the Board. The investigation found that the Board failed to provide spinal surgery in a reasonable timeframe to the complainant. This was despite clear guidance that surgery needed to be performed as an emergency on an incomplete CES. This also included a failure to provide the complainant with adequate information about their condition or make the necessary referrals for postoperative care.

This report was published in January 2018. The case was closed after the Board provided evidence it had complied with our recommendations, which was largely done by April 2018. This is significant, because A's first attendance at hospital was in September 2018, after the Board was meant to have implemented changes to reduce delays for patients with CES.

We took independent advice from a consultant orthopaedic surgeon and a consultant neurosurgeon. Both advisers identified avoidable delays in A's care and treatment. The orthopaedic adviser said that A had been displaying red flag symptoms of CES when they first attended hospital on 20 September 2018. The delays in scanning A were unreasonable and A's treatment had not been in line with national guidance on the management of possible CES cases.

The neurosurgery adviser said that it was unreasonable for the Neurosurgery Department at Hospital 2 to refuse to provide diagnostic advice, or accept A for transfer on 28 September 2018. A should have been admitted as a neurosurgical emergency and undergone decompression surgery on 28 September 2018. It was also unreasonable to have delayed A's surgery further once they were admitted to a neurosurgical ward.

We found that there were significant failings by the Board in the care and treatment that was provided to A. These included the failure to recognise that A was displaying red flag symptoms of CES, unreasonable delays and incorrect decisions to discharge A, as well as avoidable delays to performing surgery on A, once the severity of their condition had been grasped.

We also found that the Board had failed to investigate C's complaint appropriately or adequately. The Board did not appear to be aware of Public Report 201608430, even though it was closely related to the issues raised by C in this case, and the Board had previously confirmed they had taken action to address the failings identified in that report.

We considered that this case raised significant concerns, given the failings in care and the failure by the Board to identify these, despite their lengthy complaint investigation. This took place within months of the Board having provided this office with assurances that they had taken action to improve the identification and treatment of patients with CES symptoms.

We upheld all of C's complaints.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C and A:

Complaint number	What we found	What the organisation should do	What we need to see
a)	A's care for CES was not in line with the appropriate standards	Apologise to C and A for failing to provide care for A in line with the appropriate standards. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets	A copy or evidence of the apology. By: 19 June 2021
b)	The Board's actions resulted in an unreasonable delay in admitting and treating A	Apologise to A for the unreasonable delay in admitting and treating them. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets	A copy or evidence of the apology. By: 19 June 2021
c)	The Board have not explained why A was discharged on 28 September 2018	Apologise to C and A for failing to provide an adequate explanation for the decision to discharge A. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets	A copy or evidence of the apology. By: 19 June 2021
d)	The Board failed to refer A to the appropriate specialisms for ongoing care, resulting in further delays to their treatment	Apologise to C and A for failing to refer A to the appropriate specialisms for ongoing care resulting in further delays to their treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets	A copy or evidence of the apology. By: 19 June 2021
e)	The Board failed to handle C's complaint reasonably	Apologise to C and A for failing to handle their complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets	A copy or evidence of the apology. By: 19 June 2021

We are asking the Board to improve the way they do things:

Complaint number	What we found	Outcome needed	What we need to see
a), b) and c)	A's incomplete CES was not recognised as a neurosurgical emergency	Relevant staff understand the standard operating procedure, based on the British Association of Spine Surgeons guidelines for the care and management of CES, and provide appropriate treatment in line with it	Evidence of staff knowledge of the standard operating procedure, including guidance for staff and an explanation of how its application will be monitored. By: 19 July 2021
a), b) and c)	A's referral from the Orthopaedic Department to the Neurosurgery Department was not fully documented	Document referrals to the Neurosurgery Department accurately and comprehensively by medical staff in the Orthopaedic Department	Evidence the Board are monitoring the documentation of referrals to ensure they are comprehensive and accurate. By: reporting monthly for the next six months
a), b) and c)	Orthopaedic staff were unclear what to do when A's referral to Neurosurgery was refused	Orthopaedic staff should have a clear procedure to follow when a referral is declined by the Neurosurgery Department	Evidence of a clear procedures, including an explanation of how the Orthopaedic and Neurosurgery Department have collaborated in its creation. By: 19 August 2021
a) and b)	A's surgery was unreasonably delayed	Surgery for CES must be performed within recommended timescales	The Board must evidence they have systems in place to ensure that patients are operated on within reasonable timescales and that these are being monitored on a monthly basis for the next twelve months. By: 19 June 2021
d)	No referrals or aftercare arrangements were made for A	Discharge should be planned with prompt referral to appropriate services. The Board should ensure that patients have the appropriate referrals made to community based services to support their care on discharge from hospital. This should include the transfer of care plans with the patient, where appropriate, to ensure continuity and consistency of care	Evidence the Board have taken steps to address the difficulties in providing coordinated care for CES patients and that the effectiveness of these measures is monitored on a monthly basis. By: 19 June 2021

We are asking the Board to improve their complaints handling:

Complaint number	What we found	Outcome needed	What we need to see
e)	The Board's complaint investigation failed to identify that treatment of CES by the Board had been the subject of a public report a matter of months before A's case	To ensure the Board has effective complaint monitoring arrangements in place to identify when a new complaint concerns the same issues or clinical matters (CES in this case) as previous complaints, and that the relevance of outcomes and learning from previous cases are considered, as appropriate, in any new investigation	Evidence the Board have effective complaint handling and monitoring systems in place. By: 19 August 2021
e)	The Board's Morbidity and Mortality meeting was unreasonably delayed and did not involve all relevant staff	Morbidity and Mortality meetings should be held timeously and should involve representatives of all specialisms involved in a patient's care	Evidence that Morbidity and Mortality procedures require the involvement of all relevant specialisms. By: 19 July 2021
e)	The Board failed to properly implement their duty of candour	Appropriate implementation of the duty of candour, in line with General Medical Council guidance	Evidence that the need to apply the duty of candour has been fed back to staff in the Orthopaedic and Neurosurgery teams in a supportive manner. By: 19 June 2021

Complaint number

What we found

Outcome needed

What we need to see

The Board's complaint investigation failed to identify that treatment of CES by the Board had been the subject of a public report a matter of months before A's case

To ensure the Board has effective complaint monitoring arrangements in place to identify when a new complaint concerns the same issues or clinical matters (CES in this case) as previous complaints, and that the relevance of outcomes and learning from previous cases are considered, as appropriate, in any new investigation

Evidence the Board have effective complaint handling and monitoring systems in place.

By: 19 August 2021

The Board's Morbidity and Mortality meeting was unreasonably delayed and did not involve all relevant staff

Morbidity and Mortality meetings should be held timeously and should involve representatives of all specialisms involved in a patient's care

Evidence that Morbidity and Mortality procedures require the involvement of all relevant specialisms.

By: 19 July 2021

The Board failed to properly implement their duty of candour

Appropriate implementation of the duty of candour, in line with General Medical Council guidance

Evidence that the need to apply the duty of candour has been fed back to staff in the Orthopaedic and Neurosurgery teams in a supportive manner.

By: 19 June 2021

The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:

Complaint number	What we found	What the organisation should do	What we need to see
a)	The Board said they had already taken steps to ensure that patients with possible CES were not discharged without their case being discussed with an orthopaedic consultant first	Provide evidence that it has been monitoring the effectiveness of these measures	Evidence showing the procedural changes implemented by the Board, as well as the mechanisms in place for monitoring them. By: 19 June 2021

Complaint number

What we found

What the organisation should do

What we need to see

The Board said they had already taken steps to ensure that patients with possible CES were not discharged without their case being discussed with an orthopaedic consultant first

Provide evidence that it has been monitoring the effectiveness of these measures

Evidence showing the procedural changes implemented by the Board, as well as the mechanisms in place for monitoring them.

By: 19 June 2021

Report no:

201807854
Date:

November 2020
Body:

Greater Glasgow and Clyde NHS Board - Acute Services Division
Sector:

Health

Mr C complained about the follow-up care and treatment Greater Glasgow and Clyde NHS Board (the Board) provided to Mr A after he suffered a subarachnoid haemorrhage (a type of stroke caused by bleeding on the surface of the brain) which occurred when an aneurysm (a bulge in a blood vessel in the brain) ruptured.

Mr A underwent an endovascular coiling procedure (a procedure to block blood flow into an aneurysm) at Queen Elizabeth University Hospital (the Hospital) in August 2016. During his admission, he developed a perforated bowel and had colostomy surgery (a surgical procedure to divert one end of the colon (part of the bowel) through an opening in the tummy. The opening is called a stoma). He was discharged the following month.

In February 2017, Mr A attended the Hospital for a follow-up Magnetic Resonance (MR) angiogram scan (a test that provides images of the blood vessels). This showed a recurrence of the aneurysm. A further examination in the form of a Digital Subtraction Angiogram (a procedure which provides an image of blood vessels) was recommended, which was requested in July 2017.

In September 2017, the Digital Subtraction Angiogram was carried out and Mr A’s case was discussed at the neurovascular Multi-Disciplinary Team (MDT) meeting. The meeting proposed that Mr A have further endovascular treatment.

In November 2017, Mr A attended an out-patient appointment with a consultant neuroradiologist (a radiologist who specializes in the use of radioactive substances, x-rays and scanning devices for the diagnosis and treatment of diseases of the nervous system) where it was recommended that the reversal of the colostomy be undertaken prior to the endovascular treatment. The colostomy reversal was to be carried out at Mr A’s local hospital, which is the responsibility of a different health board.

The Board wrote to the consultant general surgeon at Mr A's local hospital in December 2017 advising that it was considered it would be better to perform the colostomy reversal before the endovascular treatment. However, Mr A died the same month having suffered a further brain aneurysm.

Mr C complained that there were unreasonable delays, poor decision-making and poor communication by the Board, which he considered resulted in Mr A’s death. In making the complaint, Mr C was representing his family (including Mrs B, Mr A’s sister).

We took independent advice from a consultant neurosurgeon (a surgeon who specialised in surgery on the nervous system, especially the brain and spinal cord).

We found that when Mr A suffered a subarachnoid haemorrhage in August 2016, the care and treatment he received during his admission to the Hospital was timely and expedient and his overall management was reasonable.

A significant recurrence of the aneurysm was identified following the MR angiogram scan in February 2017 and a follow-up Digital Subtraction Angiogram was recommended. Despite this, no action appeared to have been taken for five months, until requested in July 2017. There was then a further two month delay until the Digital Subtraction Angiogram was carried out in September 2017. By this time the aneurysm had grown in size. We found that these delays were significant and unreasonable.

We also found that there was a lack of communication with Mr A subsequent to the identification of the presence of the recurrence of the aneurysm and the need for prompt further management to make him aware of this. However, communication subsequent to the Digital Subtraction Angiogram in September 2017 appeared overall to have been reasonable although the Board acknowledged that communication in relation to a letter which Mr A received about the colostomy reversal could have been better.

Mr A did not have a consultant review for a further two months until November 2017. We found that there were then further unreasonable and significant delays and poor communication in following up the need for the colostomy reversal prior to treating the aneurysm. This was further exacerbated by the fact that the general surgical team were in a different hospital. Relying solely on written communication between clinicians about this was inappropriate and insufficient in this case, which was urgent.

Whilst it is not possible to say whether earlier treatment would have led to a different outcome for Mr A and there was risks attached to surgery, we found that treating Mr A at the earliest opportunity would have minimised this possibility.

Mr C also complained about the Board’s handling of their complaint, which was made to the Board by Mrs B.

We noted that the Board held a Morbidity and Mortality meeting in February 2018 to review Mr A’s case which was attended by a number of consultants including Mr A’s doctors. This outlined a number of contributory factors leading to Mr A’s poor outcome, the reasons why, and the action to be initiated to help mitigate future occurrence and as future learning points.

However, despite this, at no point during the Board’s correspondence with Mrs B or our office was any reference made to the Morbidity and Mortality meeting and its findings. While the Board acknowledged that there had been process failures in their second response to Mrs B, more could have and should have been done to identify and act transparently on the failings the Morbidity and Mortality meeting identified. It was not clear from the Board’s responses to Mrs B and to our office whether all of the actions identified had been completed.

Our investigation identified significant failings and, accordingly, we upheld both of Mr C’s complaints.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C and his family:

Complaint number	What we found	What the organisation should do	What we need to see
(a) and (b)	The Board failed to provide Mr A with a reasonable standard of care and treatment There was failings in communication with Mr A after he suffered a recurrence of a brain aneurysm There was failings in communication between staff involved in Mr A’s care and treatment There were failings in the Board’s handling of the complaint	Apologise to Mr C, Mrs B and Mr A’s family for: the failings in care and treatment and communication identified in the report; and the failings in complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets	A copy or record of the apology By: 18 December 2020

Complaint number

What we found

What the organisation should do

What we need to see

(a) and (b)

The Board failed to provide Mr A with a reasonable standard of care and treatment

There was failings in communication with Mr A after he suffered a recurrence of a brain aneurysm

There was failings in communication between staff involved in Mr A’s care and treatment

There were failings in the Board’s handling of the complaint

Apologise to Mr C, Mrs B and Mr A’s
family for:

the failings in care and treatment and communication identified in the report; and
the failings in complaint handling.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

A copy or record of the apology

By: 18 December 2020

We are asking the Board to improve the way they do things:

Complaint number	What we found	Outcome needed	What we need to see
(a)	There were unreasonable delays in Mr A’s care and treatment after he suffered a recurrence of a brain aneurysm There was unreasonable failings in communication with Mr A after he suffered a recurrence of a brain aneurysm There was unreasonable failings in communication between staff involved in Mr A’s care and treatment	There should be in place a streamlined and efficient system for highlighting reports of an aneurysm and acting upon its findings Communication with patients and/or their families should be proactive and timely, especially in relation to a serious diagnosis Communication between staff should be appropriate and timely especially where a patient has had a serious diagnosis and requires treatment	Evidence that the Board have reflected on the failings identified in Mr A’s case and reviewed their processes and guidance for highlighting reports of an aneurysm Details of the review and any changes, including how any changes will be shared with relevant staff, to be provided to this office Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions) By: 18 February 2020

Complaint number

What we found

Outcome needed

What we need to see

(a)

There were unreasonable delays in Mr A’s care and treatment after he suffered a recurrence of a brain aneurysm

There was unreasonable failings in communication with Mr A after he suffered a recurrence of a brain aneurysm

There was unreasonable failings in communication between staff involved in Mr A’s care and treatment

There should be in place a streamlined and efficient system for highlighting reports of an aneurysm and acting upon its findings

Communication with patients and/or their families should be proactive and timely, especially in relation to a serious diagnosis

Communication between staff should be appropriate and timely especially where a patient has had a serious diagnosis and requires treatment

Evidence that the Board have reflected on the failings identified in Mr A’s case and reviewed their processes and guidance for highlighting reports of an aneurysm

Details of the review and any changes, including how any changes will be shared with relevant staff, to be provided to this office

Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions)

By: 18 February 2020

Evidence of action already taken

The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:

Complaint number	What we found	Outcome needed	What we need to see
(a)	There were unreasonable delays in Mr A’s care and treatment after he suffered a recurrence of a brain aneurysm There was unreasonable failings in communication with Mr A after he suffered a recurrence of a brain aneurysm There was unreasonable failings in communication between staff involved in Mr A’s care and treatment	The Board convened a Morbidity and Mortality Meeting in February 2018 in which they recommended action points Action included: a more robust system for MDT referral; improved team working and communication between the neurosurgery and neuroradiology departments; better safety netting to ensure that a patient diagnosed with a recurrent aneurysm is tracked for urgent review; at least one vascular neurosurgeon is present at a Morbidity and Mortality meeting; and standard operating procedure for Digital Subtraction Angiogram views for coil embolisation	Confirmation of the action the Board say they have taken (evidence of guidelines circulated and training sessions attended, such as emails; memos minutes) By: 18 February 2020

Complaint number

What we found

Outcome needed

What we need to see

(a)

There were unreasonable delays in Mr A’s care and treatment after he suffered a recurrence of a brain aneurysm

There was unreasonable failings in communication with Mr A after he suffered a recurrence of a brain aneurysm

There was unreasonable failings in communication between staff involved in Mr A’s care and treatment

The Board convened a Morbidity and Mortality Meeting in February 2018 in which they recommended action points

Action included:

a more robust system for MDT referral;
improved team working and communication between the neurosurgery and neuroradiology departments;
better safety netting to ensure that a patient diagnosed with a recurrent aneurysm is tracked for urgent review;
at least one vascular neurosurgeon is present at a Morbidity and Mortality meeting; and
standard operating procedure for Digital Subtraction Angiogram views for coil embolisation

Confirmation of the action the Board say they have taken (evidence of guidelines circulated and training sessions attended, such as emails; memos minutes)

By: 18 February 2020

Report no:

201806286
Date:

August 2020
Body:

Greater Glasgow and Clyde NHS Board - Acute Services Division
Sector:

Health

Mr C complained about the care and treatment that he received from Greater Glasgow & Clyde NHS - Acute Services Division (the Board) after he sustained a navicular fracture to his left foot (a fracture of the navicular bone on the top of the midfoot). Mr C also complained that the Board failed to respond reasonably to his complaint.

In March 2017, Mr C attended the Emergency Department (ED) of the Queen Elizabeth University Hospital, Glasgow (the Hospital). Mr C was assessed by a junior doctor and found to have pain on touching some of the bones in his foot. An xray was ordered, which the junior doctor interpreted as showing an un-displaced fracture (a fracture where the bone fragments do not separate) of one of the metatarsal bones (the 'forefoot' bones linking the toes to the middle part of the foot). Mr C was given a walking boot, advice and discharged. Two days later, the x-ray was reported by a radiologist as showing no acute joint or bony injury.

At the start of May 2017, Mr C attended again at the ED following a referral from the GP out-of-hours service as his foot was swollen and he was still in pain. Further xrays were taken. Mr C was reviewed by the on call orthopaedic doctor. The doctor's diagnosis was that there was possibly a hairline fracture (a very fine fracture) of the fourth metatarsal. Mr C said he was advised nothing further could be done and was sent home. The following day, Mr C attended the orthopaedic out-patients department at the Hospital following a call asking him to attend. He was advised by an orthopaedic doctor that the third and fourth metatarsal were broken, in addition, the navicular bone was broken in three parts with a 5mm gap.

Subsequently, Mr C underwent surgery to address the fracture. However, he continued to experience problems with his foot. Mr C had a major limb amputation of the lower part of his left leg in October 2019.

We took independent advice from a consultant in emergency medicine, a consultant orthopaedic surgeon and a consultant radiologist.

We found that it was not unreasonable that the ED junior doctor did not identify Mr C's fracture in March 2017 as it was uncommon to see a patient present at the ED with a navicular fracture and a junior doctor will rarely see a patient present with this type of fracture and often not at all. In addition, the fracture was subtle on the x-ray. On account of this, the junior doctor who saw Mr C made an understandable, reasonable, mistake in not diagnosing that he had sustained a navicular fracture.

Notwithstanding this, Mr C's fracture should have been identified in the radiology report of the x-ray taken in March 2017 and although the fracture of the navicular on the x-ray was subtle; it was unreasonable that the radiologist did not report this fracture.

Mr C was diabetic. We found that the clinical history supplied on the request for the radiograph did not include this information. While we did not consider the failure to identify and include this information in Mr C's clinical history amounted to an unreasonable standard of treatment, had the information about Mr C's diabetes been supplied it may have further alerted the reporting radiologist to the possibility of a stress fracture.

We found that when Mr C re-attended the Hospital in May 2017 after being referred by the out-of-hours service, a further opportunity to identify the navicular fracture was missed.

In conclusion, we found that overall the Board failed to provide Mr C with a reasonable standard of care and treatment and that it was likely that the failure to identify Mr C's fracture in March 2017 had a detrimental impact on his outcome. In light of the failings identified, we upheld this aspect of Mr C's complaint.

Finally, we found that the Board failed to handle Mr C's complaint reasonably and upheld this aspect of his complaint.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

Complaint number	What we found	What the organisation should do	What we need to see
(a) and (b)	The Board failed to provide Mr C with a reasonable standard of care and treatment The Board's own complaint investigation did not identify or address the failings in Mr C's medical care	Apologise to Mr C for the failings in care and treatment identified in the report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets	A copy or record of the apology. By: 19 September 2020

Complaint number

What we found

What the organisation should do

What we need to see

(a) and (b)

The Board failed to provide Mr C with a reasonable standard of care and treatment

The Board's own complaint investigation did not identify or address the failings in Mr C's medical care

Apologise to Mr C for the failings in care and treatment identified in the report.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

A copy or record of the apology.

By: 19 September 2020

We are asking the Board to improve the way they do things:

Complaint number	What we found	What should change	What we need to see
(a)	The Board unreasonably failed to identify Mr C's navicular fracture	X-rays of patients attending hospital with a possible fracture should be appropriately reported. Patients re-attending should have their presenting symptoms fully assessed and investigated	Evidence that the case has been discussed at a radiology Learning from Discrepancies meeting. Evidence that the Board have reflected on the failings identified in Mr C's case and given consideration to any required changes to processes and guidance. Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions). By: 19 November 2020

Complaint number

What we found

What should change

What we need to see

(a)

The Board unreasonably failed to identify Mr C's navicular fracture

X-rays of patients attending hospital with a possible fracture should be appropriately reported.

Patients re-attending should have their presenting symptoms fully assessed and investigated

Evidence that the case has been discussed at a radiology Learning from Discrepancies meeting.

Evidence that the Board have reflected on the failings identified in Mr C's case and given consideration to any required changes to processes and guidance.

By: 19 November 2020

We are asking the Board to improve their complaints handling:

Complaint number	What we found	Outcome needed	What we need to see
(b)	The Board's own complaint investigation did not identify or address the failings in Mr C's medical care	The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement.	Evidence that the Board have reviewed why its own investigation into this complaint did not identify or acknowledge the failings highlighted here, what learning they identified, and what action has been taken as a result. My findings have been shared with relevant staff in a supportive way for reflection and learning. By: 19 November 2020

Complaint number

What we found

Outcome needed

What we need to see

(b)

The Board's own complaint investigation did not identify or address the failings in Mr C's medical care

The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement.

Evidence that the Board have reviewed why its own investigation into this complaint did not identify or acknowledge the failings highlighted here, what learning they identified, and what action has been taken as a result.

My findings have been shared with relevant staff in a supportive way for reflection and learning.

By: 19 November 2020

Feedback

Points to note

While it was not unreasonable that the junior doctor did not identify the navicular fracture when Mr C first attended the ED in March 2017, the Board may wish to consider raising awareness of a navicular fracture with junior doctors joining the ED on placement.
When a patient attends with a fracture at the ED, the Board may wish to give consideration to recording past clinical history as this can provide a potential alert for subsequent care and treatment.
Adviser 2 commented that the subsequent management of Mr C's case by the Board's consultant orthopaedic surgeon after the navicular fracture had been identified should be commended.

Report no:

201706689
Date:

August 2019
Body:

Glasgow City Health and Social Care Partnership
Sector:

Health and Social Care

Summary

Ms C complained about the way that the Glasgow City Health and Social Care Partnership (the HSCP) handled her complaint.

Ms C made a complaint on 16 October 2017 expressing her dissatisfaction with the HSCP's response to her complaint at Stage 1. When she then did not receive a response to her complaint of 16 October 2017, she contacted my office. We queried with the HSCP whether Ms C's complaint of 16 October 2017 had been responded to which the HSCP were unable to tell us. We found that this was unreasonable because complaint responses should be appropriately tracked and recorded under the model Complaints Handling Procedure and the NHS Greater Glasgow and Clyde Complaints Handling Procedure (NHSGGC CHP).

We asked the HSCP on four occasions to review Ms C's complaint of 16 October 2017 and provide her with a response to her complaint as we did not consider all the points raised by Ms C had been addressed by the HSCP. On each occasion we were given assurances that a further response would be sent to Ms C. The HSCP did not send a response to Ms C until more than a year after her complaint of 16 October 2017.

Following the HSCP's response to Ms C's complaint of 16 October 2017, she brought her complaint to this office.

We found that it was not made clear to Ms C why her complaint to Greater Glasgow and Clyde NHS Board was being responded to by the HSCP. Ms C's complaint was also not acknowledged in writing within three working days.

We noted that there was a significant delay in Ms C receiving a complaint response even after we referred the matter back to the HSCP. Ms C was not kept updated with the reasons for the delay in issuing the complaint response and was not provided with a revised timescale.

We found that substantially different reasons were provided to Ms C and to this office about the delay, and there was a lack of openness and accountability as to why the significant delay occurred.

We also found that the tone and language used in the HSCP's complaint responses was, at times, inappropriate.

The public are entitled to expect openness and accountability in the way in which their complaint is handled by a public body. These principles were established a number of years ago by the Committee on Standards in Public Life and enshrined in the “Nolan Principles” designed to improve standards of behaviour in public organisations. In this case, we found that the HSCP failed to live up to these principles in the handling of Ms C's complaint and the way in which they have responded to us.

In view of these failings, we upheld Ms C's complaint that the HSCP did not handle her complaint reasonably.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the HSCP to do for Ms C:

What we found	What the organisation should do	What we need to see
It was not made clear to Ms C why her complaint to Greater Glasgow and Clyde NHS Board was being responded to by the Glasgow City HSCP. Ms C's complaint of 16 October 2017 was not acknowledged in writing within three working days. There was a significant delay in Ms C receiving a complaint response after my office referred the matter back to the HSCP. Ms C was not kept updated with the reasons for the delay in issuing the complaint response and was not provided with a revised timescale. Substantially different reasons were provided to Ms C and to this office about the delay and there was a lack of openness and accountability as to why the significant delay occurred. The tone and language used in the HSCP's complaint responses was, at times, inappropriate	Apologise to Ms C for not making it clear to her at the earliest opportunity why her complaint to Greater Glasgow and Clyde NHS Board was being responded to by the Glasgow City HSCP; for not acknowledging her complaint of 16 October 2017; for the significant delay in sending her a final complaint response; for not keeping her updated about the reasons for the delay or providing a revised timescale; for the lack of openness and accountability as to why the significant delay occurred and for the tone and language used in the complaint responses. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.	A copy or record of the apology By: 18 September 2019

What we found

What the organisation should do

What we need to see

It was not made clear to Ms C why her complaint to Greater Glasgow and Clyde NHS Board was being responded to by the Glasgow City HSCP.

Ms C's complaint of 16 October 2017 was not acknowledged in writing within three working days.

There was a significant delay in Ms C receiving a complaint response after my office referred the matter back to the HSCP.

Ms C was not kept updated with the reasons for the delay in issuing the complaint response and was not provided with a revised timescale.

Substantially different reasons were provided to Ms C and to this office about the delay and there was a lack of openness and accountability as to why the significant delay occurred.

The tone and language used in the HSCP's complaint responses was, at times, inappropriate

Apologise to Ms C for not making it clear to her at the earliest opportunity why her complaint to Greater Glasgow and Clyde NHS Board was being responded to by the Glasgow City HSCP; for not acknowledging her complaint of 16 October 2017; for the significant delay in sending her a final complaint response; for not keeping her updated about the reasons for the delay or providing a revised timescale; for the lack of openness and accountability as to why the significant delay occurred and for the tone and language used in the complaint responses.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

A copy or record of the apology

By: 18 September 2019

We are asking the HSCP to improve their complaints handling:

What we found	Outcome needed	What we need to see
It was not made clear to Ms C why her complaint to the Greater Glasgow and Clyde NHS Board was being responded to by the Glasgow City HSCP. Ms C's complaint of 16 October 2017 was not acknowledged in writing within three working days. In January 2018, the HSCP were not able to tell my office whether Ms C's complaint of 16 October 2017 had been responded to. There was a significant delay in Ms C receiving a complaint response after my office referred the matter back to the HSCP. Ms C was not kept updated with the reasons for the delay in issuing the complaint response and was not provided with a revised timescale. Substantially different reasons were provided to Ms C and to this office about the delay and there was a lack of openness and accountability as to why the significant delay occurred. The tone and language used in the HSCP's complaint responses was, at times, inappropriate	The necessary systems should be in place to ensure that complaints are handled in line with the Glasgow City HSCP's complaint handling procedure and the model complaints handling procedure and that all staff responsible for dealing with complaints should be aware of their responsibilities in this respect. The tone and language used in complaint responses should be professional and empathetic	Evidence that training has been carried out with relevant staff involved in this complaint to remind them, in a supportive way, of the principles underpinning the Glasgow City HSCP's complaint handling procedure and the model complaints handling procedure. Evidence that the HSCP's systems demonstrate senior level/governance responsibility for complaint handling. Evidence of an audit of a sample of complaint responses since September 2017 to ensure that complaints are being handled in accordance with the Glasgow City HSCP's complaint handling procedure and the model complaints handling procedure and that the tone and language used is professional and empathetic By: 21 November 2019

What we found

Outcome needed

What we need to see

It was not made clear to Ms C why her complaint to the Greater Glasgow and Clyde NHS Board was being responded to by the Glasgow City HSCP.

Ms C's complaint of 16 October 2017 was not acknowledged in writing within three working days.

In January 2018, the HSCP were not able to tell my office whether Ms C's complaint of 16 October 2017 had been responded to.

There was a significant delay in Ms C receiving a complaint response after my office referred the matter back to the HSCP.

Ms C was not kept updated with the reasons for the delay in issuing the complaint response and was not provided with a revised timescale.

Substantially different reasons were provided to Ms C and to this office about the delay and there was a lack of openness and accountability as to why the significant delay occurred.

The tone and language used in the HSCP's complaint responses was, at times, inappropriate

The necessary systems should be in place to ensure that complaints are handled in line with the Glasgow City HSCP's complaint handling procedure and the model complaints handling procedure and that all staff responsible for dealing with complaints should be aware of their responsibilities in this respect.

The tone and language used in complaint responses should be professional and empathetic

Evidence that training has been carried out with relevant staff involved in this complaint to remind them, in a supportive way, of the principles underpinning the Glasgow City HSCP's complaint handling procedure and the model complaints handling procedure.

Evidence that the HSCP's systems demonstrate senior level/governance responsibility for complaint handling.

Evidence of an audit of a sample of complaint responses since September 2017 to ensure that complaints are being handled in accordance with the Glasgow City HSCP's complaint handling procedure and the model complaints handling procedure and that the tone and language used is professional and empathetic

By: 21 November 2019

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